FCL-13-1497Miami Shores Village
Building Department JUL 0 3 2013
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
FBC 20 10
BUILDING Permit No.
PERMIT APPLICATION Master Permit No. EL'13 �1 -T
Permit Type: WELDING
JOB ADDRESS: Heather Portilla
ROOFING
City: Miami Shores County: Miami Dade gip; 33138
Folio/ParceW 11- 3206- 003 -0020
Is the Building Historically Designated: Yes
NO X Float Zone:
OWNER: Name (Fee Simple Titleholder): Heather Portilla Phone#: 786-391 -0506
Address: 9130 NE 10 Ave
City: Miami Shores State: FL Zip: 33138
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: SafeStreets USA Phone#: 919 -861 -8521
Address: 5660 W Cypress St Suite G
City: Tampa State. FL Zip: 33607
Qualifier Name: William Alan Peacock Phone#: 919- 861 -8521
State Certification or Registration #. EG13000404 Certificate of Competency #:
Contact Phone#: 919- 861 -8521 Email Address: ladams @safestreets.com
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ 99.00 Square/Linear Footage of Work:
Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace ❑Demolition
Description of Work: Wireless Burglar Alarm -1 Cell, 1 Panel, 1 Button Fob, 3 Door /Window, 1 Motion
Color thru tile:
Submittal Fee $5� ' c Permit Fee $ �� CCF $ CO /CC $
Scanning Fee $
Notary $
Radon Fee $
Training/Education Fee $
DBPR $ Bond $
Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ Z'
th
Boeing 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 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 of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this 20th
day of March 20 Y
13 > b Heather Portilla
> >
who is personally known to me or who has produced DL
As identification and who did take an oath.
NOTARY PUBLIC:
�A�
JARROD M. ADAMS
NOTARY PUB LIC
Sign:
Prin . Ja Adams o
1 EE180338
Expi 3/1812016
My Commission Expires:
3/18/2016
Si gnature Pe&-V�� — Contractor
The foregoing instrument was acknowledged before me this 20th
day of March , 2013 , by William Alan Peacock
who is personally known to me or who has produced
identification and who did take an oath.
My Commission Expires: 3/18/2016
APPROVED BY /: Plans Examiner Zoning
Structural Review Clerk
(Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06(10/2009)(Revised 3/15/09)
A coRV® CERTIFICATE OF LIABILITY INSURANCE
4/28/2013
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 DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cerdflcate holder is an ADDITIONAL INSURED, the polky(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this cerdficaie does not confer rights to the
c wMcate holder In lieu of such endorsement(s).
PRODUCER JOHN T COSTA AGENCY INC
P.O. BOX 2338
WAYNE NJ 07470
c oNTA= Name: RALPH A. COSTA
mmE No
E . JTCAGY@OPTONLINE.NET
INSU AFFORDING COVERAGE
NAIC e
INSURER A: FWCJUA
E STREETS USA,LLC
5305 RAYNOR ROAD SUITE 100
GARNER NC 27529
FEIN: 274001370
INSURERB:
INSURERC:
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PERSONAL &ADVINJURY
1_nVFRAAFC r_FRTI1:7CATF NUMRER- 130426002 REVISION NIIMRER-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Lw
TYPE OF INSURANCE
Minn
POLICY NUMBHt
P
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GENERA- LIAIMM
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Fl OCCUR
EEpAApCC�HHp OCCURRENCE
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MED EXP are
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PERSONAL &ADVINJURY
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GENERALAGGREGATE
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GEML AGGREGATE LIMIT APPLIES PER:
POLICY PRO- LOC
PRODUCTS - COMP/OP AGG
$
$
AUTON013
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ANY AUTO
ALLOWNED SCHEDULED
AUTOS NON -OWNED
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$
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$
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UMBRELLA IIAe
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CLAIMS-MADE
EACH OCCURRENCE
$
AGGREGATE
DEQ,' RETENTION 1110,000
$
$
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A
WORKERS COMPENSATION
AND EMPLOYERS LIAR RY YIN
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED? FN
(Mandatory In NN)
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DESpiIPTION OF OPERATIONS below
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28570315
4/24!2013
4/24/2014
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TORY LIMITS
EL EACH ACCIDENT
$ 1,000,000.00
EL DISEASE - EA EMPLOYEE
$ 1,000,000.00
EL DISEASE- POLICY LIMIT
$ 1,000,000.00
D nON OF OPERATIONS I LOCATIONS i VENICLES (Attach ACORD 101, Ad=o" Remarks SaWwe, a more space 19 mqubad)
CERTIFICATE HOLDER
CANCELLATION
Miami Shores Village
g
10050 NW 2nd Ave
Miami Shores, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
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