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MC-14-48f Miami 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 [C) Permit Type: MECHANICAL P'-EC EIvEn JAN 0 81013 6Y: — &— =90 Permit No. Master Permit No. MCA 4 --1 OWNER: Name (Fee Simple Titleholder): `'Z c�. c c v S E 6 F Address: 9 x-18 1 %i S r` v rj- Y-1 t h -i•l1 j �0t F.$ City: state: F(. Zip: _,3 3a 3 f Tenant/LesseeName. V df Cam:,r Cr1vN.c.rl Phone#: 3a� j5F0 9 Email: JOB ADDRESS: L4 IT IV C i VS 5TH eu'' City: Miami Shores County: Miami Dade Zip: 3 3 i 38' Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: ' 4ififfiVxF CONTRACTOR: Company Name: 11' 1 Address: 6-,4 -7- u S'✓ I Ss City: ; F rl i State: Qualifier Name: State Certification or Registration #: Contact Phone#: Email Phone#: JS Zip: ? 1 Phone#. Certificate of Competency #: C- U Address: 13 M bXlz1 '14015 DESIGNER: Architect/Engineer. I Phone#. Value of Work for this Permit: $ '� Square/Linear Footage of Work: Type of Work: OAddress DAlteration ONew Description of Work: 1 c V-1 T06 n o a `l' C tivyz t 14 C i°yuv) VA Van ws-owli Mtn Submittal Fee $ Permit Fee $ CCF $ MCC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ TrainingWWacation Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 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 • Y 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. "WARN iG 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. Sigtlatul � Signature I , Owner or Agent The foregoing instrument was acknowledged before me this day of e1 , 20,t/ ! by ��• —�er� , on a or who has produced As identification and who did take an oath. NOTARY PUBLIC: r L t d� ✓_f ..t "c, Ste: 1 I Ilr•i'1'1 I yy�- APPROVED BY (Revised 07 /10/07)(Revised 06/10/2009)(Revised 3/15/09) Contractor The foregoing instrument was acknowledged before me this ` N day of k >. /, . 20 I-L by who is personally known to me or who has produced,_,_.. as identification and who did take an oath. NOTARY PUB .MARINO PASACHE � COMMISSION # EE53299 Si /< '�°9 EXPIRES: Mamb 22.2015 ��: My Commission Expires: Examiner Zoning Structural Review Clerk P • A� °® CERTIFICATE OF LIABILITY INSURANCE DATE 07/22/2013"' o7 /zz /ZO13 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(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 certlflcate does not confer rights to the certificate holder In lieu of such endorsemerlt(s ). PRODUCER 1- 425- 454 -3386 Arthur J. Gallagher Risk Management Services, Inc. E CT Joenne Manion PHONE adi: FAX Na 425- 451 -3716 EMAL ADDRESS: P.O. Box 367 INSURER(S) AFFORDING COVERAGE NAIL# Bellevue, AIWA 98009 -0367 INSURERA: T.H.B. Insurance Company 04/03/1 04/03/14 INSURED Briggs Transport, Inc. INSURER B • 8 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Modern Midways, Inc. INSURER C: INSURER D: PREMIS S Ea o fe 22901 Sherman Road INSURERS: $ Steger, IL 60475 INSURER F . COVERAGES CERTIFICATE NUMBER: 34846176 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. NS LTR TYPE OF INSURANCE ADDL NUMBER POLICY EFF MID POLICY EXP Lem A GENERAL LIABILITY CPP010090203 04/03/1 04/03/14 EACH OCCURRENCE $ 1,000,000 8 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR PREMIS S Ea o fe $100,000 MED EXP (Arty one person ) $ PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AC,G $1,000,000 POLICY PRO LOC $ • AUTOMOBILE LIABILITY CPP010090203 3 4 COMBINED U BI 1,000,000 BODILY INJURY (Per person) $ ANY AUTO ALL O S SCHEDULED AUU TOS S AUTOS BODILY INJURY (Per acciderd) $ % PROPERTY DAMAGE Persaddmd $ HIRED AUTOS 8 NON -OWNED AUTOS • UMBRELLA LIAB OCCUR ELP001021004 04/03/1 04/03/14 EACH OCCURRENCE $ 4,000,000 N AGGREGATE $4,000,000 8 EXCESS LUAB CLAIMS-MADE DED I I RETENTION 0 $ WORKERS COMPENSATION WC 3TATU- OTH- AND EMPLOYERS' LL48UiY YIN ANY PROPRIEfORIPARTLNUD, ? CUTIVE OFFlCER/MEN®ER EXCLUDED? � MIA ER EL EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ @&mdatmy M NH) ffy� destabe under DrSd ON OF OPERATIONS bebw E-L DISEASE - POLICY UMTr $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, If more space Is required) St. Rose of Lima Catholic Church a School; The Archdiocese of Miami; Archbishop Thomas Weneki and Village of Miami Shores, Florida are included as additional insureds but only as respects the operation of the named insured per policy terms and conditions - policy form CG133C 07/95. Event Dates: January 24 - 26, 2014 MULUtK Village of Miami Shores c/o Building Dept. 10050 HB 2nd Avenue Miami Shores, FL 33138 USA 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 z�� 4 41a.-on 70A ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD jomanion 34848176 01/11/2014 14:40 3052522650 PAGE 02 00�941 r—+- Miami -Dade Cour�`+,.r•tgjte •of Florida • -T gis.NbTABKL•- 1Q NOT PAY. , Y. 5234515 8��ffinwNrEnoa,�c�. ' E )( PiRES': MODERN mIDWAYS MCgHER OF Ck1Rl!T REr#EimAL Stp.T.FWillER 30,. 2014. • 14141 `CORAL WA Y 3369733 ' •Must ba disoff0d•+at PUCO Of•t• wfw m A9i'giWI FL' 33175 Parsuanq totboi ty Cddo Ct►eats� ONIIl11ER 'ima. TYPR OV. BUSBlI " . PAYMENT aiww o MODERN NUDWAYS 191 CARNIVAL.- SPONSOFIED BY TAX 4OLL.ECToA :LFn1t(s) 12 $475,00.108116/2013 TXHS1' 13 -Q479 this Land &ts n=:7iax 8MIA o0 m1fitms ' • :of tixe LM' S�iaess T� Tira tiefai is nol � irk _ pore{iL m e ca fedtiaa o4 tUe lmid�,c r ftifl a 3o da basi�rs HOIdg -M.00. Y �f i cr ,. �ga�rseyiar,' v. S��ngniree <erttswh{d!s�liYtothe�+�r ', . dis"WWI N10. shore oaaA 4 etf ail mw vawcIsK -t-. TAe "WWI ForNprat�rm9tiao,tisit i il 0 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(IffamuYYYY, 1/13/2014 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: f the certificate holder Is an ADDITIONAL INSURED, the pollcy(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 certificate does not confer rights to the certificate holder in lieu of such endorsemen s . PRODUCER CONTACT Arthur J. Gallagher Risk Management Services, Inc. P.O. BOX 367 Bellevue WA 98009-0367 PHONE FAX _ E�Aa INSURER(S) AFFORDING COVERAGE NAIC Ni EACH OCCURRENCE [NSUIRERA-T.H.E. Insurance Company DAMAGE TO RERTff PREMISES a $100,000 INSURED INSURER B PERSONAL BADVINJURY INSURER C: Briggs Transport, Inc. Modem Midways, Inc. INSURER D' $2,000,000 22901 Sherman Road Steger, IL 60475 PRODUCTS- COMPIOPAGG $1,000,000 INSURER E A INSURER F: LIAEIJTY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIREDAUTOS X AUTOS -OWNED COVERAGES CERTIFICATE NUMBER: gas2gsaso 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 TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP Lem GENERALLuunuTY CLAIMS -MADE KI OCCUR N7:01M MERCIAL GENERAL LIABILITY CPP010090203 4WO13 111=014 EACH OCCURRENCE $1,000,000 DAMAGE TO RERTff PREMISES a $100,000 MED EXP (Any one person) $ PERSONAL BADVINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO Loc PRODUCTS- COMPIOPAGG $1,000,000 $ A AUTOMOBILE LIAEIJTY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIREDAUTOS X AUTOS -OWNED CPP010090203 13/2013 /2014 C(EOa M aBINED 1000 000 BODILY INJURY (Per person) $ BODILY INJURY (Per acddend) $ X PRO�mDAMAGE $ A UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE ELP001021004 4=013 =2014 EACH OCCURRENCE $4,000,000 X AGGREGATE $4,DW,000 DED RETENTION so $ A WORKERS COMPENSATION AND EMPLOYERS' LIABU Y YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? � (Mandatory In NH) If yyeeaa describe under DESCRIPTION OF OPERATIONS below NIA WC134324 1012912013 0/2912014 X I WC STATU- OTH- E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIFiloN OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is mWhed) St Rose of Lima Catholic Church & School; The Archdiocese of Miami; Archbishop Thomas Wenski and Village of Miami Shores, Florida are included as additional insureds but only as respects the operation of the named insured per policy terms and conditions - policy form CG133C 07/95. Event Dates: January 24 - 26, 2014 Village of Miami Shores GO Building Dept 10050 NE 2nd Avenue Miami Shores FL 33138 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOROD REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All dahts reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 0 a Local Business Tax Receipt Miami —Dade County, State of Florida -THIS IS NOT A BILL -DO NOT PAY 5708137 BUSINESS NAMEILOCATION MODERN M DWAYS ST ROSA LIMA CATHOLIC CHURCH 418 NE 105 ST M RM I SHORES, FL 33138 RECEIPT NO. EXPIRES RENEWAL SEPTEMBER 30, 2014 5953303 Must be displayed at place of business Pursuant to County Code Chapter 8A -Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS MODERN MR)WAYS 191 GARNNAL _ PAYMENT RECEIVED BY TAX COLLECTOR SPONSORED 352.50 OV142014 Urdt(s) 15 0230 -14- 001962 This Local Badness Tau Recelpt only confirms payment of the Local Badness Tax. The Receipt knot an cense, permit, of a cerdlicatioa of the holder's goalificadon%to do hasiness. Holder must comply with any governmental or nongovernmental regain" lawns and requirements which apply to the basfaess. The RECEIPT N0. shove mast be displayed on an commercial vehicles - Miami -Oade Code Set 8a- X For more information. visit www d;auIdadeaov/taxcojJector