ELC-11-2278 (2)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
BUILDING
PERMIT APPLICATION
FBC 20
ft DEC 072011
B Y: - - --
Permit No. b 11 - a) l.)
Master Permit No. 11-1693
Permit Type: Electrical
OWNER: Name (Fee Simple Titleholder): Shores Square Investm-nts Phone#: 305 - 779 -8048
Address: 9017 R i a r a yn P P1 vd
City: Miami Rhnrca State: RT. Zip: 33138
Tenant/Lessee Name: Edmundo R' . Tamayo , M. D S Phone#: 3 0 5- 8 3'5 - 6 3 2 2
Email: tama157@bellsouth.net .
JOB ADDRESS: 9025 Bi scayne Rlud _
City: Miami Shores
Folio/Parcel#: 1132060110051 -25
County:
Miami Dade Zip: 3 313 8
Is the Building Historically Designated: Yes
NO Flood Zone:
CONTRACTOR: Company Name: Ok th ce&. OS)"f Phone#:
Address: [ r (0 f &LA KA 14
Ow) 61W-324/0
City: MO-f6 c7 A g- State: L
Qualifier Name: S -� es2A1 I oic
State Certification or Registration #: 6e, COO /: q 7
Contact Phone#:.3 �0 P1• -� gi Emai
Bonding Company's Name (if applicable) N/A
Bonding Company's Address N/A
City State Zip
Mortgage Lender's Name (if applicable) N/ A
Mortgage Lender's Address N/A
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certi fy 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 CONIlVIENCEMENT."
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
Owner or Agent
The foregoing instrument was acknowledged before me this
day of , 20 by t
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Signature /\
Contractor
The foregoing instrument was acknowledged before me this /L4/
day of 1 ( o , 20 1, by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
/
Sign: Sign:
Print: Print:
My Commission Expires: My Com
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7 �
APPROVED BY �'14.24aU Plans Examiner
Structural Review
(Revised 07t10/07)(Revised 05I10ro09)(Revised 3/15/09)
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,ratna` ��e' MARTHA MARTE
Notary Public - State of flora
1. ,°= Commission # EE 71341
Bonded Throu h
ym
Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Permit No.'C C l7 - e°61
Job Name )-71/1641-,p/ cy•c'
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L,...,..---- CERTIFICATE OF LIABILITY INSURANCE
DATE ORWDDIYYYY)
12/09/11
' 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: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and condltlons of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorse= s
PRODUCER 305-222-2033
Mare Jn- uranee Brokers
2700 SW 127 AVE 305 - 2220 -0760
Miami, FL 33175
Javier A. Fernandez
Wrier
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IN$UREt(S) AFFORDING COVERAGE
NAIL
INSURER AI Charter Oak Fire insurance CO,
25615
INEMEC OHMS Elacirleal Corp.
1761 Flanks Rd
Margate, FL 33063
INS»RSRe :FFVA Mutual Insurance Comp
FAOH DCOURRENCE
INSURERC:American States Insurance
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INSuRERDIC0mmarca & Industry ins. -
19410
INSURER E I -
MED EXP (AAm one perBon)
INSU +�
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CERTIFICATE 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. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONPifiON 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 13 SUBJECT To ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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PQUCY NUM R
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10/01/11
aINSURANCE
10/01/12
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COrrMERcIAI, GENERAL. LIABILITY
680- 5609C98S
FAOH DCOURRENCE
$ 1,000,000
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$ 100,000
1 CL.AIMS•MADE X ODOUR
MED EXP (AAm one perBon)
$ 5,000
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PERSONAL IAADVINJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GENT, AGGREGATE LIMIT APPUES PER
7 POLICY n. f Loo
PRODUCTS • • GCMP/OP A0G
$ 2,000,000
$
$ 1,000,000
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NON-OWNED
01015045041
10/14/11
10/14/12
COMBINED SINGLE LIMIT
1En nedetonu
ROOKY INJURY(pmpawn
$
BODILY INJURY =APES
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PROPERTY DAMAGE
accident)
$
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F5tcE88 L1AB
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OLAIMS -MADE
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EBU020738967
10/01111
10101/12
EACH OCCURRENCE
$ 2,000,000
s 2.000,000
AGGREGATE
DED 1 I RETRITiONS
$
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WORKERS COMPENSATION
AND EMPLOYERS' LIA WTI'
PROPRIETORNIARTNERIEGCUTNE 'C D
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S(erya::daterytnty
D ESaRIRTION C F OPERATIONS below
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12/02/11
12/02112
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s 1,000,00 0)
EL. DISEASE .EA EMPLOYEE
$ 1,0001000
EL DISEASE - POLICY UMR
$ 1,000,000
S /LOCATIONS ECU ��n AC1� 101, AddUarri Sctl+dt4
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Remelts 1t »>oln RPM* in rogUh d)
Ic•AL WORK-WITHIN
1' 'I9lV'ATM Lira l,s
ANCELLA
VILLAMS
Miami Shores Village
Fax: 305-756.89T2
10050 NE 2 Ave.
Miami Shores, FL 33138
SHOULD ANY OF THE ABOVE DESCRIrRE,D POIJaIE3 RE CANCELLED SWORE
THE EXPIRATION DATE 'THEREOF, NOTICE WILL BE DEUVERED IN
ACCQRPANCE METH ME POLICY PROVISIONS.
019004010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
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