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RF-13-1666' Pj c-S s Miami Shores Village JUL 2.6 2U15 Building Department 9W50 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795MM Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 7614949 FBC 20 BUILDING Permit No. I PERMIT APPLICATION Master Permit No.KC l 9 Permit Type: BUILDING ROOFING JOB ADDRESS: -66 t p s 91 S-IW6;r City: Miami shoo gI County: Miami Dade 7jp: Folio/Parcel#; �2 ®C� E� \'� ra Q Is the Building Historically Designated: Yes V' NO Flood Zone: OWNER: Name (Fee Simple Titleholder): ES F �ko(_-j Phone#; Address: I AV' Q cz c­1 °c, 9 rL- CN I _ 3 � (00 city: (-t-!C Y,,o T,_V State: C- Zip; �'� � ® 1 TenantdAssee Name: w Phone#: Email: CONTRACTOR: Company Name: #N2- �V SS �'t��V Phone #: 3dS- ��:Z S010 Address: \Z55,0 $ t 75 c-dL-C rl e, 'BLVD. 2. t k city. n/1t \ state: �l.v n� �A "y °,. zip: '33 Qualifier Name: ®A-) 1z4C.^2. UO D Phone#: 3 0$d 5cl a -so 1,0 State Certification or Registration #. cc G `'2a Z Y7 (60 Certificate of Competency # Contact Phone#: 3®5 A3S-2?_51 Email Address: Dtr� C' Ica rcJlo ; 6.2 +' o" . C.0 46% DESIGNER: Ambitect/Engineer: Phone#: Value of Work for this Permit: $ too > 4 ' Square/Linear Footage of Work: Type of Work: OAddition OAheration ONew ORepakipleplace ODemolition Descriptlon of Work: _ tj L w if u�. -� (i.cn q W N- E n. P m F t &.� 2� Color thm tile: Submittal Fee $ Permit Fee $ CCF $, CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ TralaingWAucation Fee $ Technology Fee $ Double Fee $ StradmW Review $ TOTAL FEE NOW DUE $ 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 1 ' 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 AIPROVEMENTS TO YOUR PROPERTY, IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR �AN ATTORNEY BEFORE RECORDING YOUR NOT M ICE OF COMENCEMENT:' Notice to Applicant: As a condition to the issuance of a building permit with an estimat value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien brochur will be delivered to the person whose property is subject to apachment. Also, a certified copy of the recorded notice o commenc must be posted at the job site for the first inspection whi ccurs en (7) days after the building - permit is issue . In the e e of such posted notice, the inspection will not be app r v inspection fee will be chdrged u�'I ®//II A /e AQ A &04 �O Agent Con or The foregraing instrument was ackn wl this The force ing instrument was ackn led before me thi az - *! day of , 20 % , b +Iii day ofj. 20i)—, by who is ly known has produced who is personally known to me or who has produced F"• Ow- 1. As' wh did icim -nGQ�O as identificatio d who did take an oath. NOTARY P •' .'•• MY C MISSION #FF001475 NOTARUBLIC: ��n %. op'f PIRES March 25.2017 1 Print: /y My Commission Expires: My k ��+ sa��a+ ue�x��x*• ae��s��x��xees+ ��** �x�e�e�* ee�a�e�ee���s+ ��a�v��x�x�e+ �+ s+ a* ��ae* sa�ae+► �* �er�e*+ ��e��* �xeea�a�a��w�� +a� *s�+r+� *aee��x+��x *eu APPROVED BY Plans Examiner Structural Review (Revised 3 /1212012)(Revised 0711 QVXRevised 06/10n ,009XRevised 3/15/09) Zoning Clerk 9 Tl. 4 .t. { ). ,� .ads r ,,l:, so" 11'' ©" day of October in the year two thousand and eleven (2022) An Holt t The foregoing instrument was acknowledge before me this Vh day of October, 2012, by ' t DIAZ&RU -01 SPONERJ CERTIFICATE OF LIABILITY INSURANCE DA -'`C" 06!17!1&17/1"'""' 1 3 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 certificate holder is an ADDIfiiONAL INSURED, the policy(in) must be endorsed. if SUBROGATKN IS WAIVED, suhoctto the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER _ Insurance Office of America - LNG 1855 West State Road 434 Longwood, FL 32750 NAME: Julia Baldwin PHONE 407 788 -3000 c Fax (407) 788 -7933 ADDRE : Julia.Baldwfn@loausa.com INSURER (S) AFFORDING COVERAGE NAIC # INSURER A: Star Insurance Company 18023 INSURED Diaz & Russell Construction Company 12580 Biscayne Blvd Suite 211 INSURER e: INSURER C: INSURER D: INSURER E: North Miami, FL 33181 INSURER F; -1. GAR: 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 CONTRACTOR 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, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NN��EXCLUSIONS LTRR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POL�rrITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY 1-1 PREMISES o=trrence $ MED EXP (Any one person} $ CLAIMS -MADE OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED LIAr (Ea iT accident BODILY INJURY (Per pemon) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS AAUUTO QED (PER AC CM DAMAGE PER ACCIDEN $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCE88 uA6 CLAIMS -MADE DED I I RETENTION $ WORKERS COMPENSATION X WC STATU- OTH- $ A AND EMPLOYERS' LIABILITY YIN TORY 1 E.L. EACH ACCIDENT $ 11000,00 OFFICEOPRIET PIPARTUDED ECUTIVE� N/A 0077558200 12128!2012.12(2812013 (Mandatory in NH) if yyes, deaoribe under 014 E.L. DISEASE - EA EMPLOYE $ 1,000,0 E.L DISEASE - POLICY LIMIT $ 1,000, DESC OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Reawrits Schedule, A more specs N required) ArwTltr,w �Te- •w. w,-w MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2nd AVE - MIAMI SHORES -FL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE W r aoo-AW I V Eat.Umu t+Urtr'UMATION. All rights reserved. ACORD 25 (2010106) The ACORD name and logo are registered marks of ACORD <� �,.� �, :k ,, FE ` ��.y y srrti S':: � N:. �� ®o � � ,, � t '•, x,ta 9 Sr'f;x`Yt irrT +,7§i ✓ 1 - 5 .. p� .. _ „d t �,� t ,a ��. 'd,s` 7! � �� ,s r ��� l�`xa ^�. ' N i D i e Y�•rx d x � t � � ���r rr �� , r}it g�F3q' t s a .3 Lj` .n'g ...� �rP t Ur^- '3j ;� $..z � t y4� . '�'>r �8 .✓ ,; c.'r�'�y r v a . >, • � a .... Aw qU" ' �abk o- Y � � 1• � vet �^ . , a •yet «. w" D 71, a $ I . way s ''F+• z CERTIFICATE OF LIABILITY INSURANCE °^ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIF ATE [!!�;% D -THIS 3 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 INSURERS }, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the CertMtCate holder Is an ADDITIONAL INSURED, the policy(leg) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT JOSE HERRERA All Florida Insurance PH N 954) 510-7321 (954 510 7323 7782 Wiles Road fhnyNns.com Coral Springs, FL 33067 INSURERS AFFORDMG COVERAGE Phone (954 510 -7321 Fax 54} 510 -7323 INSURER A : IONAL CONTRACTORS INSURANCE CO INCA e INSURED NAT INSURER 13: Diaz & Russell Construction Company INSURER C : 12550 Biscayne Blvd Suite 211 INSURER D: North Miami 11133181 954646 -2358 INSURER E: f INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMEDNT ABO W R RESPECT TOO W HIICCHH THIS CERTIFICATE MAYBE 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. LLTR TYPE OF INSURANCE A UBR NUMBER POLICY EFF POLICY EXP �NEPUA L LIABILITY LIMITS EACH OCCURRENCE $ 1,000,000.00 POL COMME RCIAL GENERAL LIABILITY DANA E TO RENTED PREMISES ocpnrence $ 100,000.00 A O ®CLAIMS-MADE ❑ occuR N N GLF00001423"1 09/07/2012 09!07!2013 MED EXP ( one person) $ 5,000.00 ❑ PERSONAL &ADVINJURY $ 1,000,000.00 GEMLAGGREGATE LIMIT PER: GENERAL AGGREGATE $ 2,000 000.00 ❑ POLICY ❑ PFRrO- ❑ Inr PRODUCTS.COMP /OP AGO $ 1,000,000AO AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OSWNED SCHEDULED ❑ AUTOS ❑ HIREDAUTOS ❑ NON -OWNED ❑ UMBRELLA LIAS ❑ OCCUR ❑-77 EXCESS LIAB ❑ CLAIMS -MADE L 1 RED ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS, UABlLITY YIN NH R EXCLUDED? F- 1 N I A BODILY INJURY (Per person) $ BODILY INJURY (Per accdent $ PROPERTY DAMAGE $ E.L. EACH ACCIDENT E.L DISEASE _ Eq EM E.L. DISEASE. wn r , DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remeft Schedule, if more space is required) GENERAL CONTRACTOR95555 -92338 CERTIFICATE HOLDER Miami Shores Village Building Department 10050 NE 2nd Ave. Miami Shores -FL. 33138 Fax # (305) 758-8972 ACORD 25 (2010/05) QF CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2010 ACORD CORPORATION, Ail rights reserved. The ACORD name and 1000 are registered marks Of ACORD