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DEMO-12-2416Miami Shores Village �j Building Department E fav L_ . , 1 B O 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 fl V � Tel: (305) 795.2204 Fax: (305) 756.8972 PiuV V 7013 INSPECTION'S PHONE NUMBER: (3057 762.4949 �. BY®®®®o 000000a FBC 20 tO BUILDING Permit No.prcm a - oeN I(o (fi.L) PERMIT APPLICATION Master Permit No kuru 12 -ay is Permit Type: Electrical JOB ADDRESS: y & 4 y City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes OWNER: Name (Fee Simple Titleholder): Address: / C VU City: m1ai2£ 1 c! �i State: Tenant/Lessee Name: Email: CONTRACTOR: Company Name: Address: City: NO Flood Zone: Cf�z Y� Qualifier Name: IJ A4 IT) d (q ;zt C Phone#: State Certification or Registration #: Cl—'IS od 7 P- t/ y Certificate of Competency #: _ Contact Phone#: Email Address: DESIGNER: Architect/Engineer: Phone#: S .y � Tai baa v v : 33v S`{ Value of Work for this Permit: $ 4w Square/Linear Footage of Work: Type of Work: DAddress DAlteration ONew ❑Repair/Replace WDemolition Description of Work: ��2-i<-• C"C� TQ ID OR— Dpjyy-(o T:F_ . Submittal Fee $ Permit Fee $ 100,,W9 CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ D 1. 6n 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 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 day of �rIq —, 20 /, by ()U &Vnke-y�- , who is personally known to me or who has produced P/, �- As identification and who did take an oath. NOTARY PUBLIC: bVL AA /r u i .54 oil �q Sign: Print: My Commission Expires: APPROVED BY EXPIRES: June 10, 2014 Bonded Thru Notary Pubic Underwriters Signature Contractor The foregoing instrument was acknowledged before me this day of -3 a , 20 /'1, by �uy e mb-, '` who is personally known to me or who has produced .2 Plans Examiner Structural Review (Revised 3/12/2012XRevised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Zoning Clerk AlEXPRI7CERTIFICATE OF LIABILITY INSURANCE DA�03/11/14 INSR 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(Sb AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL. INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subjed to the farms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder h1 Pau of such endomement(s). PRODUCER CONTACT CARMEN RIVERA Koski and Co. Inc 9876 Sunset DriveL (305) 595-2127 No (305) 696-9780 carmenCmykoeld.com INSURH 9 AFFORDING COVERAGE NAIC4 Miami, FL 33173 INSURERA. LANDMARKAMERICAN INSURANCE COMPANY 33138 Phone 306 695-2127 Fax (305) 696-9780 INSURED INSURER 13. AMTRUST NORTH AMERICA INSU C : RAY'S ELECTRICAL SUPPLIES INC INSURER b: 2015 Ope Locks Blvd INSURER E: Opa Lacks, FL 33054 INSURER r: L:OVEIt ur_75 UI:M I WIGA71: NUIVIL3EIC: 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADM e VD P POLICY EXP UrM.S A GENERR-LA11wTYFACH © COMMERCIAL 09NMMUABILnY ❑ ❑ CLAIMS -MADE 0 OCCUR ❑ ❑ GENIL AGGREGATE LIMIT APPLIES PER © POLICY ❑ MET ❑ LOC VBA204380 10/19/2013 10/1812014 oCCu N E $ 1,000 000.00 DAMAGE RENTED $ 100,000.00 MED EXP one arson $ 5,000.00 PERSONAL & ADV NJURY ffi 1, 000,ODD.00 GENERAL AGGREGATE ffi 2,000,000.00 PRODUCTS-CWP10PAGG $ 1,000.000.00 $ AUTOMOBILE LIABILITY ❑ ANYpAWvro ❑ AU7OS ❑ AUTHOSU� ❑ HIRED AUTOS El1AUU0� ED NO COVERAGE NGLE LIMIT OMB0Et BODILY INJURY (Per pawn) $ BODILY INJURY (Per accklard $ � Pe ffj,YRAMAGE $ ffi ❑ UM13RELLAUA13 ❑ OCCUR EXCESS LIAR El CLANS -MADE No COVERAGE EACH OCCURRENCE $ AGGREGATE $ DED El RETENTION$ B WORKERS COMPENSATIONWC AND OMPLOYERS' LIABILITY YINLIM ANY PROPRIETORIPARTNEWEXECUTNE OFFICEWMEMSEREXCLUDED? desadtNIA ((Myan a aNH) a wWa DESCRIPTION OF OPERATIONS below AWC1028682 02/27/2014 02127/2016 STATU- OTH E.L. EACH AMOUNT S 100,000.00 EL DISEASE - FA EMPLOYE $ 100,000.00 E.L. DISEASE- POL1CYL[MITj $ 500,000.00 NO COVERAGE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddHlonal Remarks Schadule, irmcre apace Is required) ELECTRICAL CONTRACTORS & SALE OF ELECTRICAL EQUIPMENT. ALL TERMS CONDITIONS, LIMITATIONS & EXCLUSIONS OF THE POLICY & THE INSUREDS WARRANTIES TO THE COMPANY APPLY. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY & CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOESNT AMEND, EXTEND OR ALTER COVERAGE AFFORDED BY THE POLICY. CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 N.E. 2ND AVENUE MIAMI SHORES VILLAGE, FL. 33138 FAX #305-7"72 ACORD 26 (2D10106) QF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE NTH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD