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CC-12-944A, Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 174303 Permit Number: CC -5 -12 -944 Scheduled Inspection Date: June 11, 2012 Inspector: Bruhn, Norman Owner: EDELMAN, ALEX Job Address: 9999 NE 2 Avenue Miami Shores, FL 33138- Project: <NONE> Contractor: T BOWLEG CONSTRUCTION Permit Type: Commercial Construction Inspection Type: Final Work Classification: Alteration Phone Number ()- Parcel Number 1132060134490 Phone: 305 -625 -1388 Building Department Comments REQUEST FOR INCREASE OF SEATING CHANGE OF OCCUPANT LOAD PassedQr/ 1,(. /1 Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 174252. CREATED AS REINSPECTION FOR INSP- 174186. BY NORM No access. NB June 08, 2012 For inspections please call: (305)762 -4949 Page 18 of 28 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 B IL G PERMIT APPLICATION FBC 201D Permit e: BUILDINGOri F G OWNER: Name (Fee Simple Titleholder): RECEIVED MAY 332012 Permit No. -C 6 ' q1-1H Master Permit No. �aa •• Phone #:3 /�U /� ` -77q Address:Q919 4 4 b 4u& / 30 City: 741//91:// State: Zip: 00/3, Tenant/Lessee Name: a7T/-5 Phone #: Email: JOB ADDRESS: 999/ 4/6- / ) , % g'' // City: M'ami Shores County: Folio/Parcel #: /7 6 6/3— QO Is the Building Historically Designated: Yes CO CTO R: any Name: Address: • 6 • City: f Qualifier Name: '710 0 State Certification or Re: istration #: 9 ' Contact Phone #: ��� %.29.0/4:0 Email Address:. Miami Dade Zip: Zone: Pito aszG ,���� (7, 2-� 77/,- 21 S-8 I��G 22 Phone #744-0_ O/9 Zip: y_ �y,�" Phone #:L �!! �� <; , ate of Competency #: /y4 (f?ydhae.c' > Phone#: DESIGNER: Architect/Engineer: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: DAddi ' °Alteration _ New 6°RReepaiir/Replace °Demolition Descriptiion of Work: � /J 7 .��� /i .00-(.°s',Ige O1� ,91~%etriA16T • j, yt ********* ***** **** * ***** ***** * * * * * **** **F Fee�/ s *** /********* **** **** * *** * * * *** ** * ** ** * ***** Submittal Fee $ Permit Fee $ /d/ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ , l • 0 Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) VA 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 Al}'r'IDAVIT: 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 $2500, the applicant must tnc intkood faith that a opy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject t attachment. Also a certified copy of the recorded notice of commencement must be posted at the job site for the first inspectimpwh ch occur seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be appr ved and rdinspection fee will be charged. Signature ye Agent The foregoing instrument Is ac w ged More m this / The foregoing instrument was acknowledged day of , 20 1_21.t- ld i day o , 20� try i • ' who is personally known to me or who has produced --i ) L) who is personally known to me or who has produced As identification and who did take an oath. NOTARY P.IJBLIC: Sign: Print: —4fole My Commission Expires: 40,9900 7: <5.r.z,ss u 4dofgh, MARIA IERESA GROSSO 4 MY COMMISSION t EE 091861 * xkkkkkk kkkkkkkkd*** *k*** ' P•ES : Ma 9 , 21 RkRkANkkFkk$ Nx+ kkkkkk**** kk****+ kkNhNkhkkkRkkAkkkkk wkkd*** e thiL( as i l,tification and who did take an oath. NOTARY P L16 STATE OF FLORIDA TASHA MARKSMAN . ■:_ *223 Ott A;��i�1 lVIES October 12, 2012,.. 1I U BONuN0 • - • C • a.s' •I c �•ir NO fA APPROVED BY J%1--- Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) Zoning Clerk May 21 2012 10:38RM CONSTRUCTION SRV 8664069542 p.2 • AWR CERTIFICATE OF LIABILITY INSURANCE DATE (11 2012 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. HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. . IMPORTANT: If the certificate holder is an ADDITIONAL (INSURED, the policy(lH7s) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain poUcies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). . PRODUCER ACT Cover All Insurance Agency ria' E04: 954 -956 -0006 r, -.--. NM: 51300 W Atlantic Blvd. Arose: coveralilns01 @gm al.c om Margate, FL 33083 W8URB4IS) AFFORDING COVERAGE NMC $ INSURER : American Vehicle Insurance INSURED essu B : Worker's Compensation Group T.BOWLEG CONSTRUCTION amass c: Thomas E Bowleg INSUrIERD: PO BOX 54 -0895 INSURER Miami FL 3 :3054 INJJRER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTIFY THAT 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 WT N RESPECT TO MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS gEXCLUSIONSAND AZ TYPE OF INSURANCE 1(MR � IROJCY N MnaI I1#Nfl 1M Py604% LBI11T8 A GENERAL X LIABILITY COMMERCIAL GENERAL I lAB)LnY 01-0 504006400-00 06/24/11 06/24/2012 EACH OCCURRENCE $ 1,000,000 DRMAGE TO RENTED PR lEauaauren el $ 100,000 1 CLAIMS -MADE ( X I OCCUR MED EP (My one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEEML AGGREGATE LINT APPLIES PER POUCY n n LOC PRODUCTS - COMP/OP AG$ E 1,000,000 6 AUTOMOBILE . UABIUTY ANY AUTO AU. OWNED AUTOS HIRED AUTOS SCHEDULED AUTDS =WINED NED _ KAIRINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILYINJURY(Pere[cctdent) $ DAMAGE $ $ UMBRELLA UAB EXCESSUAB OCCUR CLAIAS-MADE EACH OCCURRENCE $ AGGREGATE $ DED 1 1 RETENTION$ $ B WORKERS CoLIPEN$ATIow ANDEYIPLOYERS'LFABILHTY Y/N ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? n ry yes, In RID deserbe under DESCRIPTION OP OPERATIONS Wow N /A WCP760535600 05/12/12 05112/13 WC STATLI- OTH- ITORYI-NITS1 ER EL EACH ACCIDENT $ 100,000 EL. DISEASE - EA EMPLOYE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Mash ACORD 1DI,. Addillanel Remade& Schedule, if sere spas. Is required) general contractor CERTIFICATE HOLDER CANCELLATION 'Village of Miami Shores Building Department 10050 NE 2 Ave Miami Shores FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE %MILL BE DELIVERED in ACGOEmANCE WITH THE POLICY PROVISIONS. ACORD 25 (2010105) The ACORD nisme and logo are regi of 41 At D CORD CORPORATION. All rights reservmJ. May 21 2012 10:38AM CONSTRUCTION SRV 0804069542 p.1 • ;?; 06977; (V-Z17- 7(16' • .;:.• . " • • 151259-0 BUSINESS NAME! LOCATION BOWLEG T CONSTRUCT/ON 2955 NW 156 ST - 3305,M/AMI GARDENS .P.Ntga THIS IS NOT A BILL - DO NOT PAY FIRST-CLAIM U.S. POSTAGE PAID NBA" FL PERMIT NO. 231 r RENEWAL RECEIPT NO. 151259- 0 STATE* celcousot OWNER THOMAS BOWLEG Sea Type DI Busiaess WORKER/S miS 12,6 A IMERAL BUILDING CONTRACTOR 10 OMR ROT PERM' MO ROWER TO LAIR ARV TORYOR Of THE . • OCOMY ON arm NOR OOPS It MOW ME . woman FROM ANT OMER MOAT OR MOO= 6E117 prellseimum6RiicreD pArraiter RECEIVED IMMOOADO COUIOTTAX cau-tcrom DO NOT FORWARD BOWL ES T CONSTRUCT ION THOMAS BOWLEG P 0 BOX 540895 MI ANg GARDENS FL 33054 03 000121 000045.00 ; I . i .;.-... • 37 l SEE OTHER SIDE . • inaltellstinitiphatiMialhilltlistlaljaii.firhillitli ----- ,- • State of Florida Department of Business and Professional Regulation Division of Hotels and Restaurants lr v SEATING CHANGE EVALUATION Completion of this form ensures that public food service establishments are evaluated for adequate sewage and fire services before expanding seating operations. Submit the completed form to the local Division of Hotels and Restaurants district office. SECTION 1— ESTABLISHMENT INFORMATION .4 8 Establishment Name: fJ Ate License Number: - S 8S' /G' Current No. Seats: Pro•osed No. Seats: ...(417';" Address of Establ'shme t :� . �.,.% / / // L 17 ' e- �Q /�d"- ontact Pe on Name / P one o.: /�` _ 9��� / d' . .f " w /J City: , ,• /Est / x2 ounty: �. -f . p' _ Cont -ct Person E -Mail Address: ✓l/" -1'1— /d' - - ' SECTION 2 - WASTEWATER SYSTEM (To Be Completed By DOH, DEP or Utility Authority) The above named food service establishment uses the following wastewater disposal system (choose one type): ❑ Municipal / Utility Name of Provider: Grease Trap Required ❑ Yes ❑ No Location ❑ In- ground ❑ Undersink ❑ Package Plant Name of Provider: Grease Trap Required ❑ Yes ❑ No Location ❑ In- ground ❑ Undersink g Septic Tank System Permit #: T nk S'ze: ®O Drainfield Size: co( /a 001 T Grease Trap Size: SYSTEM EVALUATION RESULT: . ❑ Permit Issued YFinal Approval ❑ Denied (see comments) LIMITATIONS ON SYSTEM ❑ Single- Service Only ❑ Other Conditions Comments: ❑ Maximum Number of Hours of Operation [T"Maximum Number of Seats Permitted ?"2" ❑ Menu Restricted (see comments) Name & Title Agency Signature � Date 4, 19, 2 ,�p- Phone.,7a6 _ 3 r��� X28 ©0 l Address . _ . i l�0� w 2� ��I � f2�- SECTION 3 — FIRE SAFETY (To Be Completed By Local Authority Having Jurisdiction) The above named food service establishment proposes to Increase the seating capacity Number of Exits l Public: 32,„ Employee: 3--- Total: 37 fIRE SAFETY EVALUATION RESULT: Approved Comments: e ❑ Denied (see comments) Name & Ti le ‘ ,/ r' A•ency r -- 1 ' Signature i�AIJ / ' /ii .. .�4 . L.r Date o ' 1 Addre s v t r -JA it ! .. ' J Iii ! z // - . / ❑ H &R Change Record Form Attached DBPR Form HR 5021 -103 www .MvFloridaLicense.com /dbpr /hr 61 C- 1.002, FAC 2008 October 22