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PL-09-1998Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING Permit No. / -0? -/99 PERMIT APPLICATION Master Permit No. FBC2O ifiy►li�� Permit Type: Plumbing Owner's Name (Fee Simple Titleholder) Owner's Address /057 -4/1= City/e,;4,014° J%.�C rj State Tenant/Lessee Name E -MAIL: Phone # Zip Phone # Job Address (where the work is being done) /0S/ Aoc Fa 3-f City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL # / Is Building Historically Designated YES NO ,/ Contractor's Company Name f/9 2..-':' /9 g cf;i---ircelecy Phone # Zf e-" 20 g? f s2 Contractor's Address /I le jo . ,,,t/ 1.- o City 4 ° AihAi /r State ,��- s Zip ..7.7i. CR Qualifier Name 4e /10/ Alr.ye _ Ai ,erVX Phone #7, 3_2 1_ i State Certificate or Registration Ko. e /2'C (90, fa-- -- Certificate of Competency No. 7,4'" E -MAIL: 1" /l Architect/Engineer's Name (if applicable) Value of Work For this Permit $ / 2 406,00 Type of Work: ['Addition Describe Work: ❑Alteration Phone # Square / Linear Footage Of Work: 2/ ZOO -yam XNew ❑ Repair /Replace ❑ Demolition '4ux'4xxxak'4xaY* i::t*xxxx'F**xxxxx kxxd'** Fees' 'k r. *xx *ic **txdexx *nYxrxx*icx *xxxxxx xaYxx xxxiExxx f Submittal Fee $'5-2? Permit Fee $ CCF $ f .9.0 CO /CC Notary $ Training /Education Fee $ C - — Technology Fee $ 1 4.00 Scanning $ 5+ Radon $ DPBR $ Zoning $ Bond $ Code Enforcement $ • Double Fee $* Structural Review. $ Total Fee Now Due $ 1 5l See Reverse side –+ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City /V Zip 1 Application is hereby made to obtain a permit to do the work and installations as indicated. [ 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the ce of such posted notice, the inspection will not be approve E. an •. "reinspection e will be charged Owner or Agent The foregoing instrument was acknowledged before me this day of _ , 2001 , by kduii,, A « tAr L *4g, who is personally known to me or who has produced Contractor The foregoing instrument was acknowledged before me this 314 day of ,24.- , 20 01, by 7,4.A.cilvi Altus who is personally known to me or who has produced V 31."5-43i 4s'- aft'6..o As identification and who did take an oath. MP O-0611-99-104-0 5' _1t 4-D as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Print: y Commission Expires: xxxxxxx3rxa4************ APPLICATION APPROV (Revised 02/08/06) • Sign: Pri Notary Public State of Florida tina Sose a My Commission 0D900948 Aires 06/26/2013 My Commission Expires: Ai.a ****xxx** xxxx**xx dctic **** d.•xx$'x9:****x'xt : a e*xaja ***n ***it** t***********st ' r/a of Plans Examiner Engineer Zoning Receipt Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -4949 Permit Number: PL -12 -09 -1998 Invoice Number: PL -12 -09 -36555 Applicant: BRIAN & STACEY LEVY Company Name: Date Payment Type Check Number 12/03/2009 Cash Amount Change $50.00 $0.00 Total Payment: $50.00 Thursda December 3, 2009 Page 1 of 1 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795 -2204 Parcel Number Expiration: 06/07/2010 Applicant 1051 93 Street Miami Shores, FL 33138- 1132050150090 Block: Lot: BRIAN & STACEY LEVY Owner Information Address Phone Cell BRIAN & STACEY LEVY 1051 93 Street MIAMI SHORES FL 33138 -2938 Contractor(s) SHEAR SERVICE INC Phone Cell Phone (786)251 -9810 Valuation: Total Sq Feet: $ 1,200.00 2200 Type of Work: GAS LINE Type of Piping: PLUMBING Additional Info: Bond Retum : Classification: Residential Fees Due CCF Education Surcharge Permit Fee - Additions /Alterations Scanning Fee Submittal Fee Submittal Reversal Fee Technology Fee Total: Amount $1.20 $0.40 $180.00 $3.0o $50.00 ($50.00) $1.60 $186.20 Invoice # Total Amt Paid Amt Due PL -12 -09 -36555 $ 186.20 $ 136.20 PL -12 -09 -36555 $ 186.20 $ 186.20 $ 0.00 For Inspections please call: (305)762 -4949 Available Inspections: Inspection Type: Final Press Test ROW In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS 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. Futhermore, I authorize the above -named contractor to do the work stated. December 23, 2009 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date December 23, 2009 1 ACORJ(?'' PRODUCER CERTIFICATE OF LIABILITY INSURANCE P,0 AIRance Inaurenoe II, Inc. 5000 N. Federal Hwy. Lighthouse Point. FL 33062 Phone (954)725.0235 Fax (954)725.0237 DATE (/� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA'T'ION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTS COVERAGE AFFORDED SY THE PAL INSURERS AFFORDING COVERAGE MAC # INSURED SHEAR SERVICES, INC 14o50 NW 6 et North Miami, FL 33168 - (305) 6255450 COVERAGES iNsugER A WESTERN WORLD INSURANCE INSURER B: INSURER 0: INSURER D: INSURER 5: THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSuEO TO THE INSURED NAMED ABOVE FOR THE POI10Y PERIOD INDICATED. NOTWTHSTANDWG .ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER noct 4IENT WON RESPECT TOIIWOCH THOS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE PGUCIES ABED HEREIN IS SUBJECT TO RLL THE TERMS, EXCWSIONS AND CONDMONS OF SUCH POLICIES. AGGREGATE LINTS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. TYPE OF It1URANCE GENERAL LIABILITY ❑ coasERCIAL GENERAL LJABIIJTY LJ (: CLAMS MADE ❑ OCCUR POLICY SOLIDER GEML AGGREGATE UNIT APPLIES PER: L...I POLICY ❑ PROJECT 0 Loa EYESN -M 11/04/ DuTE1� LIMITS EACH OCCURRENCE 11/04/2010 PPRLMISES occurrence) IUD EXP (Any one person) PERSONAL 8 ADV INJURY GENERAL AGGREGATE PRODUCTS -CCMP/OP AGG 1,000,000 50,000 5,000 1,000,000 2,000,000 1,0(0,000 AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ SCHEDULED AUTOS ❑ HIRED AUTos ❑ NoN OWNED AUTOS ❑ GARAGE LIABILITY ❑ ANY AUTO 0 COMBINED SINGLE LIMIT (Ea acoiderm) BODILY INJURY (Per person) BODILY INJURY (Pee occident) PROPERTY DAMAGE Psi acddetd) AUTO ONLY - EA ACCIDENT EA ACC AGG OTHER THAN AUTO ONLY: EXCESS 1 UMBRELLA LLABLL.ITY ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION S WORKERS COMPENSATION AND EMPLOYERS I„LABLLJTY im ANY PROPRIETOR / PARTNER 1 EXEWI VS OFFICER 1 MEMBER EXCLUDED? (Mandatory In NH) gaidALPROVISIONS below OTHER EACH OCCURRENC ACsGRE3ATE Ylo ❑ ER 54_ EACH ACCIDENT E L. DISEASE - EA E IPI.oYEE EL. DISEASE • POLICY LMT DasortarrION OF OPERATIONS / LOCATIONS / vdHI CL.ES/ EXCL./JSI0N i ADDED BY ®NDDRSOIREiiT / SPECIAL PROVISIONS PLUMBING SERVICES CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 NE 2ND AVE MIAMI SHORES, FL 33136 ACORD 26 (2008101) CIF 10 3JVd SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE OANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE LSEUING INSURER WILL ENDEAVOR TO MAR_ 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR L!ABIUTY OF ANY KIND 1JPON THE INSURER, ITS AGENTS 017 REPRESENTATIVES. e131IfS AHlVD / � • W RD CORPORATION. All righs reserved. The AOORD name and (090 are registered !narks of ACORD LE305ZL1756 69 :L1 S00Z/EZ/ZT