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PL-09-1783Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 128134 Permit Number: PL -10 -09 -1783 Scheduled Inspection Date: November 19, 2009 Inspector: Levrock, James Owner: MAYER, SIMONE Job Address: 620 NE 101 Street Miami Shores, FL 33138- Project: <NONE> Contractor: AMERIGAS PROPANE AND SUBSIDIARIES Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Gas 01001•Phone Number Parcel Number 1132060172130 Phone: 305 -883 -8600 Building Department Comments INSTALL UNDERGROUND 120 TANK AND LINE TO EXISTING HOUSE AND CONNECT IT TO EXISTING SERVICE Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. iv 2 o Ora r Comments November 18, 2009 For Inspections please call: (305)762 -4949 Page 12 of 24 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING PERMIT APPLICATION FBC 2004 Permit Type: Owner's Name (Fee e Titleholder) Owner's Address 2 /may E. City i- £ &l State Tenant/Lessee Name E -MAIL: OCT 2 g 2009 i!) BY: o maoo Permit No. P1 Tt-11(64,3'' Master Permit No. I ®i Phone # J (-S- 7s- 7- 7 94/0 Zip .3 3 % .0‘:=5 Phone # Job Address (where the work is being done) City Miami Shores Village FOLIO / PARCEL # 62, N County Miami -Dade Zip 33 i Is Building Historically Designated YES NO Contractor's Company Name f GP.-41 -Q.- Phone # &v'S 8e3 Pee 00 Contractor's Address;_ /I" ■ Ak ILL) 6" � /4--&-e_. City ^ State �— Zip ��s,�5 / �� Phone # „"1 4832 6c:2,5 Qualifier Name State Certificate or Registration No. A PC. be) e'79 Certificate of Competency No. E -MAIL: Architect/Engineer's Name (if applicable) Value of Work For this Permit $ Tyj e of AVork: DeOcriber ork: ❑Addition Phone # .2®O0. ©e' Square / Linear Footage Of Work: ... > -- . %At..Ka, -aria m.- fe a _ ❑Alteration ❑New a ❑ , Repair /Replace,;, * ** *** OC' Sfrb al Fee $ SO Notary $ Scanning $ Bond $ * * * * * * ** *rxxxxx *rx * ** Fee s* * * * *a:*9:aYxxxxrxxxxxxxxxx a:xrx xx xxxr*rx xxx* * Permit Fee $ Training /Education Fee $ Radon $ Structural Review. $ DPBR $ CCF$ Technology Fee $ LI ' Zoning $ Code Enforcement $ Double Fee $ 14. n Total Fee Now Due $ V See Reverse side –+ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City Zip 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 )o The foregoin day o Owner or Agent strument was acknowledged before me this eN The fore , 20 09, by day of Signature who is personally known to me or who has produced ID 65201 s identification and who did - an oath. Con tractor as ac, , who is personally„known to me or who has produced as identification and who did take an oath. NOTAR • I LIC: ign Pr'jn My Comm xx *****x x x xerx x ee #.d ro F` u , r a��� • = C urrtiSSio /111ffirAiri Cornnssion # DD -j-e;•:%;, a an auricled ,. �;►., APPLICATION APPROVED B (Revised 02/08/06) Plans Examiner Engineer Zoning 1III. /i)) /7114 /TAIL 1f1 ' 1 AM nmerins FAX No 610 992 3Z W_ �.w.,.. P. OU 1 CERTIiF'ICA'1'E OF LIABILITY INSURANCE I °Amor/0z/2o PRODUCER Aon Risk Services Central, Inc. Philadelphia PA office fine Liberty Place 1650 Market Street Suite 1000 Philadelphia PA 19103 USA mom- 85. 283 -7122 INSURED Americas Eagle Propane, LP PO Sox 965 Valley Forge PA 194 &2 USA FAX 84 TICS CERTIFICATE IS ISSUED ASA MATTER OE INFORMATION ONLY AND CONFERS NO RIGHTS UPON TEM CERTIFICATE HOLDER. TRIs CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER TEE COVERAGE AFFORDED B? THE POLICIES BELOW. 953 -5390 INSURERS AFFORDING COVERAGE EISURERA: ACE Merl can Insurance Company NAIC#I 22667' INsus5t5: Indemnity Insurance Co of North America 43575 INSURER C: AislikEkD: INSURERS: COVERAGES TIE POI Trxrs OF IIBSUP.ANCE LISTED BELOW HAVE BEEN ISSUED TO TMEJNSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT VIT sTA ESNG A•TY P.SQUIRBMSNT, TERM ok CONtgaloN Ox ANY CONTRACT OA OTHER DbeUMBNT A'ITH RBSPBCTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, =WPM AND CONDEEONS OF SUCH POL1(Ts. Aa0REOATE firmIITS SHOWN MAY HAVE BEEN REDUCED EYPAID CLAIMS. LIMITS SHOWN ARE AS REQUESTED BUR LTA ADD'L INSRD TYPE OF INSURANCE POLICY NOVOIER POLICY WASCITYE POLICYE)GPIRATtoN DATEDD.DDDtrYyY) DA.TE{trtMtDDIEYI'V A " - LIABILM ® COMMERCIAL GINERAL LIABILITY CLAIMS MADE 171 OCCOR• U GEM_ AGGREGATE LIMIT APPLIES PRib ri FED- L1 Luc SECT ___ B+OLBcY NDO6249325SA 07/01/2009 07/01/2010 FACE OtxtlitPINcE DAMAGE TO RENTED PIIMITEES IEa o,ew'reace) MED al, (Asp Inc peruBB PERSONAL A ADV INJURY DEIDELIALAOGEBrAre PRODUCTS +GOMIDOP AGO 51,000,000 51,000,000 510,000 52,000,000 $2,000,000 52,000,000 AUTOMOBILE LIA HtLiTx A X ANY AUTO ALL MINED AUTOS SCHEDULED AUTOS AIRED afros NON OWNED AUTOS 15490857990E 07/01/2009 07/01/2010 COMBINED SINGLE LIMIT (En I 51,000,000 BODILYINIURY (Pepvson) Holder Identifier : BODILY-INJURY (Poracoidona) PROPERTY DAMAGE (Ps asekkar0 GARAGE LIABILITY ANYAOTO • AtbrO ONLY- EA ACDIbENr E xcMm i UMBRELLA LNHtLSTY =CM CLAIMS MAOS R EDUC IRIS kN4TON WD$BCET S ODStemisa Ton AND A EMPLOYERS' LIABILITY ANY .PBOBRIE713R. !PARTNER /F.h 0/AYE IPCOLUD A Pdondat,tyln Tq F8 Ifyi, doccmbo n¢dor SPECIAL PROVISIONS below OTHER WLRC456"99882 ' ADS SCFC4S699870 WE WLRC4569MSS CA 07/01/2009 07/01/2009 07/01/2009 ,It /07. /2U18 07/01/2010 07/01/2010 • IRAN AUTO ONLY: BA ACC BACH OCCURRENCE AGO AGGREGATE 0035341032 Ceitificnte No : X D SIATU- 0TH • otoEar 51,000,000 • DEBASE -BA EMPLOYE 51,000,000 ET..DLFFAac_PDT LOST? S1,DO0,0� gE DESCRIPTION OF OPERATIONSILOCAT1ONSfirEiDCLES /S).CLTtSIONS ADDED EY ENDORSEMENT/SPECIAL PRAVISIONS CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, F1.33138 ACORD 25 (2009/01) T , THE �SUTW4EA /RTO A BOW 7%E EXPIRATION DATE OF THE UINI RER"U, ED0A 30 DAYS Ti'RMENNOTICE TO THE CERCATE HOLDERNAMsu TO THE LEFT, et)TRAILbtkkf_ 10 DO ED MIALL IMADSENO OBLIGATION OR LIABILITY OF ANY MAID UPONTEE INSURER, ITS ADEN TS OEREPRBSEHTATIYBS. AUTHORIZED R PRESENTATIVE e? Je4s7 �.[assd�d��sva� X1988 -2009 ACORD CORPORATION. AR rights reserve The ACORD name and logo are registered marks of ACORD partment of Agriculture and Consumer Services Division ail' Standards Bureau of Liquefied Petroleum Gas Inspection (850) 921 -8001 Tallahassee,: Florida Certificate No: Exam bate; Issue Date: Expiration bete: Exam ::. 13554 June 7, 1982 August 8, 2009 August 7, 2012 0601 MASTER QUALIFIER CERTIFICATE This Certificate is issued under authority of Section 527.02, Florida Statutes, to: ROBERT ALLISON Valid For License Number: 00431 AMERIGAS PROPANE LP 6890 NW 25TH ST MIAMI, FL 33122 -1804 L{HtCRLES H.. SRQNS COMMISSIONER OF AGRICULTURE State of Florida Department of Agriculture and Consumer Services_ Division of Standards License Number 00899. Bureau of Liquefied Petroleum Gas Inspection Expiration Date; August31, 2010 (850) 921 -8001 Date of issue: September 1, 2000 License. Fee: $425.00 Tallahassee, Florida Type and Class: 0509 Liquefied Petroleum Gas License goo .,. POST LICENSE CONSPICUOUSLY CATEGORY I LP GAS DEALER GOOD FOR ONE .00ATION ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license is issued under authority of Section 527.02, Florida Statutes, to: AMERIGAS EAGLE PROPANE 10052 NW 89TH AVE MEDLEY, FL 33178 -1444 LARLES H. BRONS COMMISSIONER OF AGRICULTURE Florida Department of Agriculture and Consumer Services Bureau of Liquefied Petroleum Gas Inspection P.O. Box 6720 Tallahassee, Florida 32399 -6720 License Number: 00899 Business Mailing Address Licensed Location Address AMERIGAS EAGLE PROPANE 10052 NW 89TH AVE MEDLEY, FL 33178 -1409 AMERIGAS EAGLE PROPANE 10052 NW 89TH AVE MEDLEY, FL 33178 -1444 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company located at the address on the license. Each business location of a company must be licensed. All LP Gas licenses must be renewed annually. Any license allowed to expire shall become inoperative because of failure to renew. The fee for restoration of a license is equal to the original license fee and must be paid before the licensee may resume operations. IN THE EVENT OF AN OWNERSHIP CHANGE AT THIS BUSINESS LOCATION: This license may be transferred to any person, firm or corporation for the remainder of the current license year upon written request to the department by the original license holder. License transfers must be approved by the department. All licensing requirements must be met by the transferee and a transfer fee of $50 will apply. To apply for a transfer, contact the Bureau of LP Gas Inspections at 850/921 -8001. Pursuant to Chapter 527, Florida Statutes, LP Gas licensees must present proof of licensure to any consumer, owner, or end user upon request when engaged in the business of servicing, testing, repairing, maintaining or installing LP Gas systems and/or equipment. For future correspondence, please make any needed corrections or changes to your business mailing address and/or your licensed location address and return the UPPER PORTION with corrections to: Florida Department of Agriculture and Consumer Services Bureau of Liquefied Petroleum Gas Inspection P.O. Box 6720 Tallahassee, Florida 32399 -6720 Cut Were State of Florida Department of Agriculture and Consumer Services POST LICENSE CONSPICUOUSLY • Division of Standards Bureau of Liquefied Petroleum Gas Inspection (850) 921-8001 Tallahassee, Florida License Number: Expiration Date: Date of Issue: License Fee: Type and Class: Liquefied Petroleum Gas License CATEGORY I LP GAS DEALER GOOD FOR ONE LOCATION ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVAUD This license Is issued under authority of Section 527.02, Florida Statutes, to: AMERICAS EAGLE PROPANE 10052 NW 89TH AVE MEDLEY, FL 33178 -1444 00899 August 31, 2010 September 1, 2009 $425.00 0601 HARLES H. BRONS COMMISSIONER OF AGRICULTURE i . DETtRMINE NORTH . • • s1 too • b WILerret AmeriGas, LPG 00899 1005214W 89 Ave., Med'fey Fl Win" Tel 305- 388 -8800 Fax 305-884-4891 JOB: ® "fib DATE: REVISED: SCALE: DRAWN BY: APPROVED B I. . • AFFIDAVIT: T'hb .nsin shat comply vh NFPA 54, NFPA 58, . as lava as al stale &I codes and regulations. GENERAL SITE PLAN* !• . �9,