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CC-09-8481 4040 Loww-L_. BUILDING PERMIT APPLICATIO FBC 2004 Miami Shores Village Building Department t0050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Permit No. t 0 9 aster Permit No. Permit Type (circle): Building ' oofing Owner's Name (Fee Simple Titleholder) i G. „y , to i t J V i Lik Phone # -1- 13 IX , Owner's Address a't5 520 N. <. PC -0 elk< State V" ` , Zip Tenant/Lessee Name`Pr iscNs ° ten c� �, M� ,, l �,_, -� Phone # , 5 .7 -15— - 74 3 -- 45-ea Job Address (where the work is being done) I DOC 0 '3 bcaf fl C. City Miami Shores Village County Miami -Dade Zip 33 FOLIO / PARCEL # d " 30 45 ® " 00 0 Is Building Historically Designated YES NO Contractor's C o m p a n y Name 5 C ] r) GtI ■ r'1 DU' •-i-f1 C, Phone # -505 a 195 3 ° i' t 0 i Contractor's Address Oa 3b ,--,G0 134 Ave nu c Cit '+"bane. 'Qci State `PI Zip // 55toa Qualifier Name IGi o C� r l 5 . &1 t CJ 1 e e d Phone #� ) OiS' - 1® State Certificate or Registration No. P 0 5 co S I 0 Certificate of Competency No. 5e 1 r. � y Architect/Engineer's Name (if applicable) �%� Phone # 2,3° Value of Work For this Permit $ /. c' a` e Type of Work: DAddition ❑Alteration ❑New ❑ Repair/Replace ❑ Demolition Describe Work: Submittal Fee $ Notary $ Scanning $ * * *, ** * ** * *** ** * * * * ******** ********F - del Permit Fee $ 0 CCF $ '00 CO /CC Training/Education Fee $ 3 `00 Technology Fee $ l i Radon $ Square / Linear Footage Of Work: /46 e DPBR $ Zoning $ Bond $ Code Enforcement $ Double Fee $ r� ^ Structural Review. $ Total Fee Now Due $ 4' )' 2 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. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDmONERS, 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 io t be approved and a reinspection fee will be charged. Signature NOTARY PUBLIC: Owner or Agent The foregoing instrument was acknowledged before me this O l day of 20ttJDI,by R\\ -*0-0 QO ZZ •' who is personally known to me or who has produced As ide � an3w I. ,,! MY , • • SION I DD 666487 Ek,'. :,: May • 11, 2011 ,• edrnn, ny u ,wydem Sign: 4 \....1k . 1, (4 Qle) Print: e.0 01 (1 s , CY A 0. APPLICATION APPRO (Revised 07/10/07) 1 My Commission Expires: \NA \ )1- 0 *** **** rat* •,x**** ***,r•x***** * ** • _* * **** Signa Con r actor The foregoing instrument was acknowledged before me this IB day of M , 20 CR, by /ti� l* LVtha Sign: Print: / I 'e i t"3 " /0 -J-cy who is ersonally known to me or who has produced LK , s 1(OD as identification and who di NOTARY PUBLIC: My Commission Exp ******************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Engineer INSTALL FUEL TANK Passed / Inspector Comments CREATED AS REINSPECTION FOR INSP- 141658. CREATED AS REINSPECTION FOR INSP- 134802. CREATED AS REINSPECTION FOR INSP- 114720. A fire final and electrical permit are required. NB NO PERMIT NO PLANS AT SITE NB Same comments NB l Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until Inspection Date: November 23, 2010 Inspector: Bruhn, Norman Owner: VILLAGE, MIAMI SHORES Job Address: 10000 BISCAYNE Boulevard Miami Shores, FL Project: <NONE> Contractor: BRANCHING OUT INC Building Department Comments November 23, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 147091 Permit Number: CC -5 -09 -848 j For Inspections please call: (305)762 -4949 Permit Type: Commercial Construction Inspection Type: Final Building Work Classification: New Phone Number 10 5 rY Parcel Number 1132050200010 Phone: (305)258 -8101 Page 1 of 1 ' MI�DADE MUNICIPAL INSPECTION REQU I REMENTS AND RECORD 09/17/2009 MUNICIPAL .NO. 2009. 055830 PROCESS NO M2009006441 FOLIO: 1132050200010 JOB SITE ADDRESS 10000 BISCAYNE BLV PROPOSED USE CABANA /CHICKEE /GAS � ± *t� V8 /REC /ABOVE TANK REQUIRED INSPECTIONS F I RE,- 0009° FIRE-- AM:VE /BELO 209 FIFE FINA MIAMI -DADE COUNTY &-211- /t) Inspection Number: INSP - 134739 Scheduled Inspection Date: February 16, 2010 Inspector: Devaney, Michael Owner: VILLAGE, MIAMI SHORES Job Address: 10000 BISCAYNE Boulevard Project <NONE> Contractor: BRANCHING OUT INC Building Department Comments February 12, 2010 Miami Shores, FL Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -4949 Permit Number: ELC -2 -10 -170 Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1132050200010 Phone: (305)258 -8101 INSTALL 2 FUEL DISPENSORS Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments s/- (6/ L°5 Page 16 of 25 (x.\\Q,J‘t/ BUILDING PERMIT APPLICATION FBC 20 Permit Type: ELECTRICAL Owner's Name (Fee Simple Titleholder) 1■il t Rath t Ste r2 V . ((Phone # 7Y' Owner's Address C X J C ' '. a City }J Jas A . t ,�.9Mc_ State L Tenant/Lessee Name Phone # Email Job Address (where the work is being done) \ fJ]C- City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL # Is Building Historically Designated YES Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305). 762.4949 NO Contractor's Company Name i' 4,7 0 4 , 7, - r� Contractor's Address 2 3 3 c.-.) City $ ?/ '1/' / e. r 3 State �C t.." 7�/ Certificate of Competency No. Contpcl Phone ,3501 ' 3, ; /3 Qualifier Name State Certificate or Registration No. Value of Work For this Permit $ Submittal Fee $ E -mail Type of Work: ❑Addition " tAlterption 1:- +New ❑ Repair/Replace Describe Work: 5,�i�1/ (2-) Notary $ Scanning $ 3.00 Radon $ DPBR $ Double Fee $ Training /Education Fee $ =�..� s ue- ******** * * * * * * ** * * * * * * * * * * * * * * ** * * ** * ** F * * * *, * * * * * * * * * * * * * ** * * * * * * ** Permit Fee $ �� .00 CCF $ O ' Violation date: Phone # Zip Phone # S e are / Linear Footage Of Work: 7 'Z- Bond $ Structural Review. $ Total Fee Now Due $ 1S'4'(00 See Reverse side r asnwsD Permit No. fflC' Master Per it No CS q -- a-cw Zip Flood Zone e5g 34S '413 Architect /Engineer's Name (if applicable) 5" - / YS Phone # J f ^ 2.r — g ( C/ ❑ Demolition CO / CC $ Technology Fee $ D. Bonding Company's Name (if applicable) Bonding Company's Address City Mortgage Lender's Name (if applicable) Mortgage Lender's Address City Signature Signature Owner or Agent The foregoing instrument was acknowledged before me this The f day of , 20 , by , day of who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: ld 4 Plans Examiner APPROVED, BY (Revised 07 /10 /07)(Revised 06/10/2009) State State Zip Engineer OT ; Y PUBLIC: Sign: Print: My Commission Expires: 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. I 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 proptrty 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 re- inspection fee will be charged. g instrument was acknow . edged before by ersonall know to e or who has produce ication and who did take an oath. Zoning Clerk checked INDICATED. NOTWITH8TANCI NG ERTIFICATE MAY BE ISSUED OR IONS AND CONDITIONS OF Sul ;H LIMIT:; EACH OCCURRENCE ^ PIRG DAMAGE (Any Onn Fern) S 9 MED ExP (Any onn parson) ^ $ PERSONAL & AOV INJURY GENERAL AGGREGATE S PRODUCTS • COMP/OP AGG p COMBINED SINGLE LIMIT ^' (Ez ooddnnI) BODILY INJURY ^~ (Par peYbon) 3001LY INIIRY 10/22/2009 12:14 3052583812 =VA CERTIFICATE OF LIABILITY INSURANCE PRODUCER Ili:ghpoint Risk Services LLC 14/60 Dallas Parkway #500 Dallas, TX 75254 (800) 632 -5096 (972) 715-0959 Wax: (972) 404 -4450 INSURED: AM$ 1/c/f1 BRANCHING OUT, J NC . 23300 SN 131 /'VS. NOMESTF1AD, FT 33032 (305) 25 810.1 FIX: (305) 258 - 3812 rnVF RAGES THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ASOvE FOR THE POLICY PERIOD ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS C MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES bESCRIBED HEREIN t8 SUBJECT TO ALL THE TERMS, EXCLU POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INFR ,1 Trz TYPE OF INSURANCE. POLICY NUMBER nA'Cp fMMfnom>, nnTF tMrorrnnmp PaL1CY EFFECTIVE POLICY EXPIRATIOI GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE El OCCUR OEN'L AGGREGATE LIMIT APPLIES PER; — 1 POLICY r p F e L � Loc AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUToa SCHEouI„ED AUTOS HIRED AUTO3 NON -OWNED AUTOG GARAGE LIABILITY R ANY AUTO EXCESS LIABILITY OCCUR CLAIMS MADE OTHER DEDUCTIBLE RETENTION 9 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY MIAMI SHORE VILLAGE ATTN: BUILDING DEPT. C 305 ^795-2204 F 305 - .7525253 10050 NE 2nd AVE, MIAMI SHORES, FL 33123 ACORD 25 -S (7/97) WE CERTIFICATE HOLDEB 1 1 ADDITIONAL INSURED; INSURER LETTER; BRANCHING OUT INC I CERTIFICATE NO. r DATE, h.009- 7600243- 7A2055 <0.4/2009 9:44;22AM THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TIIE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Al TFILT COW RAPT AFFIZIPf1FQ$Y THE P.QJJ INSURER A; Cmmr pirr - , INSURER B: INSURER C: INSURER D: INSURER E: OA /01/2009 INSURERS AFFORDING COVERAGE 09 /0) /2010 rtv And Cas Ue.L hv,,,,j PAGE 08/09 AGGREGATE LIMITS LIMITS PROPERTY DAMAGE (Por occkMnl) OTHER THAN AUTO ONLY: EACH OCCURRENCE AUTO ONLY • EA ACCIDENT 5A ACC AGG .A 1�Yf5 E EACH ACCIDENT EL DISEASE - EA EMPLOYEE C.L. DISEAsp, • POLICY LIMIT AUTHORIZED REPRESENTATIVE ^ 1. This Certificate r.Cmains in effect, provided the clicnt'3 account I,c in good standing with ANS. COvor:Ige ls not provided for any employer for which 1•pIr client is not repporti,nq wages to AMS. Applies to 100% of the emppl.oyoos of AM9 leased to BRANCHING OUT, INC. t /;Eoctive 04 /01/2009. 2. Project Information:_ MIAMI, SHORES COUNTRY C(tJ)3 10000 E..T0CAYNE BLVD MIAMI SHORES F'1,. 3. Insured Ls afforded Workers' Componsat.Lon & Employer's Liability an , co- employer under the policy for AMS staff L000inq, ** *PLEASE SffiE ATTACHED EMPLOYEE ROSTER, * ** 10000uu p 1000000 1000000 CANCELLATION SHOULD ANY OP THE ABOVE DESCRIBED POLICIES DE CANCELLED 3EPSRE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENbEAVOR To MAIL 9) DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO bo SO SHALL IMPOSE NO OBLIGATION OR LIAB'4TY OF ANY KIND UPON THE INSURISR, ITS AGENTS DR REPREEIENTATIVE3. ACORD CORPORATION 1988 10/22/2009 12:14 3052583812 /14. f.ANCL. , PRODUCER (305) 247 -5121 2' X: (305) 2488543 T . P, . ,Zones & Corapa.:Ay 1780 N Krome Av n.011198 tea.c1 INSURto B.anchitxg Out , Inc , 23300 S .W. 134th Avenue ]?rincet -n COVERAGES 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 SYTHE POLICIES DESCRIBED HEREIN 15 SUJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD L POLICY EFFECTIVE POLICY EXPIRATION _LTCL_ _ TYPE OF 1Nen lAIrr POLICY NUMBE}Z j IMMlbotYYYY1 DATE1 /YYYYI GENERAL LIABILrre X COMMERCIAL GENERAL LIABILITY CLAIMS MADE I X l OCCUR ENV022201- 08 -0a CERTIFICATE HOLDER ACORD 26 (2009/04) INS025 (2C0P01) F 33030 FL 33032 GEN'L AGGREGATE LIMIT APPLIES PER: x POLICY PRO LOC AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS GARAGE LIABILITY H ANY AUTO EXCESS / UMBRELLA LIABILITY OCCUR CLAIMC MADE DEDUCTIBLE S RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER /MEMBER EXCLU0 07 I , (Mandatory In NN) If a dFmorl ;e under SPECIAL PROVISIONS bdcw OTHER. Mfatil 5140REs VILLAGE AFZ't: , DUi ;,DING DEPT, P 205- 7 95 -220d F 308 -755 -,5253 ";0050 NZ 2nd AVE. e* MZANii:;SHORiES, FL 93138 CERTIFICATE OF LIABILITY INSURANCE 10,00D 0 489391E0 ED7C7021282 -D8 -01 BRANCHING OUT INC PAGE 09/09 DATE (MMJIJII) • , }J 6/24/2009 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 E3Y THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER A: American Safety Iz deinrj &ty INSURERB: A 11 s tate Insurance CC ;t.E:)any INSURER C; INSURER D: INSURER F. 7.2/1/2008 6/27/2009 12/1/2008 CANCELLATION 12/1/2009 12/1/2009 12/1 /2009 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLLMONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS ❑e. ta.fioate holdox £e named ,A4di,tiona,1 Insured as sespeats to G4ar,5aa1 Ii?yoilJty. *20 days aot,ice of OancoZJ,ata.on no paymsnt o prC_a)ium DAMAGE TO EACH OCCURRE;I I:F S 1 000 OOC 1KEIIY 1 1BE RISES (Em w.oirrence 5 50 , 000 MED EXP (Any ono •oreon) a 5 . OOC PERSONAL S. AOV INJURY $ 1 000 000 GENERALAGGRE:I3ATE $ 2,000,000 PRODUCTS • COMP /OPAGG S 2 000 000 COMBINED SINGLE LIMIT (Es accidant) BODILY INJURY (Par person) PODILY INJURY (Per modelent) PROPERTY DAMAGE (Par aeC1d iit) AUTO ONLY • EA ACCIDENT OTHER THAN ALTO ONLY: EACH ocCURREEN,T AGGREGATE LIMITS WC &TATU- OTH- TaRY.IJMgIS 1 — E,L. EACH ACOIDEN' R E.L. DISEASE - EA Eil' APLOYEE $ E DISEASE - PoL CY LIMIT 5 Fes, ACC AGG 5 5 $ S 5 5 S 5 N �! 19232 1,000,000 3,000 000 5 5 000 0001 SHOULD ANY OP THE AEOVE DESCRIBED POLICIES BE CANG.: =LLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR - 0 MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED To THE LEFT, BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, I15 AGENTS OR REPRESENTATIVES, AUTHORIZED REPREBENTATIV& T Jones Jr. /JEASAN EO 1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Scheduled Inspection Date: January 12, 2010 Inspector: Levrock, James Owner: VILLAGE, MIAMI SHORES Job Address: 10000 BISCAYNE Boulevard Miami Shores, FL Project: <NONE> Building Department Comments January 11, 2010 Contractor: BRANCHING OUT INC ..Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 126711 Permit Number: PLC -10 -09 -1659 For Inspections please call: (305)762 -4949 CC-5.O�t- 8 4$ L Permit Type: Plumbing - Commercial Inspection Type: Final Work Classification: Gas Phone Number Parcel Number 1132050200010 Phone: (305)258 -8101 Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. ments OR: GAS TANK ABOVE GROUND. INSTALL FUEL TANK AT GOLF' OURSE MAINTANCE BUILDING AT CLUB DR. NORTH OF 100. Page 6 of 23 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING Owner's Name (Fee Simple Titleholder) 1 ! "` ra._�a �� t < �✓ r ` 'z- Phone # Owner's Address 100 'a City Tenant/Lessee Name M Email Job Address (where the work is being done) , / :'' c' c 6. i /w '` City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL # Is Building Historically Designated Contractor's Address City ..)'.,` T rf* f Qualifier Name Contact Phone t" Submittal Fee $ Structural Review. $ 0 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permit No. 009 - 1(Q 59 Master Permit No.CteR — �'40 State _.. Zip 1 ;�•; t ( , n / c' Phone# s -� �/ -7 36 YES NO Contractor's Company Name j��y °v a Permit Fee4 ec 1 Di E -mail Double Fee $ Violation date: c' State r ' Zip Phone # State Certificate or Registration No. �� `� �' Certificate of Competency No. Architect/Engineer's Name (if applicable) `� f� r " Phone # (2' Phone # _` .c, a Z �' Value of Work For this Permit $ 7Q00 Square / Linear Footage Of Work: /60..) Type of Work: ❑Addition ❑Alteration ['New ❑ Repair /Replace ❑ Demolition Describe Work: /de ( * * * * * * * * * * * * * * * * * * * * * * * * * *1r *******F CCF $ Notary $ Training /Education Fee $ \ • 40 Scanning $ 3.00 Radon $ DPBR $ Bond $ Total Fee Now Due $ Flood Zone C /C C $ Technology Fee $ S. • 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. I 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. Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of , 20 , by day of , 20 , by who is personally known 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 did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Print: My Commission Expires: APPROVED BY (Revised 07 /10 /07)(Revised 06/10/2009) Sign: Print: My Commission Expires: * * * * * * * * * * * * * * * * * ** ** ** *, * *: ***************************************** * * * * * * * * * * * * * ** ** * * * * * * * * * * * * ** lans Examiner Zoning Engineer Clerk checked MIAMI COUNTY PLAN REVIEW AND DEVELOPMENT APPROVALS DIVISION ENGINEERING SECTION AST SYSTEM INSTALLATION PLAN APPROVAL CONDITIONS Date: September 11, 2009 PC#: M2009006441 Facility: Miami Shores Country Club Address: 1000 Biscayne Boulevard Approval is hereby granted for: Miami Shores County Club 1000 Biscayne Boulevard , Miami Shores Page 1 of 2 Folio #: 11- 3205 - 020 -0010 UT #/ File# to be assigned • Installation of one (1) compartmental 500/500 gallons aboveground double walled FDEP approved storage tank, Convault (FDEP approved) for diesel and gasoline fuels for fueling. All piping shall be above ground with UL listed Fill Rite dispensers with location as shown on plans. • The tank shall be set on a concrete slab, properly anchored and equipped with two (2) 7- gallon containment boxes at the each fill ports, a mechanical fill limiter valve for overflow to be set at 90% high fuel level for overfill prevention and an mechanical Krueger leak detection gauge for tank interstitial monitoring to be utilized for the system as proposed. • The above ground storage tank will be located on a concrete slab with bollard system for protection of the tank for vehicle traffic to be located as shown on plans. • A vent riser constructed of schedule 40 galvanized steel with mush room vent to be located at least (10) feet from any air intake systems. • All proposed equipment to be FDEP approved, as proposed. • Fueling slab of 12 feet X 6 feet X 6 inches deep of concrete design with wire mesh for strength and with location as shown on plans • Operations shall be conducted without allowing any discharges to open ground or storm - sewer system. The following conditions are hereby incorporated as part of the AST System Installation Plan Approval and shall supersede the scope of work proposed in the approved plans if discrepancies exist. Additional approval may be required from other DERM sections, the local fire department and other governmental agencies having jurisdiction over the facility and /or scope of work. POLIO POLLUTI! ENwRONR MI11JECT IC Vam 1. This approval shall be valid for one year from the approval date; however, plans must be implemented in accordance with any regulatory timeframes. 2. All work, including all applicable safety requirements, must be performed in accordance with the approved plans, applicable requirements of Chapter 24 of the Miami -Dade County Code, Chapter 62 -762 of the Florida Administrative Code (FAC), United States Occupational Safety and Health Administration (OSHA), and National Fire Prevention Association (NFPA) Standard #30. 3. An inspection of Aboveground Tank Systems greater that 550 gallons must be conducted upon completion of installation. The DERM Storage Tank Program Inspection Coordinator shall be contacted at (305) 372 -6600 two (2) business days in advance of the desired inspection date. cc: Horatio Wong Miami Shores County Club 1000 Biscayne Boulevard , Miami Shores Page 2 of 2 Existing Railroad Tracks Gate ew Fuel Tank See Detail pg 2 Site Plan Scope of Work: 1. Install (1) new 500 Gallon gas /500 gallon diesel ConVault Fuel Tank 2. Install (2) Fil!rite FR 702 Dispensers 3. Install Placards per NFPA 1, 30 & 30A 4. All Petroleum equipment to be FDEP Approved PAVED PARKING / Existing Maintenance Stora;e Building TON CONTROL DIVISION 'R REMEDIAT QNS CTION '!'NTAL REVIEW APPROVAL THE ATTACHED CONDITIONS IV: DATE: / Miami Shores Country Club 10000 Biscayne Boulevard Miami Shores, Florida 33138 Folio # 11- 3205 -020 -0010 Mike Burchell PCC 056810. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 Steven Hurst P.E. 16278 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 Golf Course Fairway - ------- • .. TENNIS COURTS Branching Out, Inc. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 • • • • •••• • • • • •• . .... • .. •• • • • • •••• • • • • . . • • • • .. .. .. • • • • • •• •• • • • •• • • • • • .. • Page 1 of 4 TANK LEAK DETECTOR TUBE FLOAT 2" Vent Terminated 12 ft above grade with vent cap 11'3" KRUEGER LEAK DETECTOR GAUGE TYPICAL LEAK DETECTOR INSTALLATION 4" fill w/ 7 gallon U.L. listed spill containment U.L. 2085 FDEP EQ 201 500/500 GALLON SPLIT TANK (inner tank) Secondary Emergency Vent Primary Emergencey Vent • Krueger leak detector • A 5'6" Kruger Level Gaug Secondary EQ #739 Emergency Primary Vent Emergency Ven FR 702 UL listed Breaka : y FR 702 UL Listed Dispenser � Dispenser TYPICAL TANK INSTRUMENTATION & VENTS Not to Scale Miami Shores Country Club 10000 Biscayne Boulevard Miami Shores, Florida 33138 Folio # 11- 3205 -020 -0010 OUTER TANK INNER TANK FLAMABLE NO SMOKING GASOLINE Krueger leak detector • 4" fill w/ 7 gallon U.L. listed spill containment Mike urchell PCC 056810. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 TIE DOWN DETAIL Tank fill connection Drop Steven Hurst P.E. 16278 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 INTERNAL OVERSPILL CONTAINMENT "WIRE ROPE OGGLE BOLTS • • • • • •• • • • •••• • • •• •• • • • • • • • • • • •• • Branching Out, Inc. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 Tank wall • • • •• • ••• • • • •• • • • • • •• • • • • • • •••• • • • •• • • • •••• EKED '.y FIRE D. WENT . PERPAO ®ON -S6 T E E SIO y Page 2OF4 Float � Float 1 Float No Smoking Flammable 1203 Gas U Automatic Shut nozzle No Smoking Flammable 1999 off Diesel E■ TANK LEAK DETECTOR TUBE FLOAT 2" Vent Terminated 12 ft above grade with vent cap 11'3" KRUEGER LEAK DETECTOR GAUGE TYPICAL LEAK DETECTOR INSTALLATION 4" fill w/ 7 gallon U.L. listed spill containment U.L. 2085 FDEP EQ 201 500/500 GALLON SPLIT TANK (inner tank) Secondary Emergency Vent Primary Emergencey Vent • Krueger leak detector • A 5'6" Kruger Level Gaug Secondary EQ #739 Emergency Primary Vent Emergency Ven FR 702 UL listed Breaka : y FR 702 UL Listed Dispenser � Dispenser TYPICAL TANK INSTRUMENTATION & VENTS Not to Scale Miami Shores Country Club 10000 Biscayne Boulevard Miami Shores, Florida 33138 Folio # 11- 3205 -020 -0010 OUTER TANK INNER TANK FLAMABLE NO SMOKING GASOLINE Krueger leak detector • 4" fill w/ 7 gallon U.L. listed spill containment Mike urchell PCC 056810. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 TIE DOWN DETAIL Tank fill connection Drop Steven Hurst P.E. 16278 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 INTERNAL OVERSPILL CONTAINMENT "WIRE ROPE OGGLE BOLTS • • • • • •• • • • •••• • • •• •• • • • • • • • • • • •• • Branching Out, Inc. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 Tank wall • • • •• • ••• • • • •• • • • • • •• • • • • • • •••• • • • •• • • • •••• EKED '.y FIRE D. WENT . PERPAO ®ON -S6 T E E SIO y Page 2OF4 girt' ••• • • • 000 • • • •• •• • • • •• •• • • • • • • • • • • • • • ••• • • • • • • • • • • • ••• • • • • ••• • • • • • • ••• • • • • • • • •• • a • • • • •• • • •• • • • • • • l • • • • • • • • s • •• • • ••• • • •• • •• • • • •• • • • • • • • • • •• ••• • • • • • 00 TANK LEAK DETECTOR TUBE FLOAT 2" Vent Terminated 12 ft above grade with vent cap 4" fill w/ 7 gallon U.L. listed spill containment KRUEGER LEAK DETECTOR GAUGE TYPICAL LEAK DETECTOR INSTALLATION Krueger leak Kruger detector Level Gauge Primary EQ #739 Emergencey Vent Secondary Emergency Vent 11'3" U.L. 2085 FDEP EQ 201 500/500 GALLON SPLIT TANK (inner tank) 5'6" • OUTER TANK INNER TANK Kruger Level Gaug Secondary EQ #739 Emergency Primary Vent Emergency FR 702 UL Listed Ven Breaka : y FR 702 UL Listed Dispenser � Dispenser Krueger leak detector • 4" fill w/ 7 gallon U.L. listed spill containment TYPICAL TANK INSTRUMENTATION & VENTS Not to Scale Miami Shores Country Club 10000 Biscayne Boulevard Miami Shores, Florida 33138 Folio # 11- 3205 -020 -0010 FLAMABLE NO SMOKING GASOLINE 1/2 u //T Mike Bu hell PCC 056810. 23300 S. W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 TIE DOWN DETAIL Tank fill connection Drop Tu be Steven Hurst P.E. 16278 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 " WIRE ROPE TOGGLE BOLTS F POLLUTION CONTROL DIVISION 'OLLUTIC+8 REMEDIATKN SECTION ENVIRONMENTAL REVIEW APPROVAL VaJECT TO THE ATTACHED CONDITIONS Y y4 i APPROVES BY: -- cpm DATE D BY: 6ATE: ,__�,.. INTERNAL OVERSPILL CONTAI NMENT 1/2/ Branching Out, Inc. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 Tank wall Page 2 OF 4 \ Float Float Float No Smoking Flammable 1203 Gas Automatic Shut nozzle No Smoking Flammable 1999 off Diesel \ f-4 \ TANK LEAK DETECTOR TUBE FLOAT 2" Vent Terminated 12 ft above grade with vent cap 4" fill w/ 7 gallon U.L. listed spill containment KRUEGER LEAK DETECTOR GAUGE TYPICAL LEAK DETECTOR INSTALLATION Krueger leak Kruger detector Level Gauge Primary EQ #739 Emergencey Vent Secondary Emergency Vent 11'3" U.L. 2085 FDEP EQ 201 500/500 GALLON SPLIT TANK (inner tank) 5'6" • OUTER TANK INNER TANK Kruger Level Gaug Secondary EQ #739 Emergency Primary Vent Emergency FR 702 UL Listed Ven Breaka : y FR 702 UL Listed Dispenser � Dispenser Krueger leak detector • 4" fill w/ 7 gallon U.L. listed spill containment TYPICAL TANK INSTRUMENTATION & VENTS Not to Scale Miami Shores Country Club 10000 Biscayne Boulevard Miami Shores, Florida 33138 Folio # 11- 3205 -020 -0010 FLAMABLE NO SMOKING GASOLINE 1/2 u //T Mike Bu hell PCC 056810. 23300 S. W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 TIE DOWN DETAIL Tank fill connection Drop Tu be Steven Hurst P.E. 16278 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 " WIRE ROPE TOGGLE BOLTS F POLLUTION CONTROL DIVISION 'OLLUTIC+8 REMEDIATKN SECTION ENVIRONMENTAL REVIEW APPROVAL VaJECT TO THE ATTACHED CONDITIONS Y y4 i APPROVES BY: -- cpm DATE D BY: 6ATE: ,__�,.. INTERNAL OVERSPILL CONTAI NMENT 1/2/ Branching Out, Inc. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 Tank wall Page 2 OF 4 6' -O" 6' -O" k Fueling Slab 12'x6'x6 "deep 1 r T r r r J I 1 T PLAN VIEW 8" T #5 BARS @ 12" CTRS. EACH WAY 1 2'-O" 12' - 0" SECTION NEW FUEL TANK SLAB SCALE: NONE 1000 Gallon ConVault Fuel Tank Mike Bu II Miami Shores Country Club PCC 056810. 10000 Biscayne Bourievard 23300 S.W. 134 Ave. Miami Shores, Florida 33138 Homestead, FL 33032 Folio # 11- 3205 -020 -0010 (305) 258 -8101 FOLI;5 d4a LIFE tIgli rt EA UP 5 L.1 EB - ` 4 "''UPANCY: Steven Hurst P.E. 16278 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 SUBMITTED BY: Branching Out, Inc. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 #5 BARS 12" C • EACH V41A •• • • ••• • • • •• • • • •••• • • • • •• • • • • • • •• • •• •• • •• • • • • • • • •• • W.W.F • • • •• • •• •• • POLLUTION CONTROL DIVISION POLLUTION REMEDIATION SECTION ENVIRONMENTAL REVIEW APPROVAL ISJECT TO THE ATTACHED CONDITIONS PIAN APPROVED BY: Ti DATE: INSPECTED BY: DATE: PAGE 3 OF 4 SLAB DETAILS / o o Fillrite FR 702 0 Dispenser (Diesel) 0 \ 4" Dia. X 6' Long Steel bollards filled with concrete to be located in field 0 " 4$ O.C. o Fillrite FR 702 Dispenser (gasoline) o 0 \ O O 4" FILL %NTH 7 GALLON O INTERNAL OVERFILL CONTAINMENT 2" NIPPLE 2" LEAK DETECTOR TUBE o 6" E- vent r' NIPPLE 4" NIPPLE d 6" E- vent 22" tl NIPPLE 2" LEAK DETECTOR TUBE O 4" FILL WITH 7 GALLON INTERNAL OVERFILL o O CONTAINMENT o 0 Cs I o \ / 6' -O" 6' -O" k Fueling Slab 12'x6'x6 "deep 1 r T r r r J I 1 T PLAN VIEW 8" T #5 BARS @ 12" CTRS. EACH WAY 1 2'-O" 12' - 0" SECTION NEW FUEL TANK SLAB SCALE: NONE 1000 Gallon ConVault Fuel Tank Mike Bu II Miami Shores Country Club PCC 056810. 10000 Biscayne Bourievard 23300 S.W. 134 Ave. Miami Shores, Florida 33138 Homestead, FL 33032 Folio # 11- 3205 -020 -0010 (305) 258 -8101 FOLI;5 d4a LIFE tIgli rt EA UP 5 L.1 EB - ` 4 "''UPANCY: Steven Hurst P.E. 16278 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 SUBMITTED BY: Branching Out, Inc. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 #5 BARS 12" C • EACH V41A •• • • ••• • • • •• • • • •••• • • • • •• • • • • • • •• • •• •• • •• • • • • • • • •• • W.W.F • • • •• • •• •• • POLLUTION CONTROL DIVISION POLLUTION REMEDIATION SECTION ENVIRONMENTAL REVIEW APPROVAL ISJECT TO THE ATTACHED CONDITIONS PIAN APPROVED BY: Ti DATE: INSPECTED BY: DATE: PAGE 3 OF 4 SLAB DETAILS ELECTRICAL SCOPE OF WORK 1) Use existing 200 amp single phase 220 volt panel, mounted inside building wall with spare breakers. 2) Use spare breakers #3 and #5. The new load will be two 3/4 HP pumps, total new load 1606 watts. 3) Fumish and install two new branch circuits complete with emergency shut off. 4) Install (2) 5/8" x 10' copper clad ground rods 6' apart, to tank grounding lug with #6 THVIN as required. 5) All electrical equipment shall be UL listed. 6) All electrical work shall be as per NFPA 70 article 5 and NFPA 30 & 30A as required. / Install Emergency Stop Switch more than 20' but Tess than 100' from dispenser Existing Maintenance Storage Building Electrical Details Seal Offs Explosion Proof Junction Box EXISTING LOAD Total Existing Load 0Watts Fuel Tank Area Gas Pump Diesel Pump 0 Miami Shores Country Club 10000 Biscayne Boulevard Miami Shores, Florida 33138 Folio # 11- 3205 -020 -0010 Riser Diagram Mik Burchell PCC 056810. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 NEW LOAD New Load (2) Dispenser /pumps 1606 watts Total New Load = 1606 Watts Emergency stop switch greater than 0' Tess than 100' from dispenser per NFPA 30 (1) 3/4" conduit for power with (4) #12 THHN and (1) #12 gm '-.4 Existing Maintenance/ Storage buirtliig • • ; •; 5 7/49 Steven Hurst P.E. 16278 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 DA I . 'ills E a !N T E Branching Out, Ins. 23300 S.W. 134 Ave. Homestead, FL 33032 (305) 258 -8101 Bean 200 amp a2 ! 0 sirJQ.;. PM& Panel with 4gaare chilli • • • • IATIOTION • • • L REVIEW 11PPROV& • • • JACKED CONRITIORS • PM EMOIMOsa Pool®9 F'J •••• •• • Page 4 of 4 ON -SITE • • • • • • • • • • • • • • • ,Pe- �'�l'i'� �'ht. ��3 � � y U �L � /!E • • • • • • •• • • .••. • • • • • • • • ••• • • •• • •• • • • • • • • • • • • • • • •••• • • •••• • •• • • • • •• • •••• •• • • • • •••. • •••••• •• •• • • • • • • • • • • • •• .0630 %o'f7 MIAMI DADE FIRE RESCIJI♦✓ Not Arpl ea.'b! I sapp "THIS IS NOT A PERMIT. MUNICIPAL INSPECT+' RECORD CARD AT Th.. { a , VIEW s FMAL ..� OVAL ',EPA ;.. s'#W`►,;NT ENVIRONMENTAL RESOURCES CORE REVIEWER (PtttNly SIGNATURE