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PL-13-10634 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 MAY 152013; FBC20lo BUILDING Permit No. 5-1 ®I® S PERMIT APPLICATION Master Permit No. Permit Type: PLUMBING JOB ADDRESS: ,2S / /OO s% City: Miami Shores County: Miami Dade FoliolParcel #: Is the Building Historically Designated: Yes NO Flood Zone: Zip: 13s OWNER: Name (Fee Simple Titleholder): 4/01441•40 '10 2 7 Address: /25- /V4 /06 sl- aty: A/R /14/ or '5 Phone 305- 7*' ° q699 zip: �i3/ 3 �' Phone#: State: it" Tenant/Lessee Name: Rm 41: CONTRACTOR: Company Name: Pao 045- am-ti 2 e 0 0s Phone#:186 316° 302 Address: 62.561 S14) 39 le r r City M t a tvt, % / Qualifier Name: CJv //® 0t4 State Certification or Registration #: 1100 State: _f L zip: 33i 6'S Phone#: 7 SG.) 316 ' 30t( Certificate of Competency #: 2 61 %3 W (�J Contact Phone#: Email Address: DESIGNER: Architect/Engineer. Phone#: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: DAddress Alteration %New / ORepair/Replace DDemolition Description of W k: o5 / a //f %( /v f4 /i 4,r/et-id e* e* wasesev * * *e * ***ee * *a * *****ar ** + * *reF *******rr ee***** A*********+e************** *aa Submittal Fee $�' �j ermit Fee $ /b CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ Bonding Cbmpany's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) "' f'1 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 co t must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued absence of such posted notice, the inspection will not be d and a reinsp 'll be charged. Signature The f day of Owner or Agent instrument was ac tt 20a,by ,1', // wledged before who has produced As identification and who did take an oath. Signs �/7" .Pig /fi ��_ fl or ,' Contractor this The fore : � mg instrument was acknowledged before me this � ; day of 04 , 20 Lt by -1(!110 Ork y who is personally known to me or who has produced as identification and who did take an oath. NOT Sign: Print: My Commission Expires: 1 /1/3 431:.1.1N, JULIA A. TA1 JECHEL MY (AM MISSION II DD 887862 EXPIRES: Au ust 8 In e**** ea*e*aas* ** ** re**u* e*e* *"s w *as*reev*u * * ***esaraaau< *a*r* N LIC: Print: My Commission Expires: ,; s" E'PIRES: August 8,2013 Thu Budget Neirf OF0.0 Examiner Zoning Structural Review Clerk Revised 3/12/2012)(Revised 07 /10107)(Revised 06110/2009)(Revised 3/15/09) CERTIFICATE OF INSURANCE ISSUE DATE 5/30/2013 THIS CERT IRCATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER'nFTCATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AIIIEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONRACT BETWEEN THE ISSUING iN,tFtER(S), AUTHORIZED REPRESENTATIVE OR PRQDucER, AND THE CERTIFICATE HOLDER. IMPORTANT IF THE CERTIFICATE HOLDER IS AN ADDITIONAL SISURED, THE POLICYPE3) 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 S.G. & Assoc Ins Brokers, Inc 9999 Sunset Drive Suite 102 Miami. FL33173 INSURER(S) AFFORDING COVERAGE INSURER A: Scottsdale Insurance Company INSURER B: N/A INSURED Dade Gas Contractors, Inc 6259 SW 39th Terrace Miami, FL 33155 COVERAGES INSURER C: INSURER 9; INSURER E: N/A THIS IS TO CERT)FY 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 POUGIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDFTIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM$. INSR TYPE OF POLICY 7 POLICY LMT LTR INSURANCE NUMBER I EFFECTIVE DATE A GENERAL LIABILITY CPSI 987088 1013$/2012 POLICY D(PIRATION DATE 10/28f2013 GENERAL AGGREGATE PRODUCTS-COWOP AGO. PERSONAL & ADV. INJURY EACH OCCURRENCE DAMAGE PREM RENTED TO YOU ABED EXPENSE (Any one person) B C D a PERSONAL LIABILITY EXCESS LIABILrIY 2,000,000 1.000,000 1,000,000 1,000,000 100.000 5,000 COMBINOED SINGLE LIMIT MEDICAL PAYMENTS TO OTHERS EACH OCCURRENCE AGGREGATE PROPERTY BUILDING CONTENTS BUSINESS INCOME THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS UNES LAW. PERSONS INSURED BY SURPLUS LINES CARRIERS DO NOT HAVE THE PROTECTION OF THE FLORIDA GUARANTY ACT TO THE EXTENT OF ANY RIGHT OF RECOVERY FOR THE OBLIGATION OF AN INSOLVENT UNLICENSED INSURER. SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT APPROVED BY ANY FLORIDA REGULATORY AGENCY. DESCRIPTION OF OPERATIONS / SPECIALTY ITEMS COntractois suboonaadea work - construction. repair of buacrates. Gas Mains ar Connections ConctructiOn SURPLUS LINES AGENT VIRGINIA C. PHILLIPS LICENSES A208695 13577 FEATHERSOUND DRIVE PO BOX 17069 CLEARWATER, FLORIDA 33762 CERTIFICATE HOLDER Village of Miami Shoves 10050 NE 2nd. Avenue Miami, 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 PROv1SION9. AUTHORIZED SIGNATURE TFi�G�s�. 900 /ZOO'd 8163# 9Z:ZZ ZCOZ /ZZ /l0 `'` °R°® J CERTIFICATE OF LIABILITY INSURANCE DATE D°�YrY' 5/31)/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 CERTIRCATE 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 ADDRIONAL INSURED, the poiicy(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 The Fairway Insurance Group, LLC 5461 North .Federa3, Highway Fort Lauderdale FL 33308 INSURED Dade Gas Contractors, Inc, 5259 SW 39 Terrace Miami COVERAGES FL 33155 CONTACT Ausiatte Griffis MONA_Exe, (954) 772 -9819 Ass, anaetteg9 tfjgias . Mg. No): (944) 772 -9984 APPOROING COVERAGE INSURERA Florida united. Business Assoc INSURER 8 : NAIC N INSURER C I INSURER D INSURER P: INSURER F : Village of Miami Shores 10050 Northeast 2nd Avenue 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 Edward Brown /AG ACORD 25 (2010/05) II11S025 nirw>,ni 900 /600'd 646Z# @ 1988 -2010 ACORD CORPORATION. All rights reserved, TTwa AenRn mama rand k na arc ranicPanad marine of Arnim 9Z :ZZ ZCOZ /ZZ /40 THIS INDICATED. CERTIFICATE OCCLUSIONS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 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 BV PAID CLAIMS. L TN TYPE OFINSURANCE .1 INSR �r'T 1MVD POLICY NUMBER . ;.,t9LAMS GENERAL LIABILITY COMMERCIAL UABIUTY • ,-..� �.,,� $ IIIrSES(Eaa oM $ a OCCUR MED EXP (my ii pawn) $ , PERSONALS ADY INJURY S GBNERAt. AGGREGATE $ NI AGODEGATE ptiMEr APPLIES PER: Y� JFCT I I LCD - COMP/OP AC PRODUCTS $ W — ANY AUTO AUTOS HMO AUTOS • % uaal (Fa aendenH $ BODILY INJURY (Peepasan) $ AuTOS BODILY INJURY (Per se der t) $ S $ • — etas EXCESS NAB ^OCR CLAIMS -MADE EACH OCCURRENCE S • AGGREGATE $ Dal I [ RETENTION $ A WORKERS COMPENSATION .0YEREP ��/N la IA .106 -50796 20/23/2012 10/23/2013 I YCStw v 0TH X TORILI yuiTS ER B 100,000 $ 100,000 $ 500 000 ANY 1MEAIBER ExcittDEDt :� t if ra NM DE OF OPERATIONS INIDN E.L EACH A�� EL DISEASE - RA EMPLOYE$ El.. DissAss - POucY IMrr resol ns= OF OPERATIONS /LOCATIONS! YERI . (AMBCA ACORD 101. Additional Remarks Sonnetuee. E more space is requite' a) Certificate is Subject to Policy Forms E 3:tdorsements. f`rbTiensItre tiro r1srs - - _ ---- - -- Village of Miami Shores 10050 Northeast 2nd Avenue 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 Edward Brown /AG ACORD 25 (2010/05) II11S025 nirw>,ni 900 /600'd 646Z# @ 1988 -2010 ACORD CORPORATION. All rights reserved, TTwa AenRn mama rand k na arc ranicPanad marine of Arnim 9Z :ZZ ZCOZ /ZZ /40 632371 -1 sigfir W 1diMICTORS INC 6259 SW 39 TERR 33155 UNIN DADE COUNTY THIS IS NOT A BILL - DO NOT PAY RENEWAL STATE1831111A49 °MBE GAS CONTRACTORS INC DISTR /INSTALLATION TH44 4$ ONLY A LORAL VANESATAX HOLDER TO VIOLATE ANY OUSTING REGULATORY OR ZONING LAWS OF INE COUNTY OR O E& NOR r ErO TONS. PAYMENT RHW}V® NCUOMft TAX 09010374001 000450.00 sEE OTHER SIDE DO NOT FORWARD DADE GAS CONTRACTORS INC JULIO ORTA PRES 6259 SW 39 TERR MIAMI FL 33155 RRSf-CLASS U.S. PQSTAGE PAID MIAM . FL PERMIT RO. 231 659025 -2 ifl l�lFRi�li! }��f1f�If #3�lil} {��ff tfflF i� }�i!}i �i�ii}jLlilLlfj 641 900 /1700'd 6L6Z# 9Z :ZZ ZEOZ /ZZ /LO State of Florida • Depattment of Agticiature and Consumer Services Don .eirStintlerols -Bureau 'd Liquefied Plaroletim Gas trftection •(-896) 921-1600 Taftahassee, Rorida -• • Ceifilitate filo; 17040: Exatapatti:•reantster'84.21* • tssiftifiatit: SiOterithec20;2.042 . ExPkagOitaiet 4apteratber 1:9,20.15 MASTER QUALIFIER CERTIFICATE This estaftpate it.isSued:UndSr maturity of See6tm:527.02, Fokida Siattites, to: . . 41110 ORM .itaildFdr • • • • Viciiiatstathot: 2063 • ..p,moja4cciNTittActoRs • y • itioBV.swIpt.H.TtR • Ajraw.... • • ADAM H;Pmt. COMMISSIONER F AmeuouRe • • • •*, * 71:. • • *: .'11444*** SeM . • . DMscn of • • . • 44)* t1tlii**•2§".s. • ..01:4*".°41.03tSd1***41$ 111Ved" " ."17•11.°T. Da49,.6131i, 311142' • • • • • 0$500244•00' • • • Litettgar04: 1006 " 61410 6.% rid* • • * Tlieand416*:440 PetOttet*I.. *Gas Lidettse. - IP-GASINStALLER • sti;r0R. ntuc::.. ••• 4." • Altaltail:0001.14fiiigtiatgetiii*SaifENDERS ..w.ifsstiterAuto • . • . 11‘11eittise relistiOtitsicTeiviOthretity pfItraloti..#27.402,.'Hortea Staiseiztst* . DADE GAS MITRACVORS SINMICTER NOVA FL 33155-4815 900/900 'd 61.8U 9Z:ZZ ZEOZ/N/1.0 A�Rl7 CERTIFICATE OF LIABILITY INSURANCE 1 DATE 3 MS 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 policygos) 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 doss not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER The Fairway Insurance Group, LLC 5461 North Federal Highway 4 Y Fort Lauderdale FL 33300 FACT Annette Griffin arm,,s, (954) 772-9819 ya (954)772 -sss4 �� Aa�i °n�,asmrsetteg @tPig,�as.co� INSUR:ER(S) AFFORDING COVERAGE nY smsS AFlorida United Business Assoc INSURED Dade Gas Contractors, Inc. 6259 SW 39 Terrace Mute FL 33155 INSURER B t EACH OCCURRENCE INSURER c: nasuraaR0: DAMAGE i0 HEM ED _ERFAMS.FIW oexmar1001 INSURER E : w5ur......ER P : I CLAIMS -MADE MED ECP (Any one person) 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. LTR GENERAL TYPE P LIABILITY GENERAL- mum= 1LAeUTY 0 OCCUR iuzsag n POLICY NUMBER foi5d/DD f nY LatITS • EACH OCCURRENCE S DAMAGE i0 HEM ED _ERFAMS.FIW oexmar1001 $ I CLAIMS -MADE MED ECP (Any one person) S _ PERSONAL &ADVINJURY $ GENERAL AGGREGATs $ cm AGGREGATE LIMIT PRODUCTS - COMP/OP AGO oucy (� LOc $ AI--. UTOMOBILE LIABILITY ANY AUTO AUTOS HIt�AUTOS A AUTOS (Ea BINE�uSSING .E LIMIT $ S — SLY INAURY (Per person) BODILY INJURY (Per aoddea) $ _ l(Petamfdersl $ S �.. UMBREl_a LIA6 OCCUR EXCESSL� H CLAIMSASADE EACH OCCURRENCE $ AG AYS $ DED EYTION S $ ._ WORKERS EMPLOYERS' LIABILITY ANY OrFI DEsoapnow OF OPERATIONS NIA 106 -50796 10123/2012 0/ 10/25/2013 X TORYSLIIM S OER NN E�- 5 5 $ 100.000 100,000 500,000 Ei _. gs E - EA EMPLOYEE Mew E.L. DISEASE -POLICY UNIT DESCR 11ON OF OPERATIONS ILOCATIONS ( VEHICLES (Attach: ACORD 101, Adtl7aounI Rc®rks Schedule. if more apace Is wed) Certificate is Subject to Policy Forms & Endo>rs*meates. CE TIFICATE HOLDER CANCELLATION Village Of Miami Shores 10050 Northeast 2nd Avenue Masai Shores, FL 33138 SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AYTHORRES REPRESENTATIVE Edward arocfm /AG ACORD 25 (2010105) INLS02S mune nt Z00 /Z00'd OZ63# 01988 -2010 ACORD CORPORATION. All rights reserved. This A(`-ORn name. Said Lnem Bea roniclasart marine of artnef 9L :ZO ZEOZ /EZ /LO r?L., 0(03 Aceme CERTIFICATE OF LIABILITY INSURANCE 1ATh(M1I 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 policypes) must be endorsed. If SUBROGATION Ni 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 S.g. &Associates Insurance Brokers 9999 Sunset Drive, Suite #102 Miami, FL 33173 Phone (305) 279 -9002 INSURED Dade Gas Contractors, Inc. 6259 SW 39th. Tarr. MIAMI, FL 33155- ax (305) 279-9006 CONTACT NAME: Frances Diaz >wN o. Eta): (305) 279 -9001- (305) 279-9006 francea@sginsurancebrokers.com 8128 SdFHI4NIF.RIDa: INSURE AFFORDING COVERAGE INSURER A: SCOTTSDALE INSURANCE CO. NAIL S INSURER e : GRANADA INS CO. INSURER C : INSURER 0: INSURER E : INSURER F : COVERAGES 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. TV TYPE OF INSURANCE INER VD POLICY NUMBER POLICY EPP ( WDOPITYYI taDf UYYYY} LIMITS A = GENERAL UASIU1Y COMMERCIAL GENERAL UASUJ1Y • ❑ CLAIMS -MADE u nom ® BI/PD $500. Dad. N IRPPC -S 10/2812013 10/28!2014 EACH OCCURRENCE $ 1,000,000. A IEs ePRMIS o rnce) : S 50.000. MCP (Any OM ) • $ 5,000. PERSONAL PERSONAL 8 ADV INJURY $ 1,000,000. ❑ GENERAL AGGREGATE ' s 2,000.000. GETFL AGGREGATE LNG APPLIES PER ® PCX.icy • .IECT ❑ LOC PRODUCTS - COMP/OP AGG $ 1,000,000 $ B • AUTOMOBILE LIABILITY El ANY AUTO j[] ALLOYANEDAUros N .n. N 0110FL00013123 03108/2013 03108/2014 COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ 15,000. BODU.YINJIAtY(PermcIdent ) $ 3Q�30,000. i S ULED AIFIOS PROPERTY (Per suckled) $ 15,000. • H AUTOS ❑ NON -OWNED AUTOS © PIP/SO. Deductible Uninsured Motorist Non - Stacked $ 10,000. s 20,000. ❑ UMEREU.A LIAR G OCCUR El EXCESS UAE ❑ CLAIMS MADE r EACH OCCURRENCE $ AGGREGATE S • $ t•—t DEDUCTIBLE LJ RET6BTION $ �y pp l J WC STA IIMT$ C7 BF $ WORKERS COMPENSATION AND EMPLOYERS' UABILITY Y t N OFFI BE EXCLUDED? R�� I (yye�a, In DeaCRIPT.ON OF OPERATIONS betva /A EI. EACH ACCMENT $ EL DISEASE -EA EMPLOYEE $ EL DISEASE- POLICY LIMIT $ B Comprehensive & Collision N N 0110FL00013123 03/08/2013 03/0612014 $25,000. Cost New / ACV $500. Ded. DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (Reach ACORD 101. Additional Rema4w Schedule, Hmare spate is regurred) ;Gee Mains Connection CERTIFICATE HOLDER CANCELLATION Village of Miami Shores 10050 NE 2nd. Ave. Miami, 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. AuTHORBED REPRESENTATIVE Sergio D. Gonzalez, ©1958 -2009 ACO The ACORD name ACORD 25 (2009109) OF CORPORATION. All d logo are registered in d. RD Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (306)795 -2204 Fax: (305)75S -5272 'Inspection Number. INSP- 208297 Permit Number PL -5 -13 -1063 I Inspection Date: March 11, 2014 Inspector. Diaz, Osvaldo Owner. QUESADA, HUMBERTO Job Address: 125 NE 106 Street Miami Shores, FL 33138-2036 Project: <NONE> Contractor. DADE GAS CONTRACTORS INC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Gas Phone Number Parcel Number 1121360060350 Building Department Comments GAS HOT WATER HEATER TANKLESS AND RANGE Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 191510. PROVIDE DROP TEST AND PERMIT ON SITE March 11, 2014 For Inspections please call: (305)762 -4949 Page 1 of 1 Dade Gas Contractors Inc. 6259 sw 39 terr Miami F133155 Phone 786 - 316 -3021 License # 26163 Drop test Certification Florida Building Code, Fuel Gas SECTION 406 (IFGS) INSPECTION ,TESTING AND PURGING 406.1 General. Prior to acceptance and initial operation, all piping installations shall be inspected and pressure tested to determine that the materials, design ,fabrication, and installation practices comply with the requirements of this code. Owner Information: Name Permit Number: pi. 3 - l3 /063 Address /2 Aic /oa' r-- City %1/1 / AM, /State Type of Installation: ZS New 0 Upgrade to Existing Description of work: (Must include test details and include piping and appliances). fil6:(1/ e/, r �/ c. / iod/� v .4vf� W/# .4-111 Rj9/Ut)ri Lockup: // Water Column: 6" . 0 Test Duration: 3 a Date tested: 3/ y/ / ?� i4af/ / 22.f" J v /'a o/2t1 i� o ri ualifier) Signature Print Name Date