EL-14-1185.' Oak
BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Depart ent
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 758972
INSPECTION LINE PHONE NUMBER: (30 )762-4949
❑BUILDING � ELECTRIC s ❑ ROOFING
1"VED
JUN 0 6 2014
FBC 2016
iter Permit No. Z01 - �f-?A
Sub Permit No.
❑ REVISION I ❑ EXTENSION ❑RENEWAL
r-JPLUMBING [:]MECHANICAL ❑PUBLIC WORKS [:]CHANGE
JOB ADDRESS: -7 / v V e
Folio/Parcel#: Is the Building
Occupancy Type: Load:
OWNER: Name (Fee Simple
AddrPSS• 1-5-
/ ,+ 4
City: �v!
Tenant/Lessee Name:
Email:
❑ CANCELLATION [:] SHOP
DRAWINGS
Construction Type: Flood Zone:.
J6 e -6U � A -Po I 1) 19
el L,/ Al &I- S -7-
State:
Designated: Yes NO
BFE: FFE:
CONTRACTOR: Company Name:
L, i —� �� 9,:T C— ` '�`-' c' Phone#: -5
Address:.. �
City: M_7r2 State: Zip:
Qualifier Name: ®D ila 4f -rT-(.0 Phone#_ : �1� -� �a� 0'9 lip
State Certification or Registration #: ,r— -::3yo-o ` Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work,--,
Tl: !^ PAD AP"FlAd
4r,;ti ire 51,2e; = a Idaa'i 9616 "' °,
C> .� r;E„ ..1gm3 tmno� 33 4;
33 'A 001424M
+c
:'a ';tic6i it�+ff:6�iA 1$�$
Specify col 3WA
..
-
Submittal Fee $ Permit Fee $ ,90z >O0 CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $ I r
TOTAL FEE NOW DUE $ ! [1
(Revised02/24/2014)
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
0 .
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, 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.
SignatureX Signature —
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
_ 4 day f U ' , 20 '� by — 4 day of -Ju— NE ' , 20/j/ . by
15r G/ FA 1,0 who is personally known to 61 "5p 1—S�TTLC , who is personally known to
M me or who has produced /i 04108 �Q1yEtts��c�.ca� E
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
APPROVED BY �/L �.`ll��—� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
K;
06/06/2014 10;52AA Ins world
(FAX)9544307679 P.001/001
CERTIFICATE OF LIABILITY INSURANCE
DAT/
066/06/06/22Di01144
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
AA INSURANCE WORLD
8868 MIRAMAR PARKWAY
MIRAMAR FL 33025
NAMTE T Andrew Alexander
PHONE(954) 430-7676 1 F'"x Nol: (954) 430-7679
Dom. admin@aainsworid.com
INSLIRER(S) AFFORDING COVERAGE MAIC #
INSURERA: Ascendant Commercial Insurance 0
INSURED
TMLELECTRIC, INC.
C/o Toyson Lyttle
9531 Dunhill Drive
Miramar FL 33025
INSURER B: Ascendant Commercial Insurance
INSURERC:
INSURER D :
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.
INSR
LTR
TYPE OF INSURANCE
ADDLSUBR
POLICY NUMBER
MSU EFF
ILII D EXP
M
LIMITS
A
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ® OCCUR
GL -43696-0
01/14/2014
01/14/2015
EACH OCCURRENCE $ 1,000,000
PREMISES Ea occurrence $ 100,000
MED EXP (Ary one person) $ 5,000
PERSONAL& ADV INJURY $ 1,000,000
GENERAL. AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY MOT ElLOC
PRODUCTS -COMP/OPAGG $ 1,000,000
$
A
AUTOMOBILE
LIABILITY
ANY AUTO
AUT' ED SCHEDULED
AUTOS
NON -OWNED
AUTOS
HIRED AUTOS
CA -34812-0
08/09/2013
08/09/2014
CO INED SINGLE LIMIT $
Eaacadern
BODILY INJURY (Per person) $ 10,000
BODILY INJURY (Per ac ddent) $ 20,000
PROPE T DAMAGE $ 10,000
$
UMBRELLA LU18
EXCESS UAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTIONS
$
WORKERS COMPENSATIONWC
ANDEMPLOYERS'UABIUTY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
STATU- OTH-
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYE $
E.L. DISEASE -POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more apace Is required)
ELECTRICAL WORK - WITHIN BUILDING
1998 Chevy Astro Var#102077
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
10050 ME 2ND AVE
MIAMI SHORES
ACORD 25 (2010/05)
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
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