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PLC-11-1522Miami 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 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING Permit No. P 11 —1Sq Master Permit No. C _ 69, , Phone #( ro� `�. - getNv OWNER: Name (Fee Simple Titleholder): ---re .&N)60. Address: 24°00 col — (sS � r , City: kV( - /`1 i ( State: Zip: 331 t0 Tenant/Lessee Name: Phone #: Email: -r6t G sk �%A4H- M. e VA d 0 - Cot-t JOB ADDRESS: 1247 ' q2 -sr.. City: Miami Shores Folio/Parcel #: Is the Building Historically Designated: Yes County: Miami Dade CONTRACTOR: Company Name: Address: City: NO X Flood Zone: Qualifier Name: State Certification or Registration #: Contact Phone #: DESIGNER: Architect/Engineer: Phone #: 7JSij � i Zip: 6 `` 1, �y 74 o ? Phone #: �a ` �� J C15 l ' (V-777-Certificate oLCompetency : Email Address: Cam- Phone#: �J Value of Work for this Permit: $ b Square/Linear Footage of Work: Type of Work: DAddress C gyration New Des�jption of Work: .�'C.- k ' �' y ` (-e uvi � - �-y� DinanoGi qs" * * * ** ** * * * * * * * * * ****** ,+ x+ x**** *** **x:****Fees************* xm***°n ******* :+x**** +a:a:********* Submittal Fee $50 ° N. (� Permit Fee $ /51— CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ ililTO 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 �� .y,, " Owner of Agent Contrac The foregoing instrument w acknowledged b f th' 1 The instrument ;Oh kn edged before this day of who is personally known to me or who has produced 1 ' -' who is personally known to me or who has produced a' As identification and who did take an oath. as identification and wkkq.�lil °t1�`vy)ath. ;�01 •....... 1/, ''.,� 40859Caa'' .acs'' ' %� �.` U01gLk O3 RNIOli was before me this oregomg ins men s ac ow ge a ore me s 20 l b TC� �—S\f C -- )-1 �A L 7� (' y ay o f �3� U , ' by ,( � N � NOTARY PUBLIC: Sign: Print: My Commission Expires: APPROVED BY 111111//1 \\\\s\.''.? /''''.'. i� -� i▪ 70 • •~04 -:' c� x9: = _ ov- //111111 o NOTARY PUBLIC: Sign: l..' M,1:; Print: My Commission Expires: Z6OZI9OIi0 .. JS /////1111111111��\ /ZZ' /// Plans Examiner Zoning (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) Structural Review Clerk CERTIFICATE OF LIABILITY INSURANCE I DATE mmxismnrim 08/19/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: IfUte certificate holder Is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. If SUBROGATION 18 WAIVED, subject to the terms and conditions of the policy, certain polies may require an endorsement A stmt on this cerURcate does notttter rights to the certificate holder in Rim of such endorsement(s). PRODUCER Equiinsuran e, Llc 6839 Main Sloet Miami Lakes, FL 33014 Phone (305) 557 -5578 Fax (305) 557 -5197 CXINTACr FRANK FERNANDEZ 1 5 (05) 557 -5578 1 M. Not (305) 5575197 can NAIC tt INSURER A American Vehicle 10790 INSURED MITO PLUMBING CORP 7879 NN 173 St Hialeah, FL 33015 786-553-5003 INSURER B : NOgreSSilie EXINOSS Ins Compery 10193 INSURER C: INSURER D : Sun Inswanae Cottony 40134 INSURE/1E : INNDRER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBS THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDmON 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 MALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TV TYPE OF INSURANCE )iSR N WVD POLICY NUMIER GL -00 ( IDdYY�YY1 07/2312011 �LICM�VDDIY 1 07/2312012 U187S EACH OCCURRENCE $ 1.000,000.00 A GENERAL LIABILITY DAMAGE RENTED PREMISES Ea occiaronce) $ 100,000.00 V cOMIAERC AL GENERAL LIABILITY ❑ • CLAIMS -MADE Ti OCCUR ❑ �m ExP (air one person $ 5.W0.00 PERSONAL SADVINJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE a 2,000,000.00 GENT. AGGREGATE LIMIT APPLES PER d POLICY ❑ jPa ■ LOC PATS -C OMPAPAGG $ 2,x,000.00 $ B AUTO/SMILE UABIUIY ❑ ANY AUTO ALL OWNED SCHEDULED i AU OS J AUTOS ❑ HIRED AUTOS ❑ AU NED ❑ ❑ N 05372728 -2 04/13/2011 04/13/2012 COMM) SINGLE LIWT (Ea actIdara $ BODILY INJURY (Per parson) $ 25,0 .00 ��LY rNduRrr (Peraoc $ 50,010.00 p IPer p°D ea3 GE $ 25,0(0.00 $ • UMBRELLA UIB ❑ OCCUR ❑ EXCESS LIME ❑ CLAIMS -MADE EACH OCCURRENCE E $ AGGREGATE $ ❑ OED 0 RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' UASUTY Y/ N ANY AR OFFICER/MEMBER CW°� y '1x des�e ujo DESCRIPTION OF OPERATIONS below N/A WSAUIECI2218702 03/15i2011 03/15/2012 'J W 1 9t S ■ R - EL EACH ACCIDENT $ 500,x.00 $ 500,000.00 EL DISEASE -EA EMPLOYE EL DISEASE - POUCY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS / MECUM (Attach AcU RD'a1, Additional Remits Seim Xmmespace Is CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 N.E. 2nd Avenue Miami Shores, Fl 33138 SHOULD ANY OF THE ABOVE cestmeace POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THFJREOF, NOTICE WILL BE DID IN ACCORDANCE WITH TIEt MEMORIZED RlfrA11VE ACORD 25 (20100 QF (919 -2010 ACORD CORPORATION. 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