PL-12-1810Miami Shores Village
Building Department artment
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 OCT a ' ,, 4 Z
Tel: (305) 795.2204 Fax: (305) 756.8972 AL I
INSPECTION'S PHONE NUMBER: (305) 762.4949 - o
FBC 2010
BUILDING
PERMIT APPLICATION
Permit Type: PLUMBING
JOB ADDRESS: t r � t�� -j,� 3 it OE 7
Permit No. pL.,j r�— l r LO
Master Permit No. VC— 12 -- 12,( ` __
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO X Flood Zone:
OWNER: Name (Fee Simple Titleholder): N4161h T Phone#:
Address: 3 P A) L- v� L /
City: M (`0, rN t State:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: �JV. Phone#: iG 2 -
Address:
Address: (� (� ZZ (,-?_c.- '
City: AA - State: ( Zip: � 2 r
—�
Qualifier Name:
,k•%
State Certification or Registration #: at—�7c_', l'cy, Z'4 2 W Certificate of Competency #:
Contact Phone#: ) d 5 Z_44 C4 ! ' b1 Z Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ S6c > . c" C.) Square/Linear Footage of Work:
Type of Work: ❑Address DAlteration ONew Aepair/Replace ODemolition
Disc tiption of I '• = . jAS-Ia4_J_
v I -C/ /v cC Un L 2 r
Submittal Fee S,-C�—� Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ 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
Mottgage 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" ,/ Signature
Owner or Agent Contractor
The for go' g ' e1nt was acc owledged1beef r mdthiissq4�y
e fore o• g ' trument was acknowledged before me thiS 67(
day o 2012 , by V�) V vd� ►"' ' of 20 t by _ "'
and who did take an oath. as identification and who did take an oath.
NOT PUBLIC: - NOTARY UBLIC:
Sign: ign:
Print: ��eos`da t: 4- t�
o�
My Commission Expires: m,�xQ�ces �ti j gg1 pss° Commission Expires:
m
COpthA0�9RNa
�,��,vr�r,����r,���,����x�x�r���������:r��: ',, � F , � •�:�i? de,u�r��r�ar�r��r�e�r���rarara��:�ra��:r�r�:��r,u,��r�,��r�ra�a���ra���r�rs�,��r�r���r�r���r,��r,x��
APPROVED BY �� / Plans Examiner Zoning
Structural Review Clerk
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009XRevised 3/15/09)
From: 11/26/2012 10:14 #157 P.001/001
CERTIFICATE OF LIABILITY INSURANCE I
D 11/2611lDDIYYYY)
Ir26/12
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. K 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 cont ar rights to the
PRODUCER
Accurate.
8300 West Flagler Suite 114
Miami, FL 33144
Phone (305)226-8727 Fax (30
INSURED
Navarro Plumbing & Mechanical Contractors Inc
P.O. Box 226288
Miami, FL 33222-6288
I WMA W. (305) 226-8727- _ I ice. Nm: (3051226-8767-1
301
INSURER 0: Ascendant Insurance Co. i ---I
a.vvctvauca 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, 'PERM 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.
L
A
TYPE OF INSURANCE
GENERAL LL48UTY
® COMMERCIAL GENERAL LIABILITYrr0-RNTED
El El CLAIMS -MADE ® OCCUR
❑
V0131
Y
lim
POLICY NUMBER
100912000000454
M!D
10/09/2012
MM/DD
10/09/2013
LIMIT9
EACH OCCURRENCE $ 1,000,000.00
MIs a revue $ 100,000.00
MED EXP one n $ 5,000.00
PERSONAL & ADV INJURY $ 1,000,000.00
GENERAL AGGREGATE $ 2,000,000.00
GEWL AGGREGATE LIMIT APPLIES PERS
POLICY C]PRO-
❑ ❑ LOC
PRODUCTS - COMPIOP AGG $ 2,000,000.00
AUTOMOBILE LIABILnY
❑ ANYAUTO
❑ ALL OWNED AUTOS
❑ SCHEDULED AUTOS
❑ HIRED AUTOS
❑ NON -OWNED AUTOS
COMBINED SINGLE LIMIT $
(Eaaeddent)
BODILY INJURY (Per perscn) $
BODILY INJURY (Per modem $
PROPERTY DAMAGE $
(Per awdent)
$
1
❑ UMBRELLA LIAR ❑ OCCUR
❑ EXCE8S LIAR CLAIMS -MADE
$
EACH OCCURRENCE $
AGGREGATE $
❑ DEDUCTIBLE
WORKERS COMPENSATION
AND EMPLOYERS* UMUTY
B
N/AI 1000278478
03/20/2012 103/20/2013
DESCRIPTION OF OPERATIONS 1 LOCATIONS ! VEMCLES (Attach ACORD 109, Additional Remarks Schedule H more space is rsquitred?
Certificate holder is listed as additional name Insured.
CERTIFICATE HOLDER
Village of Miami Shores
10050 NE 2nd Ave
North Miami, FL
305-756-8972
ACORD 25 (2009/09) QF
E.L. EACHACCIOENT I $ 100,000
E.L. DISEASE -EA EMPLOYEif $ 100,000
E.L. DMEASE. PM ICV I ILMTI a 4M AAA
CANCELLATION
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 REPMnJM
Lucia Estrella
® SIRS-�bRD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD