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801 NE 96 St (8)BUILDING INSPECTION DEPARTMENT APPLia:A11UN FOR BUILDING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the build- ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of the work. Owner's Name and Address Registered Architect and /or Engineer Name and address of licensed contractor Location and 1pgal description of lot to be built /! Y/ 7 Block 7 STATE OF FLORIDA, COUNTY OF DADE. ' ss. AM SHORES VILLAGE n: Date Lot Street and Number where work is to be done Sta; work to be done ,rpo d pu of b ldi t fr,' � _ fir. ' 2 . -e(Ze — —. , 1 r / _ � � i f �� New Building /' Remodeling /add' ion To be constructed of/ Kind of foundation i Amount of Permit $. _Plan Cubage Size of Building Lot No Lc / .. Street..../ 7Kr .�.rz .. f K a - -- X 4 1 ` and fo.r no other purpos' Repairs No. of Stories Roof Covering e. Notary Public, State of Florida Estimated Total cost of improvements $ Zone cubage required Distance to next nearest building Maximum live load to be borne by each floor I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may be sent to The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement, and has complied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection �n the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such subcon tors, on work to be rformed under this permit, as are licensed by Miami Shores Village. J L.- " , Remarks (Signed) �/G i !i_ . - ._... -. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap- peared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him s a.>ed are true. Permit No `3 6, 1Z - Date � c p 7/ Read, Sworn to and Subscribed before me. Disapproved �_ Date__ (Signed) (!� + (1.--- Building Inspector My Commission Expires PLAN YnNG BOARD DATE Chairman Member Member Member Member ._ .- . Member Council Approved Date Disapproved Date NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from the Planning Board. A re- inspection fee of 51.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and /or workmanship. ge 2 ¢ Z G 4 77.J so 7 ITEMS SUB CONTRACTORS & SUPPLIERS NAME & ADDRESS 1. Arnhitectural MOt (olans) _ _...._,-____ 2. Isohalt iwalkLives 9 et6.) , P Y i .....,....- 30 Cabinets -7 Vanity laWifflffird11,07,-L, .0_,,, "4. Cabinets - Kitchen IPMOTANIIIIF - -0. / • .. • ..- 5. Cabinets Medicine 6. Cabinets - Unit Closet 7. Cleaning r. „....--/--/ ir 8. CiearinSiTe ---- 9. Concrete - - Foundation Slabs,Beams ilaWar = OW ..... JP - I.r.ir- .._.* . ..'_■-•,..... L.48± s 10 Ca.crete - WaIks / _4 r 110 Contractors Fee 12. Electric Fixtures r...., .... •...,...,. Ati.-..(.......-. 13. Electric T.1iring sr r # . ,e • . . ',ear 14. Eauipment Rental • 15. Excavation ilree... 16. Fir for81 Ai{ lo ors - Finish Wood & kitchen reAMMIrdIfir , e 18. 'ors - Terrazzo - 19. Garagf boors _ - WilMri- , ... Al "iAge - fotth.ass Sirdingr ---- s ---------- --- - ' _ / „, , 21. Hardware - Finish ■ ....K.', ..• ..- - ' ....... 22. Hardware - Rough ri .1.. _ ..r, : • r , ..- . .. ' .. ,..r Ake . . . / .k..t -1.1' 23. Heating._ 24. frisurance - Liabil.ilz)coEp.-bond gummaliv,L, j,, ../...„. .„- 41, 25. Labor_721yro1l 0 26. Labor - Contract . 27. Labor - Contract - ympmegmffir.„.__, , ...,:i , 28LandscagFi1dir l _._ 29 Laill Tfiste;: Stucco c. =5 -- I ..... _ _ Jo 30. Lumber (Aid) MAW, i 6.2g . ..-.0/9.3,2./A.1 126 31., Masonry Labor__ 32., MasonaMaterials Block 33. Millwork 41 r2 .; - 34. Miscellaneous 35. Ornamental Iron Work r.„..„. d..,_ ....:„.... . :,.... - 36. Oven & Plate - Built-m _ 37. Overhead 38 . Paintim / . -.:e.": -_,_.,...., / _ --...1' 111 42 6-2) •V `- ze 39. Permits. Temporary Power 111 .1M5N,Ar . _. 40. Pilin Foundation , .- /7 : .., .... / 41., Plumbin CopLeate ,-012M-Mr 42. Pool - Swimmip 43. Roofing & Sheet Metal Work i w 0. , 440 Roof Trusses - Prefab., I? if. - .or, f i 45. Screen Enclosure, F - 1 *A1 ' • 46. Se tic Tank or Set _. TAmmummit,, .. } :A . g .c _ alat _2 3. 470 Shower or Tub Enclosures_ 441/W., , . 48. Steel Reinforcing & strlo 49 Suaervision ........../. . ... . Air ...: .1., ..., .; , A ..4 J of : I 9.7 1; 50 Surveys kg,; _ 51. Tile & Marble WOJEAWAW , 0 /e' ' 52. Water - Public WIMMAINW_.. . _ 53. Water - Well & PIER ...., A 54. Windows - Glazink& Screens '0 .... . o I _____ 55. Window Frames - Concx-ete -.-- RPM, ,. 0 ■ SdIAMI SHORZS VILLAGE APPLICATION FOR FINAL INSPECTION • Prior to a final inspect n this application must be filled out; if sub contractors have failed to take out pernits the general contractor shall be responsible for the permit and fee. A final inspection nust be made prior to the release to Florida Power and Light Co. and the issueance of a certificate of occupancy. JOB ADDRESS /,17- , / • - LOT . BLOCIL210Z SUB°7 .Z4E.I__;ZO/4...-2_41_,e____ BUILDER.4 „ DAY LABOR CONTRACTX DATE SIGNED iTJCTOR 19 THIS LICENSE MUST BE DISPLAYED IN A CONSPICUOUS PLACE A PENALTY IS IMPOSED FOR FAILURE TO KEG THIS LICENSE EXHIBITED AT YOUR ESTABLISHMENT OR PLACE OF BUSINESS Village :a frla o:{ of i>u11diI 71 THIS LICENSE EXPIRES In consideration of the sum of F= ;re -zo f I LY, - ----�- ---- -- Dollars ($ Paid to Miami Shores Village, Dade County, State of Florida, axtn Jr. -- 1:,:9;:A.; eat Dime iti icy - AiamI,, =1ortth is hereby licensed to engage in or operate the business of illy own House Date Issued June 4, 1V11 THIS LICENSE NOT TRANSFERABLE WITHOUT THE APPROVAL OF THE VILLAGE MANAGER. 4 MIAMI SHORES VILLAGE, FLORIbA ABBOT asienisa. BERNARD B. BREITBART ANDREW A. GELLER, CLU, CPCU May 27, 1971 Miami Shores Village Miami Shores City Hall, Florida ATTENTION: Mr. Bradford RE: Carl Paxton & Sophia Paxton Gentlemen: Enclosed is a Certificate of Insurance for Liability coverage for the captioned. We have applied for the Workmen's Compensation Insurance and the Paxtons hate advised us they will not build prior to having the Workmen's Compensation Insurance in force. A Certificate will be in your possession upon issuance of the Policy by the Company. Very truly yours, BREITBART- GELLER, INC." Bernard B. Breitbart cc. Mr. & Mrs. Carl Paxton I3C BREITBART - GELLER, INC. INSURANCE PLACEMENT & RISK MANAGEMENT 1451 NORTH BAYSHORE DRIVE - SUITE 708 MIAMI. FLORIDA 33132 TELEPHONE: (305) - 358 -1404 BROWARD: 525 -5611 EXT. 29 Kind of Insurance Policy No. EFFECTIVE DATE EXPIRATION DATE LIMITS OF LIABILITY Bodily Injury Property Damage Comprehensive General Liability Excluding ❑ Including ❑ ❑ Completed Operations ❑ Products Liability $ Each person XXXX $ Each occurrence $ $ * Aggregate $ ** Owners' Landlords' and Tenants' Liability 1- 10s- 475034 5/24/71 5/24/72 $ 100,000.00 Each person XXXX $ 300,00o. 00 Each occurrence $ 259000900 Manufacturers' and Contractors' Liability $ Each person XXXX $ Each occurrence $ XXXX Aggregate $ Contractual Liability $ Each person XXXX $ Each occurrence $ XXXX Aggregate $ Completed Operations and Products Liability $ Each person XXXX $ Each occurrence $ $ Aggregate $ Owners' or Contractors' Protective Liability I 1 above P 5 5/24/72 $ f r • Each person XXXX $ 25,000.00 $ 25,000.00 $)00,000 • 00 Each occurrence XXXX Aggregate Comprehensive Automobile Liability _ $ Each person XXXX $ Each occurrence $ Automobile Liability $ Each person XXXX $ Each accident $ Workmen's Compensation and Employer's Liability Employer's Liability O.D. As provided in applicable law. Each accident Each Person Aggregate ;$ Glass CONSOLIDATED MUTUAL INSURANCE COMPANY 345 Adams Street, Brooklyn, N. Y. 11201 • 643 -3000 CERTIFICATE OF INSURANCE Certificate Issued to Miami Shores Village Address Cita of Miami Shores, Miami Shores, Florida ATTENTIDN: Mr. Bradford This is to certify that the policy or policies designated below by number and providing, subject to the terms thereof, the kind of insurance set forth opposite such number have been issued by the Company. The insurance afforded is only with respect to such and so many of the kinds of insurance as are indicated by limits of liability, policy period and policy number. Name of Insured CARL PAXTON & SOPHIA PAXTON Corner of 96th Street N.E. and 8th Avenue, Miami. Shores, Florida Dwelling under construction Location Covered Description of Operations Performed *Applicable solely to Completed Operations and Products Hazards. * *Separately applicable to Operations, Protective, Completed Operations, Products and Contractual Hazards. In the event of cancelation of such policy or policies, the Company agrees to make every effort to notify the party tc whom this certificate is addressed, 13 days prior to such cancelation. Notice in writing malied to or delivered at the address of such party as herein stated shall be sufficient notice. Failure on the part of the Company to give such notice she!! rot, however, impose any liability on its part. Date 5/27/71 BRE By TTj R, i B C. tj -4:( WMC PAY TO THE ORDER OF Enclosure AR 5a ABC. INSURANCE CO. Yours very truly, B. B. UhRIIBSON, WAGES rte "(Loa ?OOP The first State -Qf Miami MIMIC* FIGIM1. w l .i LITTLE RIVED ANrANDTR I r COMB Y MIAMI, FLORIDA MAY - ,n 19._ 73 No _ 4 8 4 70 0 V Oki CASHIER'S CHECK FLORIDA COMPENSATION RATING BUREAU *q 37, 1 R. E. FERGUSON Manager W as SseItst, glad Nit Patna Insurance Company 55 lila Street liattfords ,ant 06135 Broitbart4allars TAO. 1451 oath Heiberg DOAN Mod, Fl rlda 33132 ift SOO .... .,. Gentlemen: Florida Workmen's Compensation Assigned Risk Plan *MG 3 ■'ia 3 ? Sr; naaonio111Q ff100 /S4 $ 243.00 Cal 1295 Pa W. m N orth M ode 12950 Ids �7a, In accordance with the provisions of the Workmen's Compensation Assigned Risk Plan, we are assigning this risk to your Company for Workmen's Compensu:cencecoverage. Enclosed is a signed copy of this employe with other information pertinent to this assignment. We have computed the Deposit Premium to be •w _ , The employer is being no- tified by copy of this letter to forward a certified check or money order for the aforementioned amount to your Company. Upon receipt of the required premium, your Company shall issue a binder or policy to become effective as of 12 :01 A.M., on the first day following receipt of such premium. The policy shall - '66 i6su`e"i3 — tor a term OT-one year ditre"St insurance for a shorter term has been re;ttested. A copy of the policy issued the above risk trust be filed i with e ff i c e son that Company may receive proper credit far the assignment dition, if the application was submittoedcaveaaProduCer, it is ro,�,uired that such Producer be notified of the issuance All inquiries concerning the issuance of this insurance should be directed to the Assigned Carrier. 223 W. ADAMS STREET, JACKSONVILLE, FLORIDA 32202 904-354-2336 CCs Stato or na• Dept. of Corsoroo 7 el) Name of Company or Corporation License Number other iiunicipalities: Name and Amounts Insurance Carried: Financial References: BL C - State of Florid APPLICATION PO C2NTRAC`i3i;' S LICENSE i1IAi1I SHORES VILLAGE FLORIDA i Nature of Business Of Names and Numbers Employees (Masters and Journ 11y Commission Expires r , r A i timiGa (Signed) Sworn to and Subscribed Before me {7 4 27 /, 7 , Phone Phone (If a firm, the names of all members of the firm; if a corporation, the names of all officers of the corporation.) dit 1 BUILDING INSPECTION DEPARTMENT APPLICATION FOR BUILDING PERMIT . Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the build- ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of the work. MIAMI SHORES VILLAGE /' Owner's Name and Address 4e6i Registered Architect and /or Engineer Name and address of licensed contractor Location and legal description of lot to be built on: Lot---- ,�,712idd /i Block 71 Subdivision. zr,G 44 , Street and Number where work is to be done 8'� t ��vJJ-- .4.(a7 iV_d.- $ CT &12 State work to be done arut purpqse of buil in (j floor New Building__.. _., remodeling Addij4pn To be construct;; of._ Kind f f tion Repairs No. of Stories 2 Roof Covering ......... .____ __ Estimated Total cost of improvements (17° f�mount of Permit , 7 Zone cubage required Plan Cubage Distance to next nearest building Size of Building Lot "' /2f / / Maximum live load to be borne by each floor I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may be sent to The undersigned applicant for this building pennit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement, and has complied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the sil :e of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such subcontr tors, on work be erformed under this permit, as are licensed by Miami Shores Village. / 7 ) Remarks (Signed) STATE OF FLORIDA, COUNTY OF DADE. ss Before me the undersignngd author' y, a nota uublic, duly authorized to minister oaths and take acknowledgments, personally ap- peared �-� - � i1•_ a to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. J r Date 71 Permit No Disapproved (Signed) NOTE: A charge of $1.00 will be made for the Planning Board. A re- inspection fee of 51.00 will be charged materials and /or workmanship. Chairman Member Member Council Approved .Date Date 1 Read, Sworn to and Subscp'bed efore me. 7 19- No.. _ ..... Sheet Not Public, State of Flori da Building Inspector `y/ \ My Commission Expires PLANING BOARD DATE 2 -S 3 Z Member Member Member Disapproved Date making corrections or changes to this application after approval has been obtained from when such re- inspection is made necessary by improper notice for inspection or faulty and for no other purpose. t::1v "0 • A g . I " 1 oir; A 2-co /4. go co b 31: ( 7 :7> °'? — 71 ' - mi / Tom Adams, Lieutenant Governor STATE OF FLORIDA DEPARTMENT OF COMMERCE DIVISION OF LABOR Bureau. of Workmen's Compensation Tallahassee, Florida 32304 / Phone (9041 599 -8211 1569 TO: CARRIER COVERED EMPLOYERS NOTICE OF $100,00 PENALTY Stephen Matc Slepin, Director You have complied with the Florida Workmen's Compensation Law by obtaining an insurance policy from a company of your own choosing. The Workmen's Compensation Law provides that employers shall be subject to a civil penalty of $100.00 for each failure or refusal to file a report of injury. To avoid this penalty, file a report of injury with your insurance company immediately upon knowledge of an injury. Item DECLARATIONS POLICY NUMBER WC ' (U 4 LI be HIGHWAY (FLORIDA wt -oR° NEW 1. Name of insured • CAL PAXTON ADDRESS: (Number & Street, Town, County & State) • 12950 W. DIXIE • NORTH MIAMI, Locations —All usual workplaces of the insured at or from • which operations covered by this policyare conducted are lo- cated at the above address unless otherwise stated herein:** • • • . INDIVIDUAL 0 PARTNERSHIP 0 CORPORATION • • (OTHER) 2. Policy Period: DRESS DF INSURED AS STATED H REIN. From: • 6-2 0 71 To: 6-2-72 • REPRESENTATIVE: Sub -agent or broker NAME AND CODE NO ASSIGNED RISK PLAN 738 °00009 Reporting agent 3. Coverage A of this policy applies to the workmen's compensation law and any occupational disease law of each of the following states: Fl 010 DA 4. CLASSIFICATION OF OPERATIONS Entries in this item, except as specifically provided elsewhere in this policy, do not modify any of the other provisions of this policy. Code No. PREMIUM BASIS Estimated Total Annual Remuneration RATES Per $100 of Remuneration Estimated Annual Premiums CARPENTRY IN THE CONSTRUCTION OF DETACHED PRIVATE RESIDENCES FOR OCCUPANCY BY ONE OR TWO FAMILIES AND PRIVATE GARAGES IN CONNEC7ION THEREWITH 5645 ASSIGNED RISK SURCHARGE 8% Loss Constant Expense Constant Loss and Expense Constant • 5 4.06 203. 18. 12. 1 0 D Minimum Premium $ 12 O Total Estimated Annual Premium $ 243. If indicated, interim adjustments of premium shall be made: Endorsements Premium $ • Semi - Annually; • Quarterly; • Monthly. Deposit 5. Limit of Liability for coverage B— Employers' Liability: $ 100,000 . , subject to all the terms of this policy having reference thereto * *ABSENCE OF AN ENTRY MEANS "NO EXCEPTION ". COVERAGE is provided in Company (X) below: ® /ETNA INSURANCE COMPANY ❑ /ETNA FIRE UNDERWRITERS INSURANCE COMPANY fl CENTURY INDEMNITY COMPANY ORIGINAL WORKMEN'S COMPENSATION AND EMPLOYERS' LIABILITY POLICY Use with Contract Section to complete MIN /MA 6 =10 =7. Form 1.650.2388 (Rev. 9.1 .69) Ed. March 70 Countersigned by ERCRO1V9BIE- INSO Authorized Rep esentative OWNER'S NAME ` I1 , , 1 ' 1 \1 ) C ' t.a4 L . 1= .gii:n 11. PRESENT ADDRESS , ") ); ,' . J (r ,; +C LICENSE NO. PHONE NO. JOB LOCATION (ST. OR AVE.) / c, N 1 f CI c : .. - ` LOT I BLOCK t SUBDIVISION GENERAL CONTRACTOR 1r).2Z _:,r? >' C 1Y\ i. ,_, - ;- of V,C ) ADDRESS 1(Vi % ll.o t -) t}(I,' , 10'011f,' — - ' A PHONE NO, LICENSE NO. BUILDING PERMIT NO. 1 ').)4-; • ./ , 9 DATE 7 f v v PERMIT FEE $ Ille BUILDER'S BOND NO. DATE ZONE REQUIREMENTS CU. FT. PLAN CUBE CU. FT. rl EST. COST $ I i DRAWINGS. SPECIFICATIONS. RESTRICTIONS AND CUBE CHECKED BY: DATL BUILDING PERMIT AND INSPECTION RECORD -MIAMI SHORES VILLAGE NEW CONSTRUCTION TYPE STORIES ROOF CONSTRUCTION INTERIOR CONSTRUCTION REPAIRS DESCRIPTION ALTERATION DESCRIPTION ADDITION SUBMITTED TO PLANNING BOARD APPROVED REJECTED REFERRED TO COUNCIL REASONS RESUBMITTED TO PLANNING BOARD SUBMITTFJ) TO VILLAGE COUNCIL REMARKS CERTIFICATE OF OCCUPANCY NO. I ISSUED BY TO DRAWINGS. SPECIFICATIONS. RESTRICTIONS AND CUBE CHECKED BY: DATL BUILDING PERMIT AND INSPECTION RECORD -MIAMI SHORES VILLAGE INSPECTIONS DATE BY INSPECTIONS DATE BY FOUNDATION ROUGHING $ ROOF ',�jJ; )2 IY/� q ( / 7` -7/ BEAMS & LINTELS SOLAR HEATER ! POOL \ ` IS FRAMING I FIXTURES (31) AIR COND. $ IaSP kT,it,Lai)C: ")r VIM nl,l FINAL I !_ - St -7J CLEAN UP SLAB SEPTIC TANK SLAB FIXTURES & FINAL SOLAR HEATER TEMPORARY SERVICE . ...... BY . ... RE- INSPECT $ SEPTIC BY ROUGHING $ TANK 11 SEWER l r l f P i l ',�jJ; )2 IY/� q ( / 7` -7/ $ 37 s/ SOLAR HEATER ! TUB & TOP OUT \ ` IS GAS FIXTURES (31) • $ IaSP kT,it,Lai)C: ")r VIM nl,l I Y U !_ - St -7J Q ASts% �. - � 1 .. ..- �, -..� .. INSPECTIONS DATE . ...... BY . ... RE- INSPECT .. BY RE- INSPECT BY ROUGHING RANGE CONN. ( N+ / � J L 1 W RI I '7'- 9- - 7 1 $ Sci MOTORS (°-- I -1-"P")2. -1-"P")2. h TUB & TOP OUT \ ` H. W. HEATER CONN FIXTURES (31) / f LI„ti, - L I Er,„ t.IN Ir _ SEWER 1-4 -11 s 1 6''i SEPTIC TANK FIXTURES & FINAL SOLAR HEATER FIXTURES GAS SPECIAL PERMITS PERMIT NO. \ \\ \ DATE / FEE $ / $ TEMPORARY SERVICE I H. W. HEATER CONN. \ / 1) 1 RANGE CONN. ( N+ / � J L 1 W RI I '7'- 9- - 7 1 $ Sci MOTORS (°-- I -1-"P")2. -1-"P")2. h 7) \ ` H. W. HEATER CONN FIXTURES (31) / f LI„ti, - L I Er,„ t.IN Ir _ 1 a 1-4 -11 s 1 6''i INSPECTIONS DATE BY RE - INSPECTI BY RE - INSPECT BY TEMP. SERVICE I ROUGHING H. W. HEATER CONN RANGE CONN. FIXTURES & FINAL BUILDING INSPECTIONS CONTRACTOR {brne. pi Urn 10) n ten, p // & O L PERMIT NO. ���.� I DATE b - 7I NEW BLDG. ' I ALTERATION 1 ADDITION SPECIALS PERMITS 1 PERMIT NO. 1 DATE CONTRACTOR PLUMBING PERMITS & INSPECTIONS ELECTRICAL PERMITS & INSPECTIONS r)1A)fl r 4- 60;1.4E4_ PERMIT NO. 9,�, "1 I DATE 1 — �� NEW BLDG. V I ALTERATION 1 ADDITION APPROVAL TO POWER CO. FOR SERVICE DATE PHONE 1 FEE $ ) . 2 ) . R " 5-° REPAIRS FEE PHONE FEE $ It) 053,- REPAIRS BY 11. Insert Declarations page here so that top d6 utts against fold of Contract, and permits policy number to appear through window. ATTACH NNDOI IF ANY, TO TOP (3ACI OF.D ,ECLARATIONS. The insured shall maintain records of the information necessary for pre- mium computation on the bases stated in the declarations, and shall send copies of such records to the company at the end of the policy period and at such times during the policy period as the company may direct. If the insured does not furnish records of the remuneration of persons within division (b) of the definition of remuneration foregoing, the remuneration of such per- sons shall be computed in accordance with the manuals in use by the company. The premium stated in the declarations is an estimated premium only. Upon termination of this policy, the earned premium shall be computed in ac- cordance with the rules, rates, rating plans, premiums and minimum premiums applicable to this insurance in accordance with the manuals in use by the company. If the earned premium thus computed exceeds the premium previously paid, the insured shall pay the excess to the company; if less, the company shall return to the insured the unearned portion paid by the insured. All pre- miums shall be fully earned whether any workmen's compensation law, or any part thereof, is or shall be declared invalid or unconstitutional. Long Term Policy. If this policy is written for a period longer than � • one year, all the provisions of this policy shall apply separately to each consecutive twelve months period, or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written for each con- secutive period. The earned premium for each such period shall be computed as provided by Condition 1 of this policy, subject, except as otherwise pro- vided in the manuals in use by the company with respect to classifications of operations for which this policy provides a per capita premium basis, to the following provisions: (a) The premium rates for the first consecutive period shall be those stated in the declarations and those applicable for such period in accordance with the manuals in use by the company; (b) The premium bases, classifications of operations, rates, rating plans, premiums and minimum premiums for each such subsequent period shall be those applicable for such period in accordance with the manuals in use by the company. ay Partnership or Joint Venture as Insured. If the insured is a partner- Q- ship or joint venture, such insurance as is afforded by this policy applies to each partner or member thereof as an insured only while he is acting within the scope of his duties as such partner or member. �• Inspection and Audit. The company and any rating authority having jurisdiction by law shall each be permitted but not obligated to inspect at any reasonable time the workplaces, operations, machinery and equipment covered by this policy. Neither the right to make inspections nor the making thereof nor any report thereon shall constitute an undertaking on behalf of or for the benefit of the insured or others, to determine or warrant that such workplaces, operations, machinery or equipment are safe. The company and any rating authority having jurisdiction by law shall each be permitted to examine and audit the insured's payroll records, general ledger, disbursements, vouchers, contracts, tax reports and all other books, documents and records of any and every kind at any reasonable time during the policy period and any extension thereof and within three years after termination of this policy, as far as they show or tend to show or verify the amount of re- muneration or other premium basis, or relate to the subject matter of this insurance. Notice of Injury. When an injury occurs written notice shall be given • by or on behalf of the insured to the company or any of its author- ized agents as soon as practicable. Such notice shall contain particulars suf- ficient to identify the insured and also reasonably obtainable information re- specting the time, place and circumstances of the injury, the names and ad- dresses of the injured and of available witnesses. �• Notice of Claim or Suit. If claim is made or suit or other proceed- ing is brought against the insured, the insured shall immediately for- ward to the company every demand, notice, summons or other process received by him or his representative. • Assistance and Cooperation of the Insured. The insured shall cooperate with the company and, upon the company's request, shall attend hear- ings and trials and shall assist in effecting settlements, securing and giving evidence, obtaining the attendance of witnesses and in the conduct of suits or proceedings. The insured shall not, except at his own cost, voluntarily make any payment, assume any obligation or incur any expense other than for such immediate medical and other services at the time of injury as are required by the workmen's compensation law. (3) Statutory` provisions — Coverage A. The company shall be directly and S. primarily liable to any person entitled to the benefits of the work- men's compensation law under this policy. The obligations of the company may be enforced by such person, or for his benefit by any agency authorized by law, whether against the company alone or jointly with the insured. Bank- ruptcy or insolvency of the insured or of the insured's estate, or any default of the insured, shall not relieve the company of any of its obligations under coverage A. As between the employee and the company, notice or knowledge of the injury on the part of the insured shall be notice or knowledge, as the case may be, on the part of the company; the jurisdiction of the insured, for the purposes of the workmen's compensation law, shall be jurisdiction of the com- pany and the company shall in all things be bound by and subject to the find- ings, judgments, awards, decrees, orders or decisions rendered against the insured in the form and manner provided by such law and within the terms, limitations and provisions of this po icy not inconsistent with such law. All of the provisions of the workmen's compensation law shall be and re- main a part of this policy as fully and completely as if written herein, so far as they apply to compensation and ether benefits provided by this policy and to special taxes, payments into security or other special funds, and assessments required of or levied against compersation insurance carriers under such law. The insured shall reimburse the company for any payments required of the company under the workmen's compensation law, in excess of the benefits regularly provided by such law, solely because of injury to (a) any employee by reason of the serious and wilful misconduct of the insured, or (b) any employee employed by the insured in violation of law with the knowledge or acquiescence of the insured or any executive officer thereof. Nothing herein shall relieve the insured of the obligations imposed upon the insured by the other terms of ths policy. Limits of Liability — Coverage B. The words "damages because of • bodily injury by accident or disease, including death at any time resulting therefrom," in coverage B include damages for care and loss of services and damages for which the insured is liable by reason of suits or claims brought against the insured by others to recover the damages obtained from such others because of such bodily injury sustained by em- ployees of the insured arising out of and in the course of their employ- ment. The limit of liability stated in the declarations for coverage B is the total limit of the company's liability for all damages because of bodily injury by accident, including death at any time resulting therefrom, sustained by one or more employees in any one accident. The limit of liability stated in the declarations for coverage B is the total limit of the company's liability for all damages because of bodily injury by disease, including death at any time resulting therefrom, sustained by one or more employees of the insured in operations in any one state designated in Item 3 of the declarations or in operations necessary or incidental thereto. The inclusion herein of more than one insured shall not operate to increase the limits of the company's liability. 1® Action Against Company— Coverage B. No action shall lie against the company unless, as a condition precedent thereto, the insured shall have fully complied with all the terms of this policy, nor until the amount of the insured's obligation to pay shal have been finally determined either by judgment against the insured after actual trial or by written agreement of the insured, the claimant and the company. Any person or organization or the legal representative thereof who has se- cured such judgment or written agreement shall thereafter be entitled to recover under this policy to the extent of the insurance afforded by this policy. Nothing contained in this policy shall give any person or organization any right to join the company as a co- defendant in any action against the insured to determine the insured's liability. Bankruptcy or insolvency of the insured or of the insured's estate shall not relieve the company of any of its obligations under coverage B. Other Insurance. If the insured has other insurance against a loss covered by this policy, the company shall not be liable to the insured hereunder for a greater proportion of such loss than the amount which would have been payable under this policy, had no such other insurance existed, bears to the sum of said amount 2nd the amounts which would have been payable under each other policy applicable to such loss, had each such policy been the only policy so applicable. 14' Subrogation. In the event o' any payment under this policy, the com- m+• pany shall be subrogated to all rights of recovery therefor of the insured and any person entitled to the benefits of this policy against any person or organization, and the insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The insured shall do nothing after loss to prejudice such rights. 13 . Changes. Notice to any agent or knowledge possessed by any agent or by any other person shall not effect a waiver or a change in any part of this policy or estop the company from asserting any right under the terms of this policy; nor shall the terms of this policy be waived or changed, except by . endorsement issued to form a part of this policy, signed by a duly authorized representative of the company. 14. Assignment. Assignment of interest under this policy shall not bind the company until its consent is endorsed hereon. If, however, dur- ing the policy period the insured shall die, and written notice is given to the company within thirty days after the date of such death, this policy shall cover the insured's legal representative as insured; provided that notice of cancelation addressed to the insured named in the declarations and mailed or delivered, after such death, to the address shown in this policy shall be sufficient notice to effect cancelation of this policy. Cancelation. This policy may be canceled by the insured by surrender 1 - • thereof to the company or any of its authorized agents or by mailing to the company written notice stating when thereafter the cancelation shall be effective. This policy may be canceled by the company by mailing to the insured at the address shown in this policy written notice stating when not less than ten days thereafter such cancelation shall be effective. The mailing of notice as aforesaid shall be sufficient proof of notice. The time of the surrender or the effective date and hour of cancelation stated in the notice shall become the end In Witness whereof, the company has caused this policy to be signed by its president and a secretary at Hartford, Connecticut, and countersigned on the declara- tions page by a duly authorized representative of the company. Secretary of the policy period. Delivery of such written notice either by the insured or by the company shall be equivalent to mailing. If the insured cancels, unless the manuals in use by the company other- wise provide, earned premium shall be (1) computed in accordance with the customary short rate table and procedure and (2) not less than the min- imum premium stated in the declarations. If the company cancels, earned premium shall be computed pro rata. Premium adjustment may be made at the time cancelation is effected and, if not then made, shall be made as soon as practicable after cancelation becomes effective. The company's check or the check of its representative mailed or delivered as aforesaid shall be a sufficient tender of any refund of premium due to the insured. When the insurance under the workmen's compensation law may not be canceled except in accordance with such law, this condition so far as it applies to the insurance under this policy with respect to such law, is amended to conform to such law. 16. Terms of Policy Conformed to Statute — Coverage A. Terms of this policy which are in conflict with the provisions of the workmen's compensation law are hereby amended to conform to such law. 1 7. Declarations. By acceptance of this policy the insured agrees that the statements in the declarations are his agreements and representations, that this policy is issued in reliance upon the truth of such representations and that this policy embodies all agreements existing between himself and the company or any of its agents relating to this insurance. President Form 1. 650 -238A (Rev. 9.1.69) Ed. March 70 Printed in U.S.A. MIAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT APPLICATION FOR BUILDING PERMIT Application is hereby uinde for the approval of the detailed statement or we plans and specifications herewith submitted for the build in or other structure herein described, This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida. and all provisions of the Laws of the State of Florida, all ordinances of Miami Shore Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of the work. Date.. Owner's Name and Address Ge ee k c 6 iv 1 _ No Fto l Street . h ... .._ S. r Registered Architect and /or Engineer ,,,••.,,.. ,,.,,t., Name and address of licensed contractor 0- / 112. tsi, S c t+ z p irZ Location and legal description of lot to be built on: Lot 1G F" 1 7 Block 7 L t . Subdivision • Street and Number where work is to be done. ...fr ' 6 7 G S r ?c . .!' �.._..__ State work to be done and purpose of building (by floors) T° IVY Ui' T t c R•7 /G a, rya L P "R I TFrq/ L-( Ne. Aue ,mot yf• FA i c. y , oe i, �/ _.._. and for no other purpose. New Building Remodeling !' Addition Repairs No. of Stories. To be constructed of Kind of foundation oof overing ....................... ...... ..... -..__ 6 Estimated Total cost of improvements $ 5 ! Gr ' Amount of Permit $,..G '- Zone cubage required Plan Cubage Distance to next nearest building Size of Building Lot Maximum live load to be borne by each floor I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may be sent to. ... The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of Libor under the 'Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Siiplpleiuent, and has complied s itli the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as arc required by the Act. The undersigned agrees to employ only such subcontractors, on work to be performed under this pertnit, as are licensed by Miami Shores Village. Remarks ( Signed STATE OF FLORIDA, t COUNTY.OF DADE. ss. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap- peared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the. of the above described construction,.that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him � s n tate tr'te. � � r 6a � � Permit No �✓✓ O°i ( J Date.. ..Y .� .. '� O Read, Sworn to and Subscribed before me. Disapproved .... t `� " Date Notary Public, State of Florida (Signed) `4r s , . 16ti Building Inspector My Commission Expires PLANNING BOARD DATE Chairman Member Mfcrr,ber Member Member Member Council Approved Date Disapproved Date NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from the I'Linnir,g I:o.rrd. A re inspection fee of 31.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and /or workmanship. MIAMI SHORES VILLAGE BUILDING INSPECTION DEPARTMENT APPLICATION FOR BUILDING PERMIT Application is hereby mode for the approval of the detailed statement ur Inc plans and specifications herewith submitted for the build ing or other structure herein described, This application is made in compliance and conformity with the Building Ordinance of 1`fiarni Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of the work. Date D E C _....___.�'� • __ ....... ,19. /_ M Owner's Name and Address V " ffe g- C G la" /4 .. _. No F f Street A ... S T Registered Architect and /or Engineer :.. . .............,.....,...,,:,,,., Name and address of licensed contactor 1)- ? / 111(4 /12: ' R' // .3.. 3..#! G ' e,t4, 5 ChAoE PEiZ Location and legal description of lot to be built on: Lot t 17 mock 7 ' Subdivision ! / =L /4 . Street and Number where work is to be done... ' ci G 5' T ?c. State work to be done and purpose of building (by floors) T° 11/T dv /'/ffRT.t c /.I:T.l d i--r- .1— P o 0 0 Trill ion vrrv- ... xGe? i- F / Aooill �/ and for no other purpose. Ncw Building Remodeling !' Addition Repairs .... No. of Stories. To be constructed of Kind of foundation oof vering __ � f Estimates Total cost of improvements $ r Gr __ � Amount of Permit S..`IIP Zone cubage required .Plan Cubage Distance to next nearest building Size of Building Lot , Maximum live load to be borne by each floor I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may be sent to.. ... ... . ,... The under igncd applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of Libor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent SiiimIlctuent, and has complied ssith the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as arc required by the Act. The undersigned agrees to employ only such subcontractors, on work to be perfofined under this permit, as are licensed by Miami Shores Village. Remarks __.._.__ (Signed). ✓�� ... , _ .. ti' STATE OF FLORIDA, COUNTY ,OF DADE. ss. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap- peared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the. of ti:e shove described construction,. that he has care read the foregoing application, and that he did sign the same, and that all facts therein by him stated ar e. M P Permit No ■ Date.._ 4 J 1 ^ 4 Read, Sworn to and Subscribed before me. ti Disapproved .._. i ... .. ... Date Notary Public, State of Florida (Signed) Building Inspector My Commission Expires PLANNINC BOARD DATE Chairman . , ... Member Member Member Member Member Council Approved Date Disapproved ,.. Date NOTE: A charge of $1.00 will be made for making corrections or changes to this application after npproval has been obtained from the I'I,r Board. A re inspection fee of $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty materials and /or workmanship.