EL-10-2075Miami 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 No.
NOV 2 2010
Master Permit No/0 gD Z
Permit Type: Electrical ate° OWNER: Name (Fee Simple Titleholder): et&m 1J T 1 JO Phone #: i 4 s i q49
Address:/ reU 14)
/ e22- S1a
City: mj State: PC-
Tenant/Lessee Name: Phone#:
Email:
Zip: 3/:5-0
JOB ADDRESS: Jg9 /1),141- /0 2- 7✓
City: Miami Shores County:
Miami Dade
Zip: 5/ SC)
Folio/Parcel #: ` ` ' 0 / 620630
Is the Building Historically Designated: Yes NO Flood Zone:
CONTRACTOR: Company Name: 6a-1057.— ��47-777-1 C
(Address: S2 3 4 C,,,
City: `d o r` k La c.C.d
Qualifier Name: J 0.1 ' 'EN
State Certification or Registration #: /E-
Contact Phone#: .S ® V i
DESIGNER: Architect/Engineer:
Phone#: ? V.5
State: FL
13 d0 yoy
Email Address:
zip: 3 9 25,
Phone #: /'5Y 5020 Z7 4/8
Certificate of Competency #:
CA-4..f I dtJr'r. i n C.& &f{'o I te, �---
Phone#:
Value of Work for this Permit. $ - ` (5-z9--6 Square/Linear Footage of Work:
Type of Work: OAddress DAlteration UNew
- I.
DeseriptiflII X'or CO-" C� t° k� V� l C COQ c
-Mo.& --4- VZ-E-0"--riti-_ ( CNS-1 rile- (s_ye.,_ ?-12-4-
DRepair/Replace DDemolition
** ** **** * * * ** * * ** * *** * * * * * * * * * * * **** Fees*************** * * *** *** * *x: ****** * * *** *** * ***
Submittal Fee $ Permit Fee $ %geP 60)4' CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
—.r,---
Owner or Agent 7 7 l Contractor]
The forey�gping instrument was acknowledged before me this 23 The foregoi ng instrument was acknowledged before me this /
day of N ,20 `L, by , day of Nover't'igq'£OU),byJeCk(C.
Signature
Z.
who is personally 1c au to me or who has produced to me or who has produced_FL
As identification and who did take an oath. Di, Z- t C.4tshildentification and who did take an oath.
NOTARY PUBLIC: NOTARY Oi J e:' < (fad G 3 e ICI c)
Sign: �{A---,,r Sign:
Print: ,Lct. t) J Lt. �t' G``4 ('c.- ( Print:
My Commission Expires. �tµ'��'• iAFARLEY
. y * MY COMMISSION # DD 646761
EXPIRES: March 16, 2011
Bonded That Blest Notary Seth
* * * ** ***aim * * * * * **
APPROVED BY
***nano * * * * * ** * **
My Commission E triter_ — —
f` (lyyvel Pr ��,4P"'v'p,,;e,�, SANDRA K GDRRIVEAU
OD Q f 4 ev i4 ,, `'c �. Notery Public -State , �to�ida '
J a My Comm t�;��re� 1m(".,._ 4 2u14
�k�k Hoak Haak�kaksk�is ak a, ;` :.` ;�:u ',o'�rr `i `.„ i`�a�x *t 1 sd�gt,
„' 9
‘'...740 /re �' � '1 Ci!" �' %;;;;�,.;,�'� Brnded Though NaliC,.i "iutd't Assn.
lrl
4/ Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Clerk
11/19/2010 15 :06 7722197970 LIVINGS INS
AGIC-:�._..- ._._.._.._._.CERTIFICATE OF_LIAS_ILITY INSURANCE oATE(MMIDbIYYYYj
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT$ UPON THE _ 11/19/10
CERTIFICATE DOES NOT AFFIRMATIVELY, OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY rHE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S) AUTHORIZED HOLDER. THIS
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: tf the evrtlflr:ata holder Is an ADDITIONAL INSURED the it !ea roust 49 endorsed, N 3UBROf AT10N 13 WAIVE zD, subJect to
tha terms and condikiorrs of the II ce Po oY( ) ....._. ..... ••......._ .
p° ay, main pellcles may require in endoraerr r� A statement oe this curiiflcate does oat confer rights to th
certificate holder in Ilea of such ontlors ®ment(sL_ - -
PRODUCER —
Livings Insurance __ r- ___• •.. -••_ -- _•_ -• •- .. -_ .- _
Par' : _ Matthe y L(vIngs _ --
2646 SW Mapp Rd., Suite 101 PHON -
�ah (772) 221 - 0000 -.. -�:,; - ..
Palm City, FL 34990 ao . ESS:
Pitons (772)219.4171 I o Ugnit • -°
_- (77 • Fax (772)219 -7970 C.T.oMER ID.n.: -_.
INSURED ... -.. ._. • _ M....... _. .. __. _._.
INSLIRER(3),AFFORDINt ^ y COVERAGt3
Crest Electric Inc • iNsuReR 4:._N_ atlonal Group Insurance oo -
5234 NW Reba Cir _• • -
Port St Lucie, FL 34988-
(954) 520 -2748
954 -- ..
COVERAGES -.. _- _... -... --- _ - —
CERTIFICATE NUMBER: URER F� :
THIS IS TO CERTIFY THAT THE POIZIES OF INSURATV¢� LISTED BELOW-RAVE BEEN iSBUED TO THE«INSURED NAMED ABOVE FOR THE WO -di; PERIOD
INDICATED. NO REVISION NUMBER: NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wrrn RESPECT TO !VHICH THIS �-
CER71FICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TH TERMS,
EXCLUSIONS AND CONDmONS OF SucH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED I3Y PAID CLAIMS,
_ _TYp6pFlNSURANC@ ..._...._._ ...... . —_.
_. IN3tt..vl!I!D.i.. - _.�.tl�j>aQiTBRIr ' - -
GEWSRAL LIABILITY Tvim. •.—.. .-- — POLICY NUMBER, 04114/DO , ••.' • -• _ _..
DiYYYY -j lydl _ • e COMMERCIAL GENERAL LABILITY 1 I EACH OCCURRENCE i ^000,000
( [ GLAIMS •L EN [�f OCCUR I 0=09 -rtmet TED • -- - -- -•-
A .' 104L 0000059 00 PBIS.ti'a °rcurro"oa1._ ? _ 1 00,000
00 Deductible I I 105/29/2011 EXIT M one - • _ -- 06/29/2010 1 y parson).. 111 __ _ • Excluded
PERSONAL,.& ADV INJURY_ S 1 000,000�
WI POLICY LIMIT APPLES PER: I QENERAL AGGREGATE 3 2,000,0g9
L-;. POLICY n P li • -- - R._-
-- I ...._ .. J. & ,• ,_ Lac PRODUCTS • COMP/OP AGG $
AaTOli a1 LABILITY "° - _ _.. • ""
LE .. _• — -- • . .- .._._ _-... , .. 9 , 000,000
_ (Ea ecckronl)
1 ANY AUTO CDME3INE?D SINGLE LIMIT
I,,•a1 ALL OWNED AUTOS _ .
L._1 SCaIEDULEO AUTOS ... BODILY INJURY {Per pram/
QODILY INJURY {Per sxident
I....J HIRED M DULTps
1:...1 NON -OWNED p AUTOS (Pat ROVER AGE — -
r. j e�ae
— .0 umbREI.LA LIAe n OCCUR
E' EXCESS uAB [T 1 mows-mum
��[ .71 DEDUCTIBLE
WORKERS COMPeNSATION
AND EMPLOYERS' LIAaLITY
IANY PROPRIETORIPARTNE XECUTIVE rY /
OFFICER/MEMBER EXCLUDED? I ... N / A •
(Mandh+tely In NH)
IT yet describe under
— DEEGlRIPTION OF OPERATbNS below .. •
..
PAGE 01/03
INSURER D -
INSURE—
OFBCRtPT10N OF OPERATIONS/LOCATIONS _ - -"
/VEHIOLES e•' • (Attach AcORO got, AtldlUonel Rn;nerp;9 S� ltedulo, it ma--re. Bents Ig roqulretl)
FAX 30ts -756 -8972
EACH OCCURRENCE_._....
_AGGREGATT —... ...__. .
1-12* 'V✓t; STATU —' rid
f
E.L. EAOHACCIDENT
2.L. CIS @ASE.. EA EMPLOYE
E_L. D1S ASE . POLICY uM I
... CERTIFICATE HOLDER _
. _ _ .. _ -• - • .-_ •-.-.. • _---- CA NCELLATION .-.
SHOULD ANY OF THE ABOVE DESCRIBED POUClts BE CANC ELLED BEFORE
Miami Shores Village Building Dept THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVER? • IN
10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS.
Miami Shores, FL 3 3 1 3 8 - . . . , . -- iiiie NR ESHNTATIVE
$
3
ACORD 25 (2009/09) QF
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