PL-13-272A+CuFeb, 25. 2013 12:24PM FLORIDA BANKERS INSURANCE No. 2223 �P, l /1001,0
:::• CERTIFICATE OF LIABILITY INSURANCE 02/25/13
PRODUCER Florida Bankers Insurance
7278 SW 8 Street
Miami, FL 33144
Phone (305)28 &6493
Fax (305)2620679
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC #
INSURED M.G. EXCELLENT SERVICES CORP.
7221 NW 174 Terr Alit. #102
HIALEAH, FL 33015
INSURER A: FEDERATED NATIONAL INSURANCE
INSURER 3: PROGRESSIVE INSURANCE
INSURER C:
INSURER 0:
INSURER E:
COVERAGES
•
THE
ANY
MAY
POLICIES.
POLICIES
REQUIREMENT,
PERTAIN.
OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
TERM OR CONDITION OF ANYCONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED
THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS, EXCLUSIONS AND CONDITIONS
AGGREGATE LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
OR
OF SUCH
MISR
LTR
ADM
NSW
TYPE OF INSURANCE
POLICY NUIYBet
I.I.0 EFFECTIVE
(MIMVDDII Yr
POLICY EXPIRATION
DATE DimioDmo
LIMITS
A
GENERAL LIABILITY
GL- 0504010307-00
02/16/13
02/16/14
EACH OCCURRENCE
1,000.000.00
COMMERCIAL GENERAL LIABILITY
SSE , occureence)
100.000.00
• • CLAIMS MADE n OCCUR
MED EXP (Anyone Person)
5.000.00
•
.
PERSONAL & ADV INJURY
1,000.000.00
❑
GENERAL AGGREGATE
2,000.000.00
GEM AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
2000.000.00
M POLICY ❑.PRQJECT • LOC
B
AUTOMOBILE LIABILITY
01604850 -0
05/14/12
05/14/13
COMBINED SINGLE LIMIT
(Ea accident}
• ANYAUro
• ALL OWNED AUTOS
BODILYINJURY
(Per person)
10000.00
•
n SCHEDULEDAUTOS
12 HIRED AUTOS
IN NON OWNED AUTOS
BODILY eras Id INJURY
(Perm)
20000.00
ill
n
PROPERTY DAMAGE
(Per accident)
1000000
GARAGE LIABILITY
AUTO ONLY- EA ACCIDENT
•
•AUTO
OTHER THAN EA ACC
•
AUTO ONLY: AGO
EXCESS/MORELLA LIABILITY
EACH OCCURRENCE
❑ OCCUR • CLAIMS MADE
AGGREGATE
•
WORKERS
• DEDUCTIBLE
• RETENTION $
AI AND
OYEI;TIO
ANY PROPRIETOR / PARTNER / EXECUTIVE
OFFICER / MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
•
TORYLIN9TS ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICYLIMIT
OTHER
DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES! EXCLUSION ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
con TICICATE HOLDER
CITY OF MIAMI SHORES
10050NE2AVE
MIAMI SHORES, FL. 33138
ACORD 25 (2001/08) OF
SHOULD ANY OF THE ABOVE DESCRBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
THE LEFT, BUT FAILURE TO DO 80 SHALL MIPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
•
ACORD CORPORATION 1888
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 185619 Permit Number: PL -2 -13 -272
Scheduled Inspection Date: June 17, 2013
Inspector: Hernandez, Rafael
Owner: HAISCH, CHARLES
Job Address: 160 NW 92 Street
Miami Shores, FL
Project: <NONE>
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number 305 - 788 -0416
Parcel Number 1131010000210
Contractor: MG EXCELLENCE SERVICE CORPORATION Phone: (786)247 -7067
Building Department Comments
PLUMBING WORK FOR 2 BATHROOM REMODEL
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Infractio Passed Comments
INSPECTOR COMMENTS
Inspector Comments
False
June 14, 2013
For Inspections please call: (305)762 -4949
Page 6 of 34
Miami Shores Villa
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
Permit Type: PLUMBING
JOB ADDRESS: /h/.&/ /
6
� �e ao°aoeomeoemme�� - --
FBC 201 /1._
Permit No.
Master Permit No.
City: Miami Shores County: Miami Dade
Folio/Parcel #:
Is the Building Historically Designated: Yes NO Flood Zone:
Zip: / co
OWNER: Name (Fee Simple Titleholder): '7 cd, ) G , Phone#:
Address: /d® 1-"Cc/ .?472
City: ` State: 4=4 'd— Zip: 5 3 "_.t-o
Tenant/Lessee Name:, .7-7,474//..4-- Phone#:
Email:
CONTRACTOR: Company Name: / U` Zxe �((Z� -Y 7P.s"U t Phone#:
Address: /54 g
City: /.`4,/,o -�,�v��� / State:
Qualifier Name: .li 4a / oc ,
av9 -906?
Zip: 3 Q/ 6�
Phone#: 96 Pod;
State Certification or Registration #: / 1/� .?� Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ 6, 4"vv Square/Linear Footage of Work:
Type of Work: ❑Address ❑IAlte ra tio n ❑New ❑Re eair/R
eplace ❑Demolition
Description of Work: P-a t C . - 1p LL J- eb vui , 4-v 1 1 (�v-� „C. _
�-- - r -./ �,L. c_
Jri.40 Lie.4,-,..1iik
&014.- 4.6 ■ O•,.i w�c,- / fps cs-ve. ,'-4
ea..e_ .
* * ** * * ** ** ** n** * ********x ******* mix** Fees +x************* ****** **** *************** *gas **
Submittal Fee $ Permit Fee $ / CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL 1'BE NOW DUE $ I 0:)11
Bonding Company's Name (if applicable r
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 .t be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence .f such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Owner or Agent
The foregoing instrument was acknowledged before me this
day of 20 43 , by ga,t
Signature
k "PA
1 r •.•tractor
The foregoing instru ��f - nt w); ackaowl eded befo e me this
day of , 20 /3b by
who is personally kn., n to me or who has produced who is personally known to me or who has produced
^, i• entification and who did take an oath. as i ��'� and who did take an oath.
NOTARY P : • : NOTARY P
Sign: Sign:
Print: 'VW Print
My Commission Expire
Notary Public State of Florida
Marta Pulida
,j My Commission EE 174161
dr Expires 05/22/2016
,
My Commission
Structural. Review
(Revised3 /12/2012)(Revised 07110 /07)(Revised 06/10f2009)(Revised 3 /15/09)
Zoning
Clerk