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PL-13-746, 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�,J7, Permit Type: PLUMBING Owner's Name (Fee Simple Titleholder) Owner's Address LND NEI ia CityMm' O W State Tenant/Lessee Name Email Job Address (where the work is being done) City Miami Shores Vi11aQe FOLIO / PARCEL #� � - 5-M 5 - I Is Building Historically Designated YES APR 1120 3 Permit No. �` k 3 � L4 �--' Master Permit No. Zip Phone # County Miami -Dade Zip -/,\[)I n NO A Flood Zone Contractor's Company NameQI(IPhone # t ffrmq Contractor's Address City State Zip U Qualifier Name Q, Phone # ®` — State Certificate or Registration No rJ�C ! �� y Certificate of Competency No. Contact Phone` - �2� E-mail i . Wo Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ 2-3 �0 . OD Type of Work: ❑Addition ❑Alteration Describe Work: --ClG ►Q Square / Linear Footage Of Work: NewRepair/Relace EJ Demolition U �r -�t',r an 6 40 mal 144 e . Submittal Fee $ i- �` Permit Fee $ /� CCF $ CO/CC $ Notary $ Training/Education Fee $ Technology Fee $ Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Structural Review. S Violation date: Total Fee Now Due $ 1 15 See Reverse side 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 incompliance 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this "I day of �� , 20� by who is person=A0 of e orojho has produced � R -40 itlentification and who did take an oath. NOTARY PUBLIC: Sign:' Print: My Commission Expires: Signature 6a/u- Contractor The foregoing instrument was acknowledged before me this day of , 20�, by �N who ' personally known to" n��o who has produced MONICA GARCIA Commission # EE 845702 '' My Commission Expires 10-22-2016 Bonde Thresh �annW` Western Surety Company -SE Team as identification and who did take an oath. My Commission Expires: MONICA GARCIA Commison # EE 845702 ommi$ si sion Expires 10-22-2016 Bonded Through pony- E Team APPROVED BY �'` %� Plans Examiner Zoning Engineer (Revised 07/10/07)(Revised 06/10/2009) Clerk checked CFN: 20130279822 BOOK 28575 PAGE 3237 DATE:04/11/2013 08:23:53 AM HARVEY RUVIN, CLERK OF COURT, MIA DADE CTY NOW OF lk�o OnlyFFL3TK 0 MNWJWINl81FZMOFWWtt OG FlEffiff-�� , FOLIO 13z -C SM OF FLORM, 001$+I1Y OF MUUVA44DE THE tNtDFBi INED hereby gives rada that Zepeawerrra I a vA be meds b arleh md pmp ft wd h saoade I I with CtwrpW 713, FWW SWu6w the bdomedon h pwftd In lids Notios of Commeraen wL 2 3.O+pner( vh" and addroex I ton In properly: Nana and aditw d far! dmpb 1jtlMroldw: 4. CaebaotWs nemw eddisee mW phow nwrber: (305)867-1687 301 F agler Drive Nlami Springs, F1 33166 6. &mW- {Pa .w bard regtrtrad by owner hon cmbsotm P rM Nems. addro I I and phone number: •----- Atnaert of bard $ — — G. Lrideft Wane end akkaw 7. Pareone WM the Stets d Raft deeWW@d by Ovmer upon whom n t or otter doaemrde may be e n ad as p e dd, by 3eol m 718. s"Maj7.. Roddy Stamm Nana addrew and phone rrerom %---v 8. h 01 NO n to hh0 OIL OVA= deaigrrelas the fobr& g personl ! to a%*m a Dopy d the lbnorlr Noltoe asp wMed in Sedan 713.13(1f, Ronk $tdrns. Name. address and phone.U.d r: 8.6iplrmw deer dents Noft d L`wnw oeme * Pa &UblvMftMarawaraeI NI WON adftmffidft kvpmd" ION 719.U. RAMA SNUUTl?8. MID CMF FWU I MCBMW Ml6T BE FEGo11 W MD FOWW CN COFlSW WITH YOM LIN= OR M ArTORW N UWler pendd m of pwo% I deolere 00 I neve road the faegoiq and that the faole abrEed h b m bus, to the beet of ay btorbdge and b@M t M41 was sw L' 0 .e 445228-0 THIS IS 040T A Rif I _ r* NOT PAY Busomm NAME /LOCATION ORR DOUGLAS PLUMBING INC 301 FLAGLER DR 33166 MIAMI SPRINGS OWNER ORR DOUGLAS PLUMBING INC 'I;rgL'dMrNG CONTRACTOR 11U8&O Y A tACAL rAX ter, rr oo u" air nm maim ro v�Arte 'alt rex arary 'alt 'nom pam" all ORR DOUGLAS PLUMBING INC NOMAD BYLW. naa ORR WAYNE `�",�„ ,*_ 301 FLAGLER OR FST -CLASS U.S. POSTAGE '. PAID MIAN, PERMIT NO. 2311 RENEWAL RECWT NO. 464791-4 STATE# CFC052664 WORKERIS 1 DO NOT FORWARD MIAMI SPRINGS FL 33166 MUM (UW M &MlXMM TAX 07/11/2012 09010431001 000045.00 SEE OTHER SIDE 116 —'lo1 DOUGORR-02 STWIGGS '�� ' CERTIFICATE OF LIABILITY INSURANCE °A 1120"""'' 8N/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS AELOW. RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 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 CONTACT Collinsworth, Alter, Fowler & French, LLC NAMPHONE - FA7c 8000Governors30 errors Square Blvd �l&No, EX0; (305) 822-7800 305 362.2443 - lac No! �._.� . Miami Lakes, FL 33018 1 ADDRESS; INSURER(8) AFFORDINO COVERAGE - NAIC 1 Insurance Co 19488 INSURED INSURER a: First Mercury Ins. Company 10657 Douglas Orr Plumbing, Inc. INSURER C : 301 Flagler Drive INSURER D : Miami Springs, FL 33166 - - — -- ------------- —. - --- - - INSURER E: ' _._ —---._.. - --- ---- ----------- ---- INSURERF: — 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 CONTRACTOR 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 1ADtsLT$i)SRi —'--- LTR CE TYPE OF --.0188 NYYD 1- — POLICY NUMBER__ MBER - ... -- POLICY EFF POLICY EXP -- --- " {MIAIDDIYYYY�_ IMMUDD/YYYY�,,,___ LIMITS GENERAL LIABILITY _— -- - EACH OCCURRENCE $ 1,000,0001 A X COMMERCIAL GENERAL LIABILITY X X GL20783570002 - 8/2/2012 8/2!2013$ 300,0001 LEoccurrence)_ CLAIMS -MADE X OCCUR - - -- - MED EXP (Any one person) $ 10,0001 X Broad Form PD Incl — - - - -- _ PERSONAL 8 ADV INJURY $ 1,000,0001 X , Contractual Incl -- --""- GENERAL AGGREGATE_ $ 2,000,0001 GEN1. AGGREGATE LIMIT APPLIES PER PRODUCTS -COMP/OP AGG : $ — 2,000,000 PRO l— POLICY I X • JECT__+_ LOC G - — -- - • $ —: AUTOMOBILE LIABILITY ----------------- - _ ....__-- — COMBINED SINGLE LIMIT (Ea accident) �, 1,000,000_ i A X ANY AUTO _ X i X CA2063607 8/2/2012 8/2/2013 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED -- --- --- - AUTOS _ AUTOS BODILY INJURY (Per accident) $ NON -OWNED X ;HIRED AUTOS X f AUTOS PROPERTY DAMAGE - - ' $ j -- {Per accident) J( UMBRELLA LIAR X: OCCUR -- EACH OCCURRENCE � $ 8,000,0001 B EXCESS LIAR i CLAIMS MADEI X I X NJEXOOOOOI523001 — j — 8/2/2012 8/212013 AGGREGATE $ A X .RETENTION$ _�__ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ! N 1 ANY PROPRIETORIPARTNr-RrFcar•n rrnrc --- (Mandatory In NH) N yea, describe under DESCRIPTION OF O A Inland Marine AI N/A; X WC206360803 8/2/2012 ' 812/2013 CPP2063609020011 8/212012: 8/2/2013 CPP2063609020011 8/2/2012 8/2/2013 DESCRIPnON OF OPERATIONS / LOCATIONS I VEHICLES (Atiaoh ACORD 101, Additional Remarks Schedule, K more space is required) *Except 10 days notice for Non -Payment of Premium RE: Plumbing Contractor No. CFCO21462 CERTIFICATE HOLDER CANCELLATION Aggregate $ 510001000I X E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE S 1,000,0001 E.L. DISEASE - POLICY LIMIT 1$ 1_1000,000 Rented/Leased Eqpt 100,008 Scheduled Eqpt. 21,0001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami Shores Building & Zoning THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 N.E. 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33154 — AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. 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