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PL-09-1999Owner Information Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 363 98 Street Miami Shores, FL 33138- 1132060135640 Block: Lot: PAUL SIMAS PAUL SIMAS 363 98 Street MIAMI SHORES FL 33138 -2409 (786)259 -5258 Contractor(s) SUBURBAN PROPANE Phone 305 -891 -8393 Cell Phone Type of Work: GAS LINE Type of Piping: PLUMBING Additional Info: Bond Retum : Classification: Residential Fees Due CCF Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $0.60 $0.20 $180.00 $3.00 $0.80 $184.60 December 17, 2009 Address Building Department Copy Authorized Signature: Owner / Applicant / Contractor / Agent Phone Valuation: Total Sq Feet: Invoice # Total Amt Paid Amt Due PL -12 -09 -36556 $ 184.60 $ 184.60 $ 0.00 Expiration: 06/07/2010 Cell $ 300.00 0 For Inspections please call: (305)762 -4949 Available Inspections: Inspection Type: Final Press Test ROW 1 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. December 17, 2009 Date 1 Inspection Number: INSP- 130741 Permit Number: PL -12 -09 -1999 Scheduled Inspection Date: July 12, 2010 Inspector: Hernandez, Rafael Owner: SIMAS, PAUL Job Address: 363 NE 98 Street Project: <NONE> Miami Shores, FL 33138- Contractor: SUBURBAN PROPANE Building Department Comments July 09, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 SET TANK AND GAS LINE TO STOVE Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments 701(' For Inspections please call: (305)762 -4949 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Gas Phone Number (786)259 -5258 Parcel Number 1132060135640 Phone: 305 - 891 -8393 Page 4 of 15 DEC 1 7 2009 c Ifi}giefS VILLAGE PERMIT APPLICATION FBC 2004 Permit Type: Plumbing Owner's Name (Fee Simple Titleholder) re-Res/4- g/$77' Phone # 3 Btu" 757' /t'° Owner's Address 363 /V/ 9 7 g City /V/ /97 S it s State 1� Zip 5.3 1i Tenant/Lessee Name Phone # E- MAIL: Job Address (where the work is being done) 3493 N [ q g „GT City Miami Shores Village County Miami -Dade FOLIO / PARCEL # f / — Od a:Q _0/,3- 5-c y0 Is Building Historically Designated YES NO f Contractor's Company Name . 060,6 PSS'd,4= it Contractor's Address ./A ©/G J3 0 6,– City )V j 7, f State / 4. = -7 e— Qualifier Name Spit/pig-Ai "ZI Miami Shores Village' . DEC, 1 o 3 2009 J Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795.2204 Fax: (305) 756.8972 Permit No.1 O_ I I q 9 Master Permit No. Zip ,33/ 3g Phone # g4 75 " --- Zip ; � ' / Phone # 2 dc'" ? 2 r;,-5 State Certificate or Registration No. Certificate of Competency No. E -MAIL: Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ 3D0 — Square / Linear Footage Di Work': Type of Work: Addition ❑Alteration New Repair/Replace molition ❑ � ❑ Demolition Describe Work: 7 yea I i-s I ./47 It) ****** ir* * * * * * * * * * * * * * * * * * * * * ** * *x * * * * ** F * x********* * * ** * * *xxxxx * * * * * * * * * *xxxxxxxxx ame Submittal Fee $ "—! Permit Fee $ CCF $ 0'1120 CO /CC Notary $ Training /Education Fee $ 0 ��'lJ Technology Fee $. 0 Zoning $ Scanning $ 'no Radon $ Bond $ Code Enforcement $ Double Fee $ Structural Review. $ Total Fee Now Due $ 1 84•( DPBR $ See Reverse side —* Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. 1 understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. r Agent Contractor The foregoing instrument was acknowledged before me this a The foregoing instrument was acknowledged before pge this c9 day of , , 20G , by des, S /MAS , day of ,/2f , 200/, by nown to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who • id take . oath. NOTARY PUBLIC: Sign: Print: My Co ****. ..**x* * **** otary Public . State of Florida .1 My Cammtsslon Expires Jun 15, 2411 **, 4„94;,;00* Bonded Through National Notary Assn. F = APPLICATION APPROV (Revised 02/08/06) NOTARY P .` C: Sign: Print: My Commission Plans Examiner Engineer Zoning THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD L INSRt TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE M/ DATE (MDD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A INSURER A: Liberty Mutual Fire Insurance Company GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY - TB2- 631 - 507975 -039 03/01/09 03/01/10 EACH OCCURRENCE $ 2,000,000 $ 250,00 $ 10,00 $ 2,000,000 DAMAGE TO RENTED PREMISES(Ea occurence) --•I CLAIMS MADE X OCCUR MED EXP (Any one person) _ GENERAL. PERSONAL & ADV INJURY GENERAL AGGREGATE $ 2,000,000 AGGREGATE LIMIT APPLIES PER POLICY n JE a n LOC PRODUCTS - COMP /OP AGC $ 2,000,000 A AUTOMOBILE X X X X X LIABILITY 1 ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS AS2- 631 - 507975 -049 03/01/09 03/01/10 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,00C BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per acoklent) $ GARAGE LIABILITY — 1 ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA n —� LIABILITY A EACH OCCURRENCE $ OCCUR I CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ 1 m IM WORKERS COMPENSATION AND EMPLOYERS' ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below WA7 -63D- 507975 -019 (AOS) WC7- 631 - 507975 -029 (OR) 03/01/09 03/01/09 03/01/10 03/01/10 X [AC STATU- OTH- .L EACH ACCIDENT 1,000,000 =.L DISEASE - EA EMPLOYEE $ 1,000,000 =.L DISEASE - POLICY LIMIT $ 1,000,000 OTHER y DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS RE: SUBURBAN PROPANE LIC #01196 ACORD,. CERTIFICATE OF LIABILITY INSURANCE 02/24/2009 02/24/2009 A t REPRESENTATIVE -will. - _ - a _ I �J = of Marsh USA Inc. `,R_f1/4� / "�?° Mary RadaszeWski PRODUCER MARSH USA, INC. 44 WHIPPANY ROAD PO BOX 1966 MORRISTOWN, NJ 07962 Attn: Morristown.Certrequest ©Marsh.com Fax 212 - 948 -0979 -.108990-ALL-CAS-09-10 -_ -- _ .. CLIE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED SUBURBAN PROPANE PARTNERS, L.P. 1 SUBURBAN PLAZA P.O. BOX 206 WHIPPANY, NJ 07981 INSURER A: Liberty Mutual Fire Insurance Company INSURER 0: Liberty Insurance Corporation 42404 INSURER C: INSURER D: INSURER E: --•I MIAMI SHORES VILLACE BLDG DEP. 10050 NE 2nd Ave MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. A t REPRESENTATIVE -will. - _ - a _ I �J = of Marsh USA Inc. `,R_f1/4� / "�?° Mary RadaszeWski COVERAGES CATS HOLDER ACORD 25 (2001/08) CANCELLATION 0 POST LICENSE CONSPICUOUSLY Valid For License Number: 01196 SUBURBAN PROPANE, LP 1491 NE 130TH ST NORTH MIAMI, FL 33161 -4497 • State of Florida Department of Agricuk, 'e and Consumer Services Division ofStandards Bureau of Liquefied Petroleum Gas (850) 921 -8001 Tallahassee, Florida State of Florida Department of Agriculture and Consumer Services Division I Standards Bureau of Liquefied. Petroleum Gas Inspection (850) 921 -8001 Tallahassee, Florida Liquefied Petroleum Gas License SUBURBAN PROPANE, LP 1491 NE 130TH ST NORTH MIAMI, FL 33161 -4497 Certificate No: Exam Date: Issue Date: Expiration Date: Exam: MASTER QUALIFIER CERTIFICATE This Certificate is issued under authority of Section 527.02, Florida Statutes, to: SULLIVAN C. PALERMO JR. CATEGORY I LP GAS DEALER ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSI NESS RENDERS THIS LICENSE INVALID This license is issued under authority of Section 527.02, Florida Statutes, to: H RLES H. BRONS COMMISSIONER OF AGRICULTURE e License Number: Expiration Date: Date of Issue: License Fee: Type and Class: 16037 December 14, 1982 March 22, 2008 March 21, 2011 0601 01196 August 31, 2010 September 1, 2009 $425.00 0601 HARLES H. BRONS COMMISSIONER OF AGRICULTURE 4 • SUBURBAN PROPANE 1. :-'11) of Buslness AL EIVD itTR/INSTALtAr SUBURBAN PROPANE 1491 NE 130 ST N MIAMI FL 33161 DO NOT FORWARD L . E 0 THERSIDE DE S e. k Owe g L/'' 6-s ,-had- Ll/ta gtveie- 1--,0)--A),4c /z, 6.� e -d ,g / 2.J1 Cc4_ >. . A/ 7 10. 1 0 --5 -5`1( Gd c°_ e jr-di - th2 bo4 G"a/y -10 -J 41 I re/ rt° 4A L • • • •• •• • • • • . •••• • • • • • 0• • • • • •• • • •• • • • •• • • •••• • • • •• • • . ••• . • •••• • •• • •••• Suburban Propane 1491 N. E. 130th Street N. Miami, FL 33161 305 - 891-83 Qualifier .lob Address 363 /yG 9 e St Longest Run e Total BTU's ge; cve • • • rvu•v- 6e —e9 MOM 17:47 PAUL S I MAS i e't ,This proparty described as: Lots 70 and 21, Black 41, "?�a71t • 1 ....;..,; - AN AMENDED PLAT OF M1AM1 SHORES SECTION 2.. _ according to the Plat • thereof, as recorded in N0. 1 Plat Book 10, 'Page 70 of the Public Records of r ` !�� 11 2 = n ' Dade County, Florida. I /eon god Boon • n� • • • • ••• • /00.0' • • • ••• • • • • • • ••• • • • • • • • • • • • • •• •• • • • •• •• • • • ••• • • • 9' PoVe/r)e'i,l` /5%kc•y DATE SCALE //-BO -43 ,°•• FO 1 0 fig C s G• 6 1 1 Cv 7.5S ?' ■ 274 h &a 34' NI' 3'4410A' 7' ti • . �•ua• • • 'r • 1 • • • • mum r h e 1 11Mt- F,3,1.11., the �� L �� 144 tho F.B.La. (7mturkol standonk 04104/70n. Tuw•h• •tfdher•ari• tM p� tooth* *mu- • ,I� to FL Rag. Nurysyar No. 224a • • ••• • • • • • • • •• • -Step; • neyt ..s ro 46 /!1.15' 276 $' :.. ra ' a u d 33.50: aa•• _. t1 / • •• • LANNES and GARCIA, INC. ENGINEERS • LAND SURVEYORS . LAND PLANNERS P. 0. .Pox $61131 bllaott, Florida 33 t SS PRAWN ov ar.tleif DRWG. NO tA�t sO' . -5•: a' acs "�� 554„ N.E. 9B 1" t=/7fiser .. .eQC.4rioti e c. •/y mi; Po Ppana iC7�'GV ^Ji,t.' - •r 4 ti 55 Ann Ape - J wn , �z-- _ N. E 9e .5reEE_T Ed. f rv‘ PROPERTY OF: Black, 36 E �� •9h.5tr'eet., Miarta Shores, Florida.