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PL-12-1582Witnit") BUILIMNG PERMIT APPLICATION Fsc 2,0 \GI 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) 7614949 # .• -k-f- • • OWNER: Name (Fec Simple Tideholder); 1 • s--0.- !ho :LI Address: City: t Stare: tt--C/P-- Tenant/Lessee Naine:. • -• ' . •-• • -;r• • Ph** Emailt. ,... • k .,•• • .„ . RECEIVED AUG 17 2012 Permit Na Master Permit No. tAP-Akelco 0 . eti JOB ADDRESS: SC) N City: Miami Shores County: Miami Dade Folio/Parcelt Is th e Big llediYe s NO CONTRACTpR: Company NIrx: ""c345)-"S -PLUM& 'V 5 LAj C phonet za 9 ?9 Address: S City: 4dt State: ---Zip: LC, 5 Qualifier Name: - niotte4t: 79 to -"k27e-A- State CertiteatioiletitokistratenA C91 Contact Phone:3°5 -119 c(c? L. Email Address: 43c7` &*-S Pi—tikka .Ncp c-sz. DESIGNER: ArebiteCt/Eigineei: • Phone* Value of Work for this Permit: $ 14(CF d Square/Linear Foo of Work: Type of Work: ClAddress °Alteration CINew i! • au/Replace °Demolition Description of Work ce--Q1K etA f1410.- SC-Afse' Submittal Fee $ , tk • Permit Fee $ e9 0 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 StiitC Zip .1 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 Et.„EgmcAL. 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 NC,PE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO -- YOUR PROPERTY: IF YOU INTEND f1'O 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 delivve,red to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of coritrnenCernent 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 wil not be approve and a reition fee will be charged. Owner or Agent The fore oin instrument�was acknowledged before me this /7 day of , 20 a-by //f(4 01 c -Arz Z- , who is personally known to me or who has produced r_/ 0 As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: ti 0 if CO mot. ��Oljge�d491 // .•• ******* * *** * * * * * * * * * * * * * * * * * * * *** **a Signature The fore day of who i NOT (Revised 07 /10/07XRevised 06/10t2009)(Revised 3/15/09) Contractor ment was acknow ged before me this ! t0 _, by t T , (Q1r/� Structural Review me or who has produced identification and who did take an oath. PUBLIC:, Sign. Print. • L4 M r 4 ';• °' #EE117945 y Commis • ` Novi 25, 2015 R to. www•A J 0NNo714RYc, * * * * * * * * ** a*** ** ***** * ***e **+t*s ******** ***** Zoning Clerk PWWWWW*MY THIS DOCUMENT HAS A COLORED BACKGROUND • MICROPRINTING • LINEMARK'" PATENTED PAPER AC# 6226168 STATE oF FLORIDA DEPARTMENT' OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCT/ON INDUSTRY LICENSING HOARD SEQ# L12072501168 LICENSE NER 07/25/2012 128017263 CFC055672 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 4 Expiration date: AUG 31, 2014 BLOSSER, JOHN EMMETT BOB'S PLUMBING CO INC 4055 SW 89 AVE MIAMI FL 33165 RICK SCOTT GOVERNOR DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY 022953 -4 BU PLUMB PLUMBING CO INC 4055 SW 89 AVE 33165 UNIN DADE COUNTY THIS IS NOT A BILL — DO NOT PAY ��aI RENEWAL ST AT Cffl55672 OWNER BOBS PLUMBING CO INC Sec. of CONTRACTOR 7195 15 ONLY A LOCAL RUMNESS TAX RECEIPT. IT ROT PEAK T TAM TO VIOLATE ANY HAWING REGULATORY OR zofSNO LAWS OF THE COUNTY OR CRIES. NOR 00E5 R EXEMPT THE PERMIT OR ANY OINER REOIURED BY IAN. TIPS IS NOT A CERTIFICATION OP THE HOLG1R'9 OU;YIFICA. TWINS. PAYMENT RECEIVED M1AIR -DAOE COUNTY TAX COLLECTOR: 08/09/2011 60060000177 000075.00 SEE OTHER SIDE WORKER /S 10 DO NOT FORWARD BOBS PLUMBING CO INC ROBERT BLOSSER 4055 SW 89 AVE MIAMI FL 33165 ► r�irtr�' 11tr1�rl i1tti1111 t1 `rtt►ryttllelrt$,htttitltlti++t FIRST -CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 022953 -4 OP ID: NM AC-C PREP' �- CERTIFICATE OF LIABILITY INSURANCE DATE (AAM/DD/YYYY) 08/23111 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 policy(Ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certlflcate holder In lieu of such endorsement(s). PRODUCER 305- 455 -7250 Global Risk LLC 5959 Blue Lagoon Dr Suite 101 305 -455 -7251 Miami, FL 33126 Gayle Bainbridge CONTACT FAX tA/C N . tel: (AICC, No): E-MAIL ADDRESS: CUSTOMER ID #: BOBSP -1 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Bob's Plumbing Co., Inc. 4055 SW 89 Avenue Miami, FL 33165 INSURER A :Gemini Insurance Company INSURER B : Mapfre Insurance Company of FL VIGP012769 INSURER C : Technology Insurance Company 11/28!11 INSURER D : $ 1,000,000 INSURER E : DAMGO a R EoNcxTuErD rence) INSURER 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 WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DOIYYYY) POLICY EXP (MM/DD/YYYY) VMI I S A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR VIGP012769 11/28/10 11/28!11 EACH OCCURRENCE $ 1,000,000 X DAMGO a R EoNcxTuErD rence) $ 50,000 CLAIMS -MADE X MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY PRO- JECT LOC $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 4150110004169 02/28/11 02/28/12 COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ 100,000 BODILY INJURY (Per accident) $ 300,000 X PROPERTY DAMAGE Per accident) $ 50,000 X X $ $ UMBRELLALIAB EXCESS LAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If Yes, descxibe under DESCRIPTION OF OPERATIONS Y 1 N N / A TWC3250764 09/01/11 09/01/12 X WC STATU- °E7- TORY LIMITS ER E.L. EACH ACCIDENT $ 600,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule it more space Is required) Plumbing- Commercial/Residential I Miami Shores Village g 10050 NE 2 Avenue Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BOBSP01 OP ID: EA �iC�RU° �,,,�- CERTIFICATE OF LIABILITY INSURANCE DATE (MMmD/YYY1() 12/01/11 THIS CERTIFICATE 15 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 15 WAIVED, subject to the terms and conditions 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 endorsement(s). PRODUCER 305 - 270 -2100 L4S N U7 venuNC. 940 7 INSURANCE, 305 - 270 -2195 Miami„ FL 33156 Joe l Zaragoza CONTACT NAME: Michelle Wilson FAX i2, , E :305- 270 -2100 (Arc, No): 305- 270 -2195 ADDRESS: mwilson@fllerins.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Alterra Excess & Surplus Ins LIABILITY COMMERCIAL GENERAL LIABILITY INSURED Bob's Plumbing Co., Inc. 4055 SW 89 Ave Miami, FL 33165 INSURER B: MAX2GL0002182 INSURERC 11/28/12 INSURER D : $ 1,000,000 INSURER E : $ 100,000 INSURER F : $ 5,000 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 WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POUCY EFF IMM!DDIYYYY) POLICY EXP (MMIDD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY MAX2GL0002182 11/28/11 11/28/12 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (My one person) $ 5,000 CLAIMS -MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 GEN'L AGGREGATE -7 POLICY X OMIT APPLIES FJET PER: LOC $ AUTOMOBILE LIABILITY ANY AUTO ALLOWNED AUTOS HIRED AUTOS SCHEDULED NON-OWNED AUTOS COMBINED BBI tSINGLE LIMIT $ $ BODILY INJURY (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UA EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENT ON $ WORKERS COMPENSATION AND EMPLOYERS' UABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/ N N / A WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY UMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, AddMional Remarks Schedule, If more space Is required) MIAMI09 Miami Shores Village 9 10050 N.E. 2nd Avenue Miami Shores, FL 33138 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE //r /)/ �1 / ELENA ANDRES - A006835 ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TANK INS [ (01] TANK SIZE [1]Jbrc; [2] ( _ [-...---r [02] TANK MATERIAL C rr Y [ ] [ [03] OUTLET DEVICE EA- [ ] I' (04] MULTI- CHAMBERE,[ / N ] / I 1 [ (05] OUTLET FILTER ` 'r, -�2_ A/ i'cft 1 [ [06] LEGEND s L [j [ ],, [07] WATERTIGHT [ •/] (� [08] LEVEL I� [ ] [09] DEPTH TO LID ( 1 DRAINFIELD INSTALLATION [10] AREA [1],/. (2], ....-:SQFT [ [11] DISTRIBUTION B X _ HEADER ' [ ] [12] NUMBER OF DRAINLINES: r� [ ] [13] DRAINLINE SEPARATION ,ia> ( ] [14] DRAINLINE SLOPE [15] DEPTH OF COVER/4„, t' [16] ELEVATION [ABOV /BELO "' BM [17] SYSTEM LOCATION [18] DOSING PUMPS [19] AGGREGATE SIZE [20] AGGREGATE EXCESSIVE FINES [21] AGGREGATE DEPTH FILL [22] [23] [24] [25] [26] / EXCAVATION MATERIAL FILL AMOUNT `l FILL TEXTURE EXCAVATION DEPTH AREA REPLACED REPLACEMENT MATERIAL [27] [28] [29] [30] [31] [32] [33] [34] [35] SURFACE WATER DITCHES PRIVATE WELLS PUBLIC WELLS IRRIGATION WELLS 6 POTABLE WATER LINES .3. 0 BUILDING FOUNDATION PROPERTY LINES a4j OTHER FILLED / MOUND SYSTEM [36] DRAINFIELD COVER [37] SHOULDERS [38] SLOPES [39] STABILIZATION FT FT FT FT FT FT FT FT FT ADDITIONAL INFORMATION [40] UNOBSTRUCTED AREA [41] STORMWATER RUNOFF [42] ALARMS [43] MAINTENANCE AGREEMENT [44] BUILDING AREA [45] LOCATION CONFORMS WITH SITE PLAN [46] FINAL SITE Gt [47] CONTRACTOR [48] OTHER ABANDONMENT [49] TANK PUMPED / /'d / 0)? [50] TANK CRUSHED & FILLED cf / /{,/ 1 EXPLANATION OF VIOLATIONS / REMARKS: H CONSTRUCTI APPROVE DISAPPROVED] :6 -4,/ CC - G/ Q FINAL SYST [APPRO D /DISAPPROVED]: DH 4016, 08/09 (Obsoletes all previous editions Incorporated: 64E- 6.003, FAC 7 which may not be used) CHD DATE: N•-/4 CHD DATE : Page 2 of 3