MC-13-1847Miami 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) 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: MECHANICAL
AU6 3 2a 13
FBC 20 -�,
Permit No. .)2 J -
IND
Master Permit No. ??P- -� l
JOB ADDRESS: VSi tri A42
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11 - 3 ,�O6 - 0713 _3 OqQ
Is the Building Historically Designated: Yes
NO - - Flood Zone:
OWNER: Name (Fee Simple Titleholder): U2= Phone#:
AddressAsi kg 0 wee
city: UIN\/4 S e r State•.--
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company
Address: 2,3 G
City: M l
Qualifier Name: e.(2
Name:
�`1
6'�00
C- Phone#: �S Z��Q
.,. 1
tlA4
A at --.d— (All)
State Certification or Registration #: �' l C( �� Certificate of
Contact Phone#: 3Cll;� ?LT �1 Z Email Address: y S LC
DESIGNER: Architect/Engineer: Phone#:
,71 �
Value of Work for this Permit: $ �0 (0 ® Square/Linear Footage of Work:
Type of Work: OAddress
Description of Work:
Submittal Fee $ Permit Fee
Scanning Fee $
Notary
Radon Fee $
Training/Education Fee $
Double Fee $ Structural Review $
CCF
ORepair/Replace ODemolition
CO /CC $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $
0(1�
Bonding Company's Name (if applicable) _
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
zip
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 eyed to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of comme went must be sled at the job site
for the first inspection which occurs seven (7) days after the building permit is issued the absence posted notice, the
inspection will not be approved and a reinspection fee will be charged
Signature Cb,7 Signature
Owner gent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of , 20 L3, by CER0—D C R 00 1 day of 0 20a, by CXQCU ,\C_ Pty �
who ' me or who has produced who is arson y o o me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
t
Print:
MY Co on *pig
APPROVED BY
Y COMMISSION # DD935608
EXPIRES October 25, 2013
Examiner
NOTARY PUBLIC:
Sign: 1 v Fv
Print: Q ) if°1 lot ") (_ I a f
My Co ; *,: DAVID M DIPtJGLIA
MY COMM*61ON # DI)935608
'�0lovn;?P' EXPIRES October 25. 2013
Zoning
Structural Review Clerk
Revised 3/12/2012XRevised 07/10 /07)(Revised 06/10/2 MXRevised 3/15/09)
. i
CERTIFICATE OF LIABILITY INSURANCE 08113/13
T HOLDER. THIS CERTIFICATE IS ISSUED AS A MATTER OF IN iidp-jo—NLy-4N—DdONFtRSNoFuGHTSI&bWfi4E IERTWi�- ATEHO R. TH is-
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEN0,011-ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERTIFICATE OF INSURANCE DOES NcyrcowwrUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER; AND THE CERTIFICATE HOLDER.
If the certificate holifer Is an ADDITIONAL INSURW, #0 must be endo ff SUBROGATION IS WAWED, subject to
IMPORTANT.
the term and conditions of the polli:16 certain policWs nm require an entforsenwift A statement on #ft owwIcift owe not conter rights to the
certificate bottler in lieu of such eniloriisrrisrit(s).
PRODUCER
Sunflovais Insurance Group Inc
11401 SW 40th St Ste 311
Miami, Fl. 33165
Phone Fax (305)553 -4858
INSURED
V J S SERVICES GROUP
1117 SW 141 Ave
MIAMI, FL 33184-
WESTERN WORLDINSURANCE CO.
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,
......... M 1#,L'r% OV DAM M APAQ
iDESCRIPTION OF OPERATIMI LOCATIONS I VEHICLES (AnWhAUUMIUI,FAURIOMIKenlarRoolptecRe ®,
CERTIFICATE HOLDER CANCELLATION . ......
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BE FORE
MIAMI SHORES
THE EXPIRATION DATE THEREOF, NOTICE MLL BE
DELIVERM IN
I ACCORDANCE WITH THE POLICY PROVISIONS,
BUILDING DEPARTMENT
ACORD 26 (2010" AF
tO IM-2010-ACORD CORPORATION. All rights reserved.
The ACORD name WW logo are registared merles of ACORD
rME OF INSURANCE
ADDLIURR
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LIMITS
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COMMERCIAL GENERAL
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NPPI314393 09/03120`12:
100 ,000.
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PERSONAL & AM INJURY
$ 1,000,000,00
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BODILY INJURY (Per Pe—)
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iDESCRIPTION OF OPERATIMI LOCATIONS I VEHICLES (AnWhAUUMIUI,FAURIOMIKenlarRoolptecRe ®,
CERTIFICATE HOLDER CANCELLATION . ......
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BE FORE
MIAMI SHORES
THE EXPIRATION DATE THEREOF, NOTICE MLL BE
DELIVERM IN
I ACCORDANCE WITH THE POLICY PROVISIONS,
BUILDING DEPARTMENT
ACORD 26 (2010" AF
tO IM-2010-ACORD CORPORATION. All rights reserved.
The ACORD name WW logo are registared merles of ACORD
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