DEMO-11-2143Miami 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
FBC 20
Permit Type: BUILDING ROOFING
OWNER: Name (Fee Simple
Permit No.
Master Perm... r.u.
Address:
City: - l State: ei_ Zip: / !2 (22 f
Tenant/Lessee Name:
Email:
JOB ADDRESS:. 10 °nC> 10-5
zz
City: Miami Shores County: Miami Dade Zip: J -31 '-J.0
Folio/Parcel*
Is the Building Historically Designated: Yes
NO Flood Zone:
CONTRACTOR: Company,1 Name: LA �A 0� \\0015- ' Phone#:
Address:y
City: %✓1 ( —State: ��� Zip: Cf
Qualifier Name:
�JL ���— Phone#•
State Certification or Registration #: G 1 G 1� Certificate of Competency #:
Contact Phone#: Email Address: ',I t
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ Square/Linear Footage of Work: _
Type of Work: ❑Addition DAlteration
❑New ORepair/Replace
Description of Work: LT Z) cA.-k
1
Submittal Fee $ Permit Fee $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF
CO /CC $
DBPR $ Bond $
Technology Fee $
&IFfemolition
TOTAL FEE NOW DUE $ �z 2 d ( o
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
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 Signat e
Owner or Agent Contractor r�
The foregoin in trument was acknowlledgeed��bef re me this �- The foregoing ins ment was acknowledged before me this " `
day of , 20 t � , by \'t" N S!s, ';'day of , 20 L, by V lC0r `k1 ,
who is personally known to me or wh4h # W &1� who is personally known to me or who has produced Ock1fl
As identifi�t�� "olio di4 taken oath. as identification and who did take an oath.
NOTARY PUBLIC: `�� �°�` :ms's_ NOTARY PUBLIC: �\ %JJII"'JJ/ /�
CD
Sign: ' Sign:
Print: '�i �h /yT_ 4,�•�° Print: ®: ���,�\ o j
My Commission Expires: My Commission Expires�� ' ,yam ®�a��co
APPROVED BY .. �1" �o� Plans Examiner Zoning
Structural Review Clerk
(Revised 07 110 /07)(Revised 06 /10/2009)(Revised 3/15/09)
11/17/2011 15 :53 3052648996 LANDSTONE BUILDERS 1 PAGE 01102
5 FATE OF FLOMA
DEPARTMENT p
3iT3INESS AND PRCFLSSIONAL ..�QLATION
CONSTRUCTION INDUSTRY LICENSING HOARD
"q 1940 NORTJK MONROE STREET ($50) 487 -1395
TALLAX&SSEZ FL 32399 -0783
['►AMMrARA
LANbSTONE'BU �S .TNC
6600,00111SN 70TE STREET APT 350
FL 33143
Congratulationsl With this license you become one of the nearl
Our one million
Floridians licensed by the Depart Of Businc and Professional Regulation.
ur professionals and businesses range from architects to yacht brokers, from
boxers to barbeque restaurants, and they keep Florlda's economy strong.
Every day work to improve the way we do business in order to serve you better.
For informatiti on about our services, please log onto www.mytioridalicense.com.
There You can find more fnfomzation about our divisions and the regulations that
impact You, subscribe to deparlmAnt newsle am and loam moro about the
Department's initiatives.
Our mission at the Department Is: License Eftiriently, Regulate Fairly. We
contently strive to serve you beHui ao that you can servve your customers.
Thank you for doing business in Florida, and congratulations on your new license!
DETACH HERE
From:Abby McDowell Faxia.Roemer Insurance Page 1 of 1 Date: 1/17f2012 01:27 PM Page:1 of 1
OP ID: AM
`♦4r- "'`r"- CERTIFICATE OF LIABILITY INSURANCE
°A 01117°"Y'"'
01 /17/12
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 ADDITIONAL INSURED, the policy(ies) 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 certificate does not confer rights to the
certificate holder in lieu of such endorsement s
PRODUCER 954 -731 -5566
W.F Roemer Insurance Agency
William F. Dowd 954 -731 -8438
P.O. Box 190689
Fort Lauderdale le FL 33319
William F. DowWlll
CONTACT
PHONE FAX
c No Ext : A/C No):
E-MAIL
ADDRESS:
PRUSTOMEODUCER R ID is LANDS -2
INSURER(S) AFFORDING COVERAGE
NAIC S
INSURED Landstone Builders Inc
7005 N Waterway Drive # 304
Miami, FL 33155
INSURER A: Association Insurance Co.
11240
INSURERS: Mid - Continent Casualty Cc
23418
INSURER C
EACH OCCURRENCE
INSURER 0
X
INSURER E
$ 100,000
INSURER F
MED EXP (Any one person)
\.V VCRlib C0 CERTIFICATE 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. 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.
INSR
LTR
I TYPE OF INSURANCE
POLICY NUMBER
POLICY EFF
MM/00
POLICY EXP
MMMDIYYW
LIMITS
B
GENERAL
LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
04GL000837895
12/22/11
121=12
EACH OCCURRENCE
$ 1,000,000
X
PREMISES Ea occurrence
$ 100,000
MED EXP (Any one person)
$ Exclude
PERSONAL & ADV IN.URY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY M PRO LOC
PRODUCTS - COMP /OPAGG
$ 2,000,000
B
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIREDAUTOS
NON -OWNED AUTOS
O4GL000837895
12122111
12/22112
COMBINED SINGLE LUIT
(Ea accident)
$ 1,000,000
BODILY INJURY (Per person)
$
BODILY N.URY (Per accident)
$
X
PROPERTY DAMAGE
(Per accident)
$
X
$
UMBRELLA LIAB
EXCESS LIAR
HCLAIM
OCCUR
MADE
EACH OCCURRENCE
$
AGGREGATE
$
DEDUCTIBLE
RETENTION $
$
A
AND EMPLOYERS LIABILITY
ANY PROPRIETOR/PARTNER/F�CUl1VE Y / N
OFRCER/MEMBER EXCLUDED* ❑
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA A
CV002140504
05/21/11
05/21/12
TORY IM TS R
E.L. EACH ACCIDENT
$ 1,000 s 000
E.L. DISEASE - EA EMPLOYEE
$ 1,000,00
E.L. DISEASE- POLICY LIMIT I
$ 1,000,000
L
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
M IAMIS2
Village of Miami Shores
10050 NE 2 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.
AUTHORIZED REPRESENTATIVE
w 'I aas -ZUUV AcvRD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
NOTICE OF COMMENCEMENT
AMON101 C1111111WE PW= 07NJOB ffMff7=8FRuF MMM
PERMIT NO __W FOLIO NO�_
"I'll 1� I -Ilel,
41,141 11be I . a
STAfE OF
THE UNDSRWMM hereby gives dW knWavOnierts will be n!W
property. and In accontance with Chapter 713. Rorkle Statutes, the *qqv*gh*
Is wavided in Oils Magog, of Covivirwmarnent
C-FN 2C-i12Rf_-iC-j3564j-_j
OR Bic 27964 F9 4156; (1p9 )
RECORDED 010"18/2012' 14:2C,:(,':-
HARVEY 6:UV1Nt CLERK OF COURT
MIAMI -DARE COUNTY? FLORIDA
LAST PAGE
COjjNr1 OF DA!)F-
. I of the
this N C jrao C C Y
dvY Of
Pip C01MAt.
4Y
- yl�
I Some above naerved *ff use at reconfto ovine
1. Legal desmipflon otproperty and WaWadftm logo 0_6� jo-5
2. Desm"m of kqx&v=wjt k"40—T) 4 L- L-1 T)c.-.,,
C.-j
3. Ownw(d) name and ad&esm V E a.,O%-> k A 0& t I opw %J
Intel In propertr. I,
Name and address of fee simple jdahalder.
e120 owe
6. SureV. (Payment bond wed by
curer from contractor, if arq) -
Neme, widnaes; and phone number
Amount of bond
6 Landees name and address:
7 Persons within the State of Florida designated by Owner upon whom notloss or other documents may be served as provided by
Section 713.13(1)(a)7, P"Jda St&gh*k
Nmft aftm and "m rhtetlber
U. us au"u"'O"s w "gnw o vwnem Geognafts the fokwV pwso*) to reems, a copy of #0 Usnorms Magog as provided in Section
713.13(1)(b), Florida SWhft&
Name address and phone number-
-- �y,... ..w. w v wo u mm La Loommencement
(11*60num ddekl raw tram Ow daft ofnx=dng Noss e,m i I dab bspeaqkM
WAIVUNQ TO OWNER ANY PAYMENTS MADE SYTHE OWNERAFTER THE EXPIRATION OFTHENOTICE OF 00MMENCEMENTARE CONSIDERED
IMPROPER PAYMENTS UNDER CHAPTER M FART I. SE=DN 713.13. FLORIDA SMUTES AND CAN FMU IN YOUR PAYING TWICE FOR
'MPROVEMEMM TO YOUR PROPERTY A NOTICE OF COMMENCEMENT MUST BE RECORIM AND ON THE j0S SITE B THE
OBTAIN FINANCING. CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK
FIRST INIM-ECTM. IF YOU INTEND TO COT POSTED 84NE
OR RECORDING YOUR M071M OF COMMENCEMENT.
signeftings) of qwner(s) qr Owns"'
Prepared By LPrepared BY
Print Name
TwOffice, Print Name
rdWOff !Ce
STATE OF FLMDA
COUNTY OF MIAMI -DADS
— day 01 /05 /ZO17- ZU 12
BY VZ-e0^.iqLAe_ M<'CrZL
O ln&4iduagy, or ❑ as —lbr
Personally Wown, 0rjqproduced the ftftwing type of
Signature Of Notary Public:
Print Name:
(SEA4
Under Penalties Of Mpy, I declare that I ho w read the foregoing am Noy
Public State of Florida li
that the bols stated In It am
true, to the best of rrr `3U Egana
1 knowledge and beW.
- M_". Do 0681
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