EL-12-911 Miami Shores Village MAY P, 1 26 r�
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Building Department BY; m®mappep..........
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(3057 762.4949
FBC 20
BUILDING Permit No. r 1
PERMIT APPLICATION Master Permit No.
Permit Type: Eleddeal
JOB ADDRESS: M
City: Miami Shores County: Miami Dade -zip: ���
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder);-,\C�% GC 4 A-1 K)k �� Phone#:M3
Address: Is 2m�_
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name:FRS6 1SlOW QOLAX,e 4- ,N(�D� Phone#:43U_-a-3c(.5 j-(�
Address:(( �. . (O ST
City: State: �2 Zip: �3pt C7
Qualifier Name: 612 WA,i1/P_)n 'a(.t IA Phone#: 30.E � '�5 C 910
State Certification or Registration#: h C C)0?S9 Y-&—certificate of Competency#: N �
Contact Phone#: SL50 ( (o( Email Address:
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit: '* Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ONew ORepair/Replace ❑Demolition
Description of Work: C�C o 2l� €)c9' - iciavoes� PkgI1 k
s,
Submittal Fee$ Permit Fee$ Xk.5 CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Educadon 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 inf6rmation 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 st inspec •on which occurs seven (7) days afier the building permit is issued. In the absence of such posted notice, the
inspectio will t approved and a reinspection fee will be charged.
Signature r I f
Owner or Agent C ctor
The forego g instrument was acknowledged before me thishe foregoing instrument was acknowledged before me this
day of A440 t:� 20 Lam' ,by 2F/�1 4S day of ft°iAIL(!4 ,20 by /�/�C� A
who is perso yfor who has produced whois personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
n
Sign: Sign.
Print: Print 1 ,Ne�/lr'
,N. Adr�a1> rznieilto — �n � �,_ A
My Sion u My Commission Expit = Adri1 arniiento
Comnnission BD6123�3 -Commission DD81233
xpires: AUG. 0,2012 ��,, .> Pxpires: ATIG.10,2012
E
BONDED THRU ATLANTIC BONDING CO.,INC BONDED WRU A1L AYdTIC BONDING Ca,INC.
4rdceFoY7t�Y:@sOoY�Y:k�oY9e k9e�YtY�Y9e��YoYde3r3:>ti�F�Y���Yabde��Y3roYoYeYd:3c3e9c9e k4r4:Ye�Y�Y9:k k&4:eY��4nk:YN:3:k3:k�1r4e keYrfe Y k�Y4e�Y4e�Y>Y3:>�sY�dr k�4e:4�Y k�F kiY9nY
k4c3:*8nkaka�3c9e�Yde
APPROVED BY 4kLJPA Z//L/a, Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07XRevised 06/10/2009XRevised 3/15/09)
Mar.28.2012 09:56 AM PRECISION POWER & CONTROL 3058251810 PAGE. 5/ 5
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CERTIFICATE OF LIABILITY INSURANCE r DATE 0312OD/YYYY)
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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 QOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: It the oeft(flcate holler Is min 150—m—MAL KWNIED,the pafiey(lee)must be arndorred. If SUBMUMN iS'WAIVED,subject to
the terms and Conditions of the policy,certain pollcles may require an endorsem errt. A statement on this oerdficate dose not eonfer tight*to the
oertltloate holder In lieu of such endorsems 4). WE
1P,qRsO2wiwi Reynolds Inc. �-238-1000
Mtanti�FL 33 y8 a Highway 305-255.9643 Prto
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INSIAM s FORDING CMRAOR rIAC:
"MR= Precision Dower I Control Corp JOURIM A I 009ofield Empiffers Ins.Co. 10701
241 East 10th Street INWFM s
Hialeah,FL=10 (NOURER C:
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COVERAGES CEniFICATS 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. NOTWITHBTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY HE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DEBOR113ED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Ran Wien LTR TYPE OP INSURANCE POLIOY NIiMbER LOM
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CEnTIFICATIEE HOLDER CAN Tl N
MIAMISH
SHOULD ANY OF 7146 ABOVE DESCRIBED POLICES 86 CANCEL•LSO 9EFORE
THE EXPIRATION DATE THEREOF, NOTICE VYILL BE DELIVERING IN
Mimi Shores Village ACCORDANCE WITH THE POWY PROVISIONS.
Building Department
10050 North East 2 Avenue AUYNORIM REPROWTATroe
Miami Shoroe,FL 33038
0 lgallw2009 ACORD CORPORATION. All rights reserved.
ACORD 25(200"9) Thee ACORD name and I"*are registered rawks of ACORD