MC-12-2201 Miami Shores Village
Building Department NOV 2 6 20'2
10050 N.E.2nd Avenue Mi
amp Shores,Florida 33138
Tel:(305)795.2204 Fax:(305)756.8972 _.
INSPECTION'S PHONE NUMBER:(305)762.4949
BUILDING Permit No. MT'_ P201
PERMIT APPLICATION Master Permit No. i Z-t ~r�
FBC 20
Permit Type: MECHANICAL
OWNER:Name(Fee Simple Titleholder): KA�Z_?14OrO Phone#•
Address: .1921
City: Pr State: Zip: j
Tenant/lessee Name: Phone#•
Email:
6e �
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip: j 3 C'1,
Folio/ =el#•
Is the Building Historically Designated:Yes NO Flood Zone:-
CONTRACTOR:Company Name: c
Z-22' l I V C- Phone#. t��_ ��"6 7z �P
Address: 2/VO I-S LU ee c-t
City: A7 Z. State: rrL Zip: sl$l
Qualifier Name: !l e dw e5�<%_j Phone#.
State Certification or Registration#: C-(C- `76E�16 q- Certificate of'Competency#•
Contact Phone#:._F®'' &j6 "- Email Address: I/V4/1fu® 1P G
�-
DESIGNER:Architect/Engineer: Phone#:
Value of'VVV r or is a SquarelLin
Type of Work: DAddress 0 Iteration ONew 10,vairlReplace O emolition
criprk:
Submittal Fee$ 0'0 Permit Fee$ ®Q CCF$ COlCC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
I
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 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 absence o such posted notice, the
inspection will not be approved and a reinspection fee will be�charged
Signature (,*A Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this_2D h
day of IC-3 ,20-1' , y r1 ALX day of L ,20 9`?by\A J�1 k J C L_M f- t
who is personally kiiown'to me or who has produced i�C�l who is 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: ```����nuirrnt,1�i, NOTARY PUBLIC:
SN'Sign: oo s ��' Sign: (,L
Print: = 9 '� ' _ Print ^
��''i s• 8/Ux8 3 l`d . �`��`\
6:8ededTtMU1 ='
My Commission Expires: M Commission Ex/ .
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APPROVED BY ' Examiner Zoning
Structural Review Clerk
Av , ..
tea °
(Revised 07/10/07)(Revised 06/1=009)(Revised 3/15/09)
12/06/2012 18:20 3052647666 VIP INS PAGE 01
AC40R CERTIFICATE OF LIABILITY INSURANCE f °� 11201
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THiS CERTIFICATE iS ISSUED AS A AAATTER OF INFORiAATION ONLY AND CGINFER3 NO Mlffkf5 UPON THE CF_RTIFtCATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NE13ATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING iNSU Rte( r S,AUTHOR®
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
iMPORTANT: If do eerikiita holder�an AD�I7 IOIVAL INSURED,the polWes)muse be endor>sad: If 9Li8R17�ATiON 19 wAIV®,subJeet to
the ternle and canditinns oldie poOcy,certain pie tiles may require an endwsement.A ablemod on this Nr p does noe eoMar CMS to"
cartPACats hefder In Ifeu cf such eriftmermnrt(s).
MOUGER r=,cs
V.i.p Insurance Agency p•i�d ` (305�266n986S i � .,�r. (306)284-7686
1939 SW 87 Ave A Imo; grivipins.n.et ..
Miami,FL 33974 !Nt.9 NAIL F ;
Phone (305)266.9666 Fax (309)284-?WS INSURERA: A=ndantC=MefftIn&
INSURER E3: CaailePcint Florida Inc
'GS Mechanical Inc (N9uIC:
2140 SW 80 Ct INSUMB4;. ,,. _....._.... ..
Miarni,FL 33155- (306)798-?M INSURER 0:
COVERAGES CERTIFICATE NUMBER: E — — REVISION NUMBER:
1I.113 IS TO CERTIFY THAT THE POLICC $—OF'INVSU& CE LISTED BELOW HA{tE l3F_EN ISSUED TQ THE?INSUREO NAPRED A130vB(:OR THE f'OLtCY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
i CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE,INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREON IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LMffS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
IiNSR 4Y5►G POUGY NUNBER MrrtD ... __pp�I��{���.��I LIMITS
IL I TYPE OF U�$LiRANGE A� INt I.(PO OY Eff).IMpyopryYl Y}J
1 GEMtALLLAIIIII TY 11'egCH C��UPRR PE. $ ,.000,aoo.00
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GEN L AWREGATE UWT APPLIES PER PfiabUCt9.CCnAP10P AGG l a 1,000,000.00
J .I I POLICY I I I I Lac _
j AUTILE LIABILITY I I EGi SiIYGL�E LIMIT
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ALL OWNED S ULED i I BODILY INJURY(Pbr oCiAft i) 3
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DIED I RETENTION'J . S
WORXERSCDMPMIIBATION I »h+l.OriYTaLJNlT3 I I QTRH
AND EMPLOYERS'LIARK Y V 1 N
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B oFFIC R Etc ED i NIA 09101/2012 09/012013
(AAgm�rlldn01'Y Irt NH) I E.L.DISEASE-EA GRLO s ,100,000.00
DESCRUM N OF- OPERATIONS hRIM _ 'I E.L.DISEASE.POLICY Limn s 500,000.00
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DESCRIPTION OF OPERATIONS 1 LOCAIMNSI VENICLFS(AlYOeh ACORD IM.A&Mmsd Ramiubs--dLde.If mma space Is n"*W)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DE ECRIB®POLICIES BE GANCELL10 BEFORE
CITY OF MIAMI SHORES THE FXPtRATiON DATE THEREOF,NOTICE WILL OR OHLiVE M UN
ACCOfMiANCR WITH THE POLICY PROVISIONS,
1 AUTHORIZED REPRESENT
01886.2090 AC RD CORPORA . All righm reserved.
ACORO 25(201105)OF The ACORD and logo are ragistared marks of ACORD
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MIAM4 FL
PERIM NO.231
684559-9 TMS IS W>T A BILL DO NUT PAY RENEWAL
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2140 SW 80 CT
' 331155 UNIN DADE COUNTY
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saclW%Aft MECHANICAL CONTRACTOR WORi(E fS
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2140 SW 80 CT
PA�aAr{wp.sO�,O MIAMI FL 33155
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