PL-14-422Miami Shores Village C__,
Building Department C' 1-L � 1
10050 N.E.2nd Avenue, Miami Shores, Florida 33138,
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2010
BUILDING Master Permit No. [7=C" 3-1 -/- L/
PERMIT APPLICATION Sub Permit No. �'L.` 3- /y'�zZ
❑BUILDING ❑ ELECTRIC
❑ ROOFING
❑ REVISION
❑ EXTENSION
❑RENEWAL
XnTM_B_flqG MECHANICAL
❑PUBLICWORKS
A
CONTRACTO
❑ CANCELLATION
❑ SHOP
DRAWINGS
JOB ADDRESS: 7�- N- w l 1 a
City: Miami Shores County: Miami Dade Zip: 331 W
Folio/Parcel#: Is the Building Historically Designated: Yes NO .
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: '
OWNER: Name (Fee Simple Titleholder): • &�.E- Phone#: 79&
Address:..
City: M ' cS State: le -e ' Zip: 3 3 �
S
Tenant/Lessee Name: PA, fW61_> K u -c Phone#: 0 -sec
Email: e5777.'e P 92 -A -q "• CGS" +
CONTRACTOR: Company Name: g46.M/3�a-C Phone#: c�� uTZ�Z3fr
Address:
City: /4 State: Zip: 331(-
2
Qualifier Name: IiCJ Phone#: Z,34
State Certification or Registration #: Cyr6 IDS 69 Z- 0 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City:
State: Zip:
Value of Work for this Permit: $ y ZlJG v Square/Linear Foot a of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: 3 15 +�L' C3 'TZi ei S '3 j (2-1 TLA 1 W -Il ,
�•i--� cSi�o�- �''�`/�� � -3 J iG�'%Gt/�/ �' x.12 � fo�?N�r' �
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ "� CCF $ CO/CC $
Scanning Fee $
Notary $
Radon Fee $
Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
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
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, certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs sev ) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approve . spection fee will be charged.
Signature r Signature,. e( 146f dd2..�
Owner Bent Contractor
The foregoing instrument was acknowledged before me this3 C)
day of M 20 ,y, by !A46; A%0-0�
who is personally known to me or who has produced
As identification and who did take an oath.
0
NOTARY PUBIJC:
The foregoing instrument was acknowledged before me this_
day of M" �20 Ji' b'7 /✓/ y
' PC
who is personally known to me or who has produced
&5 /Vi entification and who did take an oath.
NOTA PU.,�MIC:
R AL�Sign: ��/ � r% r9� Sign: `(("GGIV/11
� A
rte;
Pri
= a ` ARDO 1 'RTE RICARD IRIARTE
MY 5$19 4f1�910 F M Q sSIO.'MY•MPKi1� I t
EXPIRES February 2.2018 �� t'oP°fEXPIRES February2 20 8
.'F�NF;o'�••' ry d •
(407) 398-0153 FloridallotaryService.com 1 (407) 398-0153 FloridallotaryService.com
APPROVED BY �4to®/Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
Permit N. L - 3-1 y- zz
Owner's Name (Fee Simple Title Holder): M ' 44 `� PIY2!�y Sy t4;T-s Phone #: 3 o s 90- 16 Vg-'
Owner's Address: l JO AJ -15. 1 / b-174
City: ,.Ws aState :Zip Code: 31 3k
Job Address (of where work Is being done): 75- k) - W ! 10 74
City: Miami Shores State:_Flodda Zip Code: 3313k
sixV4a J;�� _
Contractor's Company Name:PI (` —FujaBir-ad Phone #:_ q _-J 1,9z
Address: 3 S"
City: At*!N!�E State:I �- - Zip Code: V116 51
,Qualifier's Name x r-Ae i eES 2, Lie. Number. e W zo
Architect/ Engineer of Record Name:
Address:
City:
Phone #:
State: Zip Code:
Describe Work:
I hereby certify that the work has been abandoned andlor the contractorlarchitect is
unable or unwilling to complete the contract. I hold the Building Official and the
Miami hores ha for all legal Involvement.
Signature Signature ��-,�c►
owhel:.arAge �ontradororAndtk�:t
The foregoing instrument was aknowledged before me The foregoing Instrument was aknowledged before me
this., day ofAUT* 2011I,by )A U-cyt- this 11rt� day of3a , 20 by Z4�1 Y
Who is personal) known to me or who has produced
as indentification.
Notary
Sign: _
Seal:
RICARDO IRIARTE
5,,'4 ' 1 MY COMMISSION #FF088736
17 '`• Fa,t��'�•' EXPIRES February 2, 2018
9 (407).3W-0153 FlOridallotarvServicernm
who is personally known to me or who has produced
1JJC as indentiflc9on.
MY COMMISSION #FF088736
OMRES February 2, 2018
PSG Plumbing Service Inc.
3892 NW 125 Street
Opalocka, Florida 33054
June 4, 2014
RE: 75 NW 110 Street i PL 3-1yr Y ZZ
Miami Shores Village Building Depart:
This letter service as a release of contractor for the above mentioned property owned by Miami
4 Investors LLC.
Sincer ,
ro G man, CEO
STATE OF FLORIDA
COUNTY OF DADE
Subscribed and Sworn To (or affirmed) before me this day of {AM? 20L�.
Owner- Personally Known P/' or Produced ID Type of ID Produced:
S ature of Notary Serial Number
.S fes. Z i�b �` �C� o 1 S
Print Name of Notary Expiration Date
oOr AN� Notary POW State of Rodds
Notary Stam a Jose Luis Prieto
poi-. EXP W/1 3=1 5 1121 02
4
May, 15. 2014 12; 32PM Na. 7959, P 1/1
'''tL ' CERTIFICATE OF LIABILITY INSURANCE
DATE05/15/2
1151201414
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 certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Workers Compensation Group
P 0 Box 410
Boca Raton, pe cation Gro
Workers Compensation Group
NAME:ACT
Gre Carignan
PHONE
c No E :561-392-3300 FAC No : 561-361-1132
ADDRESS: certs workerscom grou .com
INSURER($) AFFORDING COVERAGE NAIC f
Castlepoint Florida Ins Co 13599
INSURER B:
INSURED M.G. Plumbing &INSURERA:
Sprinkler Service Inc
INSURER C:
1265 NW 203rd St
Miami, FL 33169
INSURER D:
INSURER E :
COVERAGES
INSURER F:
vc� �rwr� �, IYUIYI6CR: 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.
LTRLIAB
F INSURANCE POLICY NUMBER MIDD M1DD LIMITS
Y
EACH OCCURRENCE $
GENERAL LIABILITY
PREMISES Ea occurrence $
ADE � OCCUR MED EXP (Any one person) $
PERSONAL& ADV INJURY $
GENERAL AGGREGATE $
F7LIMIT APPLIES PER:PRO PRODUCTS - COMP/OP AGG $
1LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident $
ALL ANY AUTO BODILY INJURY (Per person) $
AUTOWNED
SWNEDOSULED
HIREDAUTOS NON -OWNED
BODILY INJURY (Per accident) $
AUTOS PER ACCIDDA OE $
UMBRELLA LIAB OCCUR
EXCESS LIAR EACH OCCURRENCE $
CLAIMS -MADE AGGREGATE $
DED RETENTION
WORKERS COMPENSATION $
AND EMPLOYERS' LIABILITY Y / N X TORY LAM LIMITS T
A ANYPROPRIETOR/PARTNERlF>CECUTIVE CP 760535403 10/12/2013 10/12/2014 E.L. EACH ACCIDENT $ 100,000
(MandaER
tory
In ER EXCLUDED? N / A
(Mandatory In NH)
Yes, describe under E.L. DISEASE - EA EMPLOYEE $ 100,000
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, M more space Is required)
Contractor's License #CFC056920
CERTIFICATE HOLDER CANCELLATION
MIAMIS3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Village of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE IMLL BE DELIVERED IN
10050 NE 2nd Ave. ACCORDANCE NTH THE POLICY PROVISIONS.
Miami Shores, FL 33138
AUTHORIZED REPRESENTATIVE
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD