RC-11-1595BUILDING
PERMIT APPLI
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
MAY 222013
FBC 20
Permit No.
h
:'Master Permit No. KC( 1- 15`15
Permit Type: (BUILDING —,,) ROOFING
JOB ADDRESS: t -I T 4Jce3 apt
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11-34A 0 L3 — O t ian
Is the Building Historically Designated: Yes NCT`1 Flood Zone:
OWNER: Name (Fee
Tenant/Lessee Name: Phone#:
Email
3313cr
CONTRACTOR: Company Name: Phone#:
Address: 2,3
City: t;G. State: Zip: 3-5145777
Qualifier Name: 114
Phone#:
State Certification or Registration #: CGvC /S/4- Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ .3 ,S'� . Square/Linear Footage of Work:
Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace demolition
Description '"f Worki�' ; .?4 rdrlA o
«f`t1M !�h 3i ;AI3rtP,iCefiYs�h;;,b - .:,'
Submittal Fee $ q $ 0%1- , LL/ ' 'CPCY $' CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $_
Notary $ Training/Education Fee
$ Technology Fee $
Double Fee $ Structural Review $1VJ0
TOTAL E NOW UE $ 55C . of, uoy if Mroi
?-CA=t
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. a
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this
day of /x!4/2C H , 20 /3 , by P ,
who is personally known to me or who has roduce
As identification and who did take an oath.
NOTARY
Signature
Contractor
The fore omg instrument was acknowledged before me this
day of ' U tC h, 20 j3, by y/l
who is personally known to me or who has produced
My Commission Expires:
My COMMISSION # DD MM
"p(pIRES: October 1, 2014
"m i11tn5� BWed Thru Notary Pabft Uaderw brs
APPROVED BY Plans Examiner
Structural Review .
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)
My Comm. Egfts Odt 11.11
Conte I EE IOU14
orm 1Nono NOW Notary h
Zoning
Clerk
Miami Shores Village AP 3 g 'Z013
Buildin Department
e, Miami Shores, Florida 33138
pa�
2204 Fax: (305) 756.8972
A NE NUMBER: (305) 762.4949
]BUILDING Permit No.
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: Electrical
OWNER: Name (Fee Simple
City: CX �
Tenant/Ussee Name:
Email:
State:
JOB ADDRESS: l —7! NL -j /a/
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 1-1
Is the Building Historically Designated: Yes
NO V Flood Zone:
i
CONTRACTOR: Company Name: -� d-f�2a.� , -LI t C Phone#: 3 O's 6 � T �5-20
Address: / & 6 ® N% J 2 ��,•��.
City: l% 2 1 C 01 1 State: Zip:—) S --
Qualifier Name: �' �(�� (. LeZ o Phone#:
State Certification or Registration #: Cr ® Q / / ®? Q Certificate of Competency #: 000c) /7 2 3 e�)
Contact Phone#: Email Address: 4Q :t &V4 ,/I Cts,
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition
In
Description of Work: n, iL
Submittal Fee
Scanning Fee $
Permit Fee $ �/�` ®� CCF $ CO/CC $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $•
Technology Fee $
TOTAL FEE NOW DUE $ O
Bonding Company's Name (if applicable)
Q
° Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address '
City
State
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 ab Bence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged. !l
Signature Signature
Owner or Agent Contractor
The fore g in_ strument was acknowledged bef me this
day of , 20 L a b
who is nally know a or who has pro uced
As identification and who did take an oath.
NOTARY
Sign:
Print:
The foregoing instrument was acknowledged before me this
day of o , 20 —n, by ,
who is ersonally wn to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sigr
Prin
My Commission Expires:lP " f �pt Florida My
"Awl 4A.Me
pt
V'Jawv� expo" man
Ce��nlssWe s � ��;lb
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
0
WC
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DATE(MWDDfY YY)
ACDM,. CERTIFICATE OF LIABIL TY INSURANCE
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
MSI ZZ INSURANCE • S FINANCIAL SVC
HOLDER THIS CERTIFICATE LEES NOT AMEND, EXTEND OR
508 E 49 ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
HIALEAH FL 33013 NAIL#
05 769 4936 INSURERS AFFORDING COVERAGE
INSURED C. P. S. ELECTRIC, INC .CC000017233NGamiDade INSURER w AS
1600 NW 28 AVE 90CME1243X Broward INSURER
MIAMI, FL 33125 U-21790 Palm Beach; INSURER C;
ER0011020 State of Fla. � D:
OVERAGEs
ABOVE
FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED
OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE AM4Y BE ISSUED OR
OF SUCH
ANY REQUIREMENT, TERM
DESCRIBED�1EREN IS SUBJECT TO
ALL THE TERMS, EXCLUSIONS AND CONDITIONS
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES
MAY HAVE BEEN REDUCED BY PAID CLAIMS.
OR LIABILITY OF ANY I NO UPON THE IN TTS AGENTS OR
POLICIES.
AGGREGATE LIMITS SHOWN
POLICY NUMBER
Y CINE
LBA ITS
EACH OCCURRENCE a 1 000.000
GENERAL LIABILITY
Ea orate $ $100.00O
COMMERCIAL GENERAL LIABILITY
CLAIt�{SNWDE ®OCCUR
M
MED EXP(ArryarepeBas) s
500 D
GL -34425-3
09/23/12
09/23/13
PBal'a'I'�' x 1 0 0 0 0
A
R
O 0
{;ENERAL AGGREGATE a 1DO—M-00-
PRODUCTS - COMPIOP AGG S 1 0 0 0
PR
GM AGGREGATE LIMIT APPLIES PER:
POLICY PRO LOC
AUTOMOBILE LIABILITY
0 (SINGLE LIMIT a
ANYAUTO
ALLOWNEDAUTOS
�a N a 10,000
SCHWULEDAUTOS
CA -33303-0
09/23/12
09/23/13
Y a 20,000
�
A
HIRWAVTOS
ddefty
N014-0WNEDAUTOS
PR S 10,000
GARAGE LIABILITY
ANYAUTO
EXCEsSAIMBRELLA LIABILITY
OCCUR CLAIMSMADE
DEDUCTIBLE
RETENTION a
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY
ANY PROPRIETOWPARTI
A
WC -602230
ADDED
ELECTRICAL WORK
Village of Miami Shores
10050 NE 2 Ave.
Miami Shores, Fl. 33138
ACOR026(2001/08)
EAACC 111
ZVOOOY. AGO 1 a
EACH OCCURRENCE a
S
06/02/12 06/02/13
DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
SHOULD ANY OF THE
VE
INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
DATE THEREOF, THE 141ING
NOTICE TO THE CERT
YE HOLDER NAMED TO THE LEFT. BUT F TO DO SO SHALL
WOSE NO
OR LIABILITY OF ANY I NO UPON THE IN TTS AGENTS OR
19BB
MAY 2 2 2013
Miami Shores Village
Building Department _'Y:
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.22 2
62.4949
FBC2Qw6,,,
BUILDING Permit No. V __.
PERMIT APPLICATION Master Permit No I — 6��5
Permit Type: PLUMBING
JOB ADDRESS:. 1 -7 6- k) U-) 1® t -,A- �
City: Miami Shores County: Miami Dade --------- 4p:
Folio/Parcel#: I
Is the Building Historically Designated: Yes
OWNER: Name (Fee Sim P)e Titleholder)
Address
City: - r -a-'
Tenant/Lessee Name:
P. WINPAWW"Wil",
NO � Flood Zone:
-State: Zip:
CONTRACTOR: Company Name: :W --S JAA,�
Address: 329 0AA;,2Jm A&4.4
City: ji-4.St
- -4e:. "L_0 A
Qualifier N
Zip: jA
State Certification or Registration #: kA.- CV 4-&W Certificate of Competency #:
Contact Phone#: Email Address: 6111.s JE
DESIGNER: Architect/Engineer: Phone#.: 0
Value of Work for this Permit: $
Type of Work: ElAddress
e *04jacp.,-.
p DDernolition
Submittal Fee $ Permit Fee $ ,
1 5�CCF $ CO/CC $
—
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $_
Technology Fee $
TOTAL FEE NOW IRJE $_j
clativ a wfwfpc
Bonding Company's Name (if applicable)
Bonding Company's Address V
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
e
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. I� a�sence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged. A I
Signature
Owner or Agent
The for i g instrument was acknowledged bef e this 3 10
day o - 3, by 6Cfc Z, ,
wh �ersona0 kno me or who has produced
As identification and who did take an oath.
NOTARY X#OMARA ARAUZ
two . 04do of Florme
My Ggamm ftow
Apr 19p tl?1 21d
Sign:
Print: �f D Nf(if�lZ G¢
My Commission Expires: ® 1
APPROVED BY
The foregoing mlrument was acknowledged before me this? -i" -
day of , 20L—AI, by
who is own to a or who has produc
as identification and who did take an oath.
Plans Examiner
NOTARY PUBLIC:
Sign:
Notary Ht WIC - State of Florida
MY Comm. Expires Oct 11, 2015
CommiaSIon # EE 106714
sol/i `aml.f .
Zoning
Structural Review Clerk
(Revised3/12/2012j(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
u
.. i
WWI
t . 21 R
Yla
Department of Revenue Clearance
Department of Revenue clearance is required on applications for all new, transfer, change of location, and
applications which change the licensee's name. The address for the office serving your area of interest can be
found at httr)://www.mvfloridalicense.com/dbpr/abt/forms/documents/abtdistrictofficelist.K)df.
Health Approval
Health approval is required on all applications for consumption on the premises. Businesses that serve food or
are located on premises licensed by the Division of Hotels and Restaurants, must obtain approval from that
division. Businesses that do not serve food must contact the County Health Authority or the Department of
Health. Food service establishments located in grocery and convenience stores, bakeries or delicatessens must
contact the Department of Agriculture and Consumer Services. The address for the office serving your area of
interest can be found at http://www.myfloridalicense.com/dbpr/abt/forms/documents/abtdistrictofficelist.pdf.
Affidavit of Applicant
Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, each partner
of a general partnership, a general partner of a general partnership of a limited partnership, a managing
member, manager, or officer of a limited liability company, each partner of a limited liability partnership, or one of
the officers of a corporate applicant.
Fingerprints
Note: If you are a current licensee with the Florida Division of Alcoholic Beverages & Tobacco you are not
required to submit a new set of fingerprints with your application unless you have been arrested since your prior
submission of fingerprints to the division. If you are not a current licensee but have been fingerprinted for this
division in the past three (3) years, and you have not been arrested since that time, you are not required to submit
new fingerprints unless the prior application was withdrawn or non -consummated. Applicants whose fingerprints
are returned to the division as illegible will be required to submit a second set of fingerprints.
Fingerprints must be submitted by each sole proprietor; officers, directors, individual share holders
owning more than % of 1 percent of stock in non-public corporations; general partners of general
partnerships; general partners of a limited partnership; officers, managing members or managers of a
limited liability company; partners of a limited liability partnership, and persons directly interested and
receiving financial proceeds from the business.
Applicants must use a Livescan vendor that has been approved by the Florida Department of Law Enforcement to
submit their fingerprints to the department. Costs associated with the fingerprint process will be collected by the
vendor. Vendor options and contact information can be viewed at Livescan Device Vendors List (Livescan Device
Vendors List). Please ensure that the Originating Agency Identification (ORI) number for the Division of Alcoholic
Beverages and Tobacco is provided to the vendor when you submit your fingerprints. The ORI number is
FL920150Z. If you do not provide the ORI number, or if you provide an incorrect ORI number to the vendor, the
Department of Business and Professional Regulation will not receive your fingerprint results.
Out of State Alcoholic Beverage and Tobacco Applicants only:
Your fingerprint card can be obtained from the Department of Business and Professional Regulation by
contacting the Division of Alcoholic Beverages and Tobacco at 850.488.8284, or one of the division's district
offices. A listing of the district offices on the web can be found at
http://www.myflorida.com/dbpr/abt/district offices/licensina.html . Out of state applicants must be fingerprinted by
a law enforcement agency on cards provided by the division (note: law enforcement agencies may charge for
this service). The Division of Alcoholic Beverages and Tobacco has a unique ORI number that is required for
processing the fingerprints back to the division, therefore, you must contact one of our offices to make a request
for a card to be mailed to you.
Once your fingerprint card is received, you may then go to a local law enforcement office in your area to have your
fingerprints rolled onto the card. Other information will be completed at the local law enforcement agency. For all
programs, the completed card must be mailed to Pearson VUE at: FLDBPR, Florida Fingerprinting Program,
Prints Inc. 119 East Park Avenue, Tallahassee, FL 32301 where the fingerprint card will be scanned. Prior to
mailing your fingerprint card, you must complete the following steps in order to make advance payment of $54.50
(do not send any money to Printslnk, please follow the procedure below):
OUT OF STATE LNESCAN FINGERPRINTING REGISTRATION DIRECTIONS with Pearson VUE and or its
subcontractor Morpho Trust (formerly known as L-1)
ab
1. Log.onto the Pearson VUE website at https://Dearson.ibtfingerpdnt.com/
Auth. 61A-5.010, FAC 2
-, , -1
A r-r^f A7s �
ISLAM-2 OP IQ: JA
DATE` D MW)
CERTIFICATE OF LIABILITY INSURANCE0412W13
THIS CERTIFICATE 4$ ISSUED AS A MATTER OF INFORMA71ON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMA17VELY 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. It SUBROGATION IS WAIVED, subject to
Me terms and conditions of the policy, certain pokles may require an endorsement. A statement on this Certificate does not confer rights to the
certificate holder in Hou of such endorsemen e .
PRODUCER
W.F. Roamer insurance Agency 964-731-556&
4752 W. Commercial Blvd $54-731.8436
Fort Lauderdale, FL 33319
Wiliam F. Dowd 111
E: Jennifer Arencibla
g .964-332-0231 C. 98q-731-8438
EaSAI1 , ennife rrter-ins.com
AOD
INSU AFFORDING COVERAGE MAIC 0
INsuREC island Plumbing Company
Inc
INSURER A: Mld-Continent Casualty Co 23418
INStIRERe:TraVelers 2$668
INSURER c. FCCI insurance Company 10178
P. O. Box 490984
Key Biscayne, FL 33149
WSURER O :
It@SURER E: ._._
a 100,00
INSURER F •
A
--
l�L:�7Kl7Vi� /i VIN�GR:
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.
LNSrR TYPE OF INSURANCE
WaL
POLICY NUMBER
M
LWTS
(NERAL LIABILITY
A X COMMERCIAL GENERAL majuTy
_ CLAIMS -MADE I .l OCCUR
X
L000866699
I 01/10113
01/10114ve
EACH OCCURRENCE $ 1,000,000
a 100,00
MED EXP (Airy one person) $ Excl d@
--
_
PERSONAL &ADV INJURY S 1,000,0
GEI—NERAL AGGREGATE S 2,000,0011
GEN L AGGREGATE LIMIT APPLIES PER,
POLICY ?O LOC
I
_
PRODUCTS-COMPIOP AGO$ 2,000,0011
_ $ -_
B
AUTOM�LE
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ANY ALTO
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AUTOS ALITOS
HIREDAUTOS NON -OWNED
AUTOS
BAOA320892
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BODILY INJURY (Per penal) S
BODILY INJURY (Per amkkx t) $
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or acci $
UMBRELLA$
EXCESS; 1448
_._
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
' OED RETENTION$
WORKERS COMPENSAT"
AND EMPLOYERS' LtAB1Lrry
OFFicERIMEMBERER EXCiUUEPROPMFTORIPARTNEwDtCUTNE Ya
rf yes, d orY M N4q
if y�a� describe aider
DESCRIPTION OF OPERATIONS below
i $
X WC STATU- H•
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07123112
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E.L. EACH ACCIDENT $ 1,0001
E.L. DISEASE - EA EMPLOYE $ 1,000,00
E.L. DISEASE - POLICY LIMIT S 1,00$,00
f
I
OESCrgPmON c>F OPERATIOAIS I LOCATIONS I VEKICLEB (Atmch AGORD 101, Addilionai Ramsey 8c1 rlule, V r u sp ue rg4ntre<p)
The Village of Miami Shores is included as additional insured as required by
written contract, subject to Policy terms and conditions.
rPRTI=1rAT= unl nee
MIAMtS2
Village of Miami Shores
10050 NE 2 Avenue
Miami Shores, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE VATH THE POLICY PROVISIONS.
AUTHORIZED
�REPRESENTATIVE
- -ry av esvv
ACORD 26 (201006) The ACORD name and logo are registered marks of ACORD
All rights reserved.
152533 STATE Of
MA
�aAi+ SON
MSPLAY AS REQUIRED SY LAAO � F
SEWL32061200747
KEN La
DISPLAY A5 REQUIRED SY LAWa� w
k...
Business Name (D/B/A)
"I, the undersigned individually, or on behalf of a legal entity, hereby swear or affirm that I am duly authorized to
make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a
true and correct representation of the entire area and premises to be licensed and agree that the place of
business, if licensed, may be inspected and searched during business hours or at any time business is being
conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and
Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the
beverage and retail tobacco laws."
"I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and
837.06, Florida Statutes, that the foregoing information is true and that no other person or entity except as
indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above
listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license
and/or tobacco permit."
STATE OF
C�ZilIP►��'Zi7�
APPLICANT SIGNATURE
APPLICANT SIGNATURE
The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this Day
Of , 20 , By who is( ) personally
(print name(s) of person(s) making statement)
known to me OR ( ) who produced as identification.
Notary Public
Auth. 61A-5.010 & 61A-5.056, FAC 8
Commission Expires:
Miami Shores Village MAY 2 2013
Building Department J
BYAsk
V5. nd Avenue, Miami Shores, Florida 33138
05) 795.2204 Fax: (305) 756.8972
w N'S PHONE NUMBER: (305) 762.4949
y
Permit No. A�k� �� �
PERMIT APPLICATION Master Permit Nom
FBC ZO
Permit Type: MECHANICAL
OWNER: Name (Fee Simple
City:_ State: Zip:
Tenant/Lessee Name:, Phone#:
a
Email:
JOB ADDRESS: I� 5 &'V W ) 0 � 5,
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
413
CONTRACTOR: Company Name: f % �� L�Phone#: _ 1 $81? } �
Address:�,�
City: r State: C" C Zip:
Qualifier Name: r't1A-- , --�- t
"114, / Phone#:
State Certification or Registration #: ® / 6- 3yP • Certifica of Competency #:
Contact Phone#: 2 C2 1 '�' Email Address: 05 e -
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this hermit: $ !t epe SqAareALAndr44Wfte of Work: _
Type of Work: DAddress OAlteration � t w "pa e-' air/Re lace
Description of Work:
Submittal Fee $ Permit Fee $ V W/ iJ L' v CCF $ CO/CC $
Scanning Fee $ Radon Fee $
DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
ODemolition
i
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
' 9
City
State 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
IWROVEMENTS TU 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 t e absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged
Signature ke�=Signature
Owner or Agent Contractor
Thefore n instrument was acknowledged befo a this 3 The foregoing instrument was acknowledged before me this
day of by ✓ %� l `� day of , 20 f �, by ,
o is personally known t e or who has produced who is personally known to me or who has produced 7' L °
As identification anted takei&ft4t h. as identiWVo `'and *fiWMW01&th.
464MY PgbBC - State of Florida
NOTARY PUB :;*y Comm. EXPMM Aw 18, 2016 NOTARY PUBLI ..' ��o�\oc Bay ,11 p ,
Commlsdon 8 EE 180815
Sign: Sign:
,/w • o
Print: )(/ .� /tit- `Y Print: -P -_,1 1A 1 (amt a
My Commission Expires: ie ' r /J. My Commission Expires:
V�(A rok 11,17,01�
APPROVED BY
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Examiner
Zoning
Structural Review Clerk
00' , .
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel. (305) 795 2204
AIR CONDITIONING REPLACEMENT DATA Fax: (305) 756.8972
PERMIT NUMBER: MC
This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data
sheet. Multiple units on single sheets are not acceptable.
Job Address (where the work Is being done): (vL.)
City: Miami Shores Village County: Miami Dade Zip Code:
ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB
ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION
A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS
ARI (AHRI) DATA SHEET REQUIRED
Change Disconnecting means: YES ❑ NO ❑ ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑
1. Minimum Circuit Ampacity (Wire Size): 6
2. Maximum Overcurrent Protection (Fuse/Breaker Size):
3. Voltage of Circuit (208/240/480): --� _ e? E
4. Size Disconnecting Mean;
Contractor's Company Name:
State Certificate or Regi str ' 1 N. C-- /'4- i If 6� -3 Certificate of Competency N.
Signature ) Date:
to
UNIT BEING REPLACED
DATA
NEW UNIT
MANUFACTURER°
AHU or PKG. UNIT MODEL #
COND. UNIT MODEL #
6 -
cf) 4 &
KW HEAT
NOM TONS--
AHU
CU
PKG
1 M.C.A
AHU
CU
PKG
AHU
CU
PKG
2 M.O.P
AHU
CU
PKG
AHU
CU
PKG
3 VOLTS
AHU
CU
PKG
PKG UNIT I
l
PKG UNIT
/ I
EER/SEER
YES
NO
REPLACING DUCTS'
YES
NO
YES
NO
REPLACING THERMOSTAT
YES
NO
YES
NO
NEW 4°CONCRETE SLAB
YES
NO
YES
NO
NEW ROOF STAND
YES
NO
YES
NO
NEW RETURN PLENUM BOX
I YES
NO
1. Minimum Circuit Ampacity (Wire Size): 6
2. Maximum Overcurrent Protection (Fuse/Breaker Size):
3. Voltage of Circuit (208/240/480): --� _ e? E
4. Size Disconnecting Mean;
Contractor's Company Name:
State Certificate or Regi str ' 1 N. C-- /'4- i If 6� -3 Certificate of Competency N.
Signature ) Date:
to
AHRI Certified Reference Number. 3492355 Date: 7/28/2012
Product: Split System:_ Air -Cooled Condensing Unit, Coit with Bluer
Outdoor Unit Model Number: 14AJM30
Indoor Unit Model Number. RHLL-HM3617+RCSL41*3817
Manufacturer. RHEEM MANUFACTURING COMPANY
Trade/Brand name: RHEEM 14AJM SERIES
Manufacturer responsible for the rating of this system combination is RHEEM MANUFAC URIN6a COMPANY
Rated as follows 1n accordance with AHRI Standard 2101240-2008 for Un. Air -Conditioning and Air -Source
heat Pump Equipment and subject to verification of rating accuracy by AHRI-sponsored, Independent, third
party test Ing:
CoolingCapacity (Btuh): 21200
EER Rating (Cooling): 13..00
SEER Rating (Coaling): 15`.00
'Rabn1p kbmd by w as*M 0 indicate a voWrfty hereto of pvft* PMWvd date, unfew ac=yvarWva t a VM, vd* t bicHmm an DIY rende.
@2012 /fir -Conditioning, Healing, and Refrigeration Institute CERTIFICATE NO.: IM79e6094W427e0
This combine
3
Efficiency
betvA
�'t C
Certificate of Product
Ratin
AHRI Certified Reference Number. 3492355 Date: 7/28/2012
Product: Split System:_ Air -Cooled Condensing Unit, Coit with Bluer
Outdoor Unit Model Number: 14AJM30
Indoor Unit Model Number. RHLL-HM3617+RCSL41*3817
Manufacturer. RHEEM MANUFACTURING COMPANY
Trade/Brand name: RHEEM 14AJM SERIES
Manufacturer responsible for the rating of this system combination is RHEEM MANUFAC URIN6a COMPANY
Rated as follows 1n accordance with AHRI Standard 2101240-2008 for Un. Air -Conditioning and Air -Source
heat Pump Equipment and subject to verification of rating accuracy by AHRI-sponsored, Independent, third
party test Ing:
CoolingCapacity (Btuh): 21200
EER Rating (Cooling): 13..00
SEER Rating (Coaling): 15`.00
'Rabn1p kbmd by w as*M 0 indicate a voWrfty hereto of pvft* PMWvd date, unfew ac=yvarWva t a VM, vd* t bicHmm an DIY rende.
@2012 /fir -Conditioning, Healing, and Refrigeration Institute CERTIFICATE NO.: IM79e6094W427e0
AHRI Certified Reference Number. 3412355 Date: 7/2812012
Product: Split System: Air -Cooled Condensing Unit, Coil with Slower
Outdoor Unit Model Number 14AJM30
Indoor Unit Moder Number. RHLL-HM3617+RCSL4M17
Manufacturer. RHEEM MANUFACTURING COMPANY
Trade/Brand name: RHEEM 14AJM SERIES:
Manufacturer responsible for the rating of this system combination is RHEEM MANUFACTURINGCOMPANY
Rated as follows In accordance with AHRI Standard 210/240-2008 for Unitary Air -Conditioning and Air -Source
Heat Pump Equipment and subject to verification of rating accuracy by AHRI-sponsored, independent; third
Party testing:
Cooling Capacity (Stuh): 292W
EER Rating (Cooling): 13.00
SEER Rating (Cooling): 16.00
R4*0 fdwned by;m aste M 0 Mcate a vokmtwyterat ctpmvlat*# u#ed dal, wftw acwmpw#adW1ha MSv"0bwMvWs an brjakm ary'reraW.
02012 Air -Conditioning, bleating, and Refrigeration Institute CERTIFICATE O.: t2sa7sss mm4zrso
Miami Shores Village --
Building Department OCT _i 7 200
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
FBC 20
BUILDING Permit No. _
PERMIT APPLICASEVI WNterPermitNo.
Permit Type: BUILDING ROOFING
JOB ADDRESS: F-� 5 NW M ® _ +f ek+C
City: Miami Shores County: Miami Dade Zip: 33150
Folio/Parcel#:
Is the Building Historically Designated: Yes
OWNER: Name (Fee Simple
7 !
Add,,,,- I Lj 1_FJ p
City:
NO Flood Zone:
State: 14Xr9 5 Zip; C y z- S q
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: %14-e, (',10 \k� �14Phone#: 105 —300 —1 e'
Address:: A �y�� S yIO 21"?) ?) T -e i f C(C
City:St'at$e: Zip:
Qualifier Name: � 1� 1 k t Q� Phone#:
State Certification or Registration
yy #:
Contact Phone#: �� V
DESIGNER: Architect/Engineer:
Certificate of Competency #:
Address:
Value of Work for this Permit: $ 00Square/Linear Footage of Work:
Type f Wo ❑Addition ❑Alteration ❑New ❑R ir/ eplace 1, , ODemolition
a ar :0
Desc tion of VV'ork.
Cotor thru We:
Submittal Fee $ Permit Fee $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF
CO/CC $
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, 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.
Signa
+er or Agent
The foregoing instrument was acknowledged before me this
day of vy�'20 l.�, by boadL
who is onally kno to me or J has produced
As identification and who did take an oath.
NOTARY PUBLIC:
r
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of 6 "- , 20 9 �? by
who is onally kno o e or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign:
Print: ES Print:
,,dNpp`I PVe�i ,NN doh.
My C pg N y Public - State of Florida p
•� My Comm. Expires Oct 11, 2015 My Co eNotary Public -State of Horida
714
• Commission EE 106714• •= My Comm. Expires Oct 11, 2015
,� a Bended Through Notary man e;= Commission 4E EE 106ry
r''�nq; �•� Bonded Through National Notary Assn.
APPROVED BY/ Plans Examiner Zoning
/M I Structural Review Clerk
(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)
Miami shores V
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
JANUARY 21, 2014
Permit No: RC1 1-1595
CHANGE OF CONTRACTOR
REVISION
1sr REVIEW
The plans submitted are from a different designer than the designer of record. The
plans do not represent the work at this location. Provide plans that show all work
performed without permits and provide a change of designer or plans from the designer
of record.
STOPPED REVIEW
Please meet with the Building Official to discuss the scope of work and the issues at
this property.
ARCHITECT & CONTRACTOR CHANGE
2ND REVIEW 11-26-13.
1. PLANS PROVIDED DO NOT REFLECT FULL EXTENDS OF THE WORK
PERFORMED AT THE JOB SITE.
2. STRUCTURAL APPROVAL REQUIRED.
3RD REVIEW 01-21-14
eed to schedule a meeting between e
:viewer and the building official.F
Ismael Naranjo
Building Official
neer of record and the structural plan
Plan review is not complete, when all items above are corrected, we will do a complete
plan review.
If any sheets are voided, replace them with new revised sheets and place behind the most
current page.
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (306) 756.8972
14— 2'1 —1-3
Permit No: R C -
Structural Critique Sheet
Page I of I
C'L t -Q D,--'
ON'
NMI!
A0
TE :1
-X e_�Jjt
a/�� �
0 NO
=42-
Re
co t-, "-e-
�M H
e -,CAA
J J—��ecl
STOPPED REVIEW
Plan review is not complete, when all Items above are corrected, we will do a complete plan review.
If any sheets are voided, remove them from the plans and replace with new revised sheets and Include one
set of voided sheets In the re -submittal drawings.
Mehdi Asraf
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
RECEIPT
PERMIT #:46= /` /S- 93 DATE: /r /C)/1 /-3
D Contractor �j 14
?mer
❑ Architect
Picked up 2 sets of plans and (other)
Address: ( T �- Oc,O op c 5-�- .
From the building department on this date in order to have corrections done to plans
And/or get County stamps. I understand that the plans need to be brought back to Miami
Shores Village Building Department to continue permitting process.
Acknowledged by:
PERMIT CLERK IN
RESUBMITTED DATE: t d 7-" % ,-�
PERMIT CLERK INITIAL:
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
October 17, 2013
Permit No: RC1 1-1595
Building Critique Review
PLANS ARE INCOMPLETE. THE PLANS SHOULD REFLECT ALL
MODIFICATIONS BEING DONE TO THE PROPERTY AND MODIFICATIONS
DONE WITH OUT CITY APPROVALS.
Ismael Naranjo
Building Official
Plan review is not complete, when all items above are corrected, we will do a complete
plan review.
If any sheets are voided, remove them from the plans and replace with new revised
sheets and include one set of voided sheets in the re -submittal drawings.
_P oc)6q) 5 ;
not
be- l55uPd Unle�,r
C0 f e6ions 1"11c�e
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Permit No:
Structural Critique Sheet
Page 1 of 1
q ! J'Lt ic. � I's) t' °i �°"' �. lt"j 12-11 L— �. -�-� ..
'''�'�-
J� �.� �� •�'� ��
� � i/°''�� e �0
d'�� ,�,�. d'� Q i� a°Z� � �
� 2"'/711
_ yy_
Y� �:i'� p'n E�K _��1 d"�'
l � -Ise,
STOPPED REVIEW
Plan review Is not complete, when all items above are corrected, we will do a complete plan review.
If any sheets are voided, remove them from the plans and replace with new revised sheets and include one
set of voided sheets In the re -submittal drawings.
Mehdi Asraf
2fI12014 '48MCOnftwoonSeNces Mail - Pis printihis Mfar NW 101 St pernang
PIs Print this out for NW 101 St permitting - -
Joe Chan <_--
Strucbnal Compormft
To: Benjamin MerxWe <bw uctlor cee..
Wood Cormectore
Subject Florida EUlding Cade Orrin
s
OWIC1111M Mark or Lisft
CereAgency
MWm Dade BCCO - CER
By
Miarn Dade BCCO - VAL
BCIS Nome Log In User Registration
Business er Surcha
Sims FSC BCIS
F PuL•licaticns
Tccics Surcharge
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Site Links Search
�ay`` Stagy h,ap
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Product Appro%al Menu > Product or Application Search > Application ication List a Application Doiatl
4a r #
AWHcefim Type
Code Version
Recision
Appkation Staters
2010
APpnned
comments
-APP"Yod by DBPP- APp vdit by DSPR shah be reylswed
Amhied
and FOMW by the POC rerd/or the Convnleeta
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Pmduct Manufacturer.
AddresslPhwe'EmW
Nu-Vue Irtdustdes ft.
1055 E 29th sUset
K01e2h, FL 33013
;305j E:? -i-0357
.:alai«,+sbcglc'�a. -raf
AWdhofted Silptllt a Msrk Guardedo
NolaLa'.s6cglohal.nei
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Addre WPhane/Ematl
caftMy
Subcetegary
Strucbnal Compormft
Wood Cormectore
Canplla M Method
OWIC1111M Mark or Lisft
CereAgency
MWm Dade BCCO - CER
By
Miarn Dade BCCO - VAL
Rebenced Standard and Year (of Standerd) allande
AISI 8100
ASTM 01761
NDS
EoWenw of Product Standards
Certified By
Prduct Approval Method Method 1 Option A
Date Sutanitted 07/13/12
Ode Validates 07/2M2012
F�tpsJhnell.googlet�ttl/metUut1J?td=28i1F8e242Q51648��fe�P*=jce°. ggsw u ewctFq aMF143farja�
1/$
?1,7/2014
ImMct Resistant: WA wsta CGvftdon SeNc es Mail - F113prirtthern
is outfar NW 101 St pit ng
I]esign P►eum: WA
Other. Uplift and letraal Ioads.Refr, to Miami-DW9 NOA# 12-0130.32 for detffits.Fer use in HVHZ
and outside of HVHZludscl-b ns because the third-11--ble steal straps increase was not trsed-
599.8
NVTA and NWAS
Urnits of Use ---
Approved for use in tIVHZ: Yes
APP►oved for use outside Hwa. Yes
Impact Resistant WA
Design Pressure: WA
Other. Uplift and lateral Ioads.Refr to Miami-DadO NOA#12-0130.33 for detalIs.For use in HVHz and
outside of HVHZlculsdictfota because the third alloxabla Steffi stress I.,.. was not .ed.
69,9.9
NViH
05/22/2013
Installation Iastroc6ona
FL599_R5_11 Miami-Dadei2-0130.32.pdf
VeriSea By Mtami-Dada 13COO - CER
Created by Irntependent Third Party:
Evaluation Reports
Created by bniependerd Third Petty:
Teres anchors
i Certification Agency Carocami
FL599_R5 C CAC_Miami-Dadei2-0130.33.pdf
QualltYAus--nc.e ContrectErpirefion Date
06/21/2013
Installation Instructlone
FL599 R5_It Miami-Dadei2-013o.33.pdf
`CER
Oeated by irtdePsmdent Third
Evaluation Reports
Cnmted by independent Third Party:
Umits of Use
i Truss anchors
Approved for use In HVHZ- Yes
APPnMd for use outside HVKM
Certification Agency Certificate
Yes
Impact Resi done WA
ss
Dodo Pressure: WA
FL599_ R5_ C_ CAC_ Miami-Dadei2-0130.33. pdf
Quality A�urarsee contrail tic PlraUon C to
Other. Other Uplift I -Dads. Raft to Mfarnl-Dada NOA# 12-0130.33 for details.For use in HVHZ
outside of HVHZ jurlsdlctloru because
j 08/21P2013
instructions
InstallationFR
end FL599 II
the third allowable std stress increase was not12.0130.33.pdf
use
By Mlemi-Dade BCCO
II - CER
I Created by Independent Third Party:
---
L —
I Evaluation Reports
Created
599.10
by (ndepargio t Third Party:
NVTW 26 and 28
"'----
Umits of Use --
HIP and Jack Hangers
Approved for usa in HVH2: yes
Approved for use outside HVHF. Yea
Impact
Certification Agency Cortiflcate
1 FL599RS C CAC
Resistant WA
Design Pressuure:re: WA
_ _Miami-Dade12 0130.32.pdf
Quality Az"nce contract Expiration Date
Other. UPGft and lateral Ioads.Refer to Miami -Dade NIDA# 12-0130.32 fm
anal outside of HVHZ jcaisdicttons datat7s.Forrsa in FNH2
tracause
05!22/2013
Installation Instructions
FL5Q9
the third alrouable steel stress increase was not used
R9 N 4 sett-DadeY2 0130.32.pdf
Verified By: Miami.0ade BCCO
- CER
Created by irMelowWont Third Party:
i Evaluation Reports
----
Created by hiependent Thad Patty;
MNVTT -- --
11= I
fsofL4W
Sanibel Truss Strap —
j Approved for use in HVHZ: Yes!
Approved for use outside HVHZ Yes
Certificadon Agency Certificate
FL599_R5_C_CAC
Impact Resistant WA
WaIgn Pressure: WA
Miami-Dade12-0130.32.pdf
! Qualliy Assurance Contract Est plrafdon Dale
Other: Uplift and lateral foads.Rffier to Miami
and outside of i.Me judsdictipns NOA# 12-Q13p•32 for detafis.For use in HVHZ
because
; 05/22/2013
Installation Instructions
FL599_R5_ii_Miami-Dadei2-0130.32.pdf
the third allowable st.W stress Increase was not used.
Verified By-- Munni Dade BCCO - CER
Created by Independent 71*d Panty:
_
Evaluation Reports
Created by @nt Thhd Party:
NVUH 26
Umlts of Use
Approved for use in HVHL• Yes
Approved for use outside HvHz. Yes
Impact Resistant WA
Design Pressure: WA
Other. Uplift and Graft Losds.Refer to Miami Qade NOA# 12-0130.33 for deLyis.Far use in HVHZ
ern! outside of clVF¢ jmisdictlornq becausa the third BROY'We steel stress increase was not used.
Joist Hanger
aertlfication Agency cer"c to —
FL599 R5C CAC _Miami-Dadei2-0130.33.pdf
Gtraifgv As_wranca Coastrast Erptra8on Data
O/21/Y013
Installation Instructions
FL599_R5_II Miami-Dade12-0130.33.pdf
variH� By:' Merril�B= - CER
CnWed by independent Third Party:
Evaluation Reports
Created by ktdsWtdant Third Patty:
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Product Approtel Menu > Product or Application Search > Application List > Application Debil
FL#
Apohmaorn Type
FL10458-R2
Code Version
Editorial Charge
Application Status
comments
2010
Approved
Amhhed
O
Product Manuiecturer
AddrssslPFmnva/Emati
Simpson Stang-lte Co.
2221 Country Lane
McKinney, IX 75M
(97 2) 439-3029
rshackelfordQ¢ strongtie. com
Authorized Signature
Randall Shackellbrd
rshac;�elfora�s trongtie. com
Techntcai Representation
Address/Phots/Emall
Pandeli ShackW40rd
1720 Couch Drhe
McKinney, TX75M
(800) 599-5099
rshackelfordCstrengtie. com
Quality Assurance Reprasentati.
Address/Phone/Emall
Pat Wonted
1720 Couch DrM
McKinney, TX75=
[500) 499-5099
p',', oodaAL¢,s trcngtie.ccm
CAM"
Subcategry
Structural comRonente
Wood Connectors
Compliance Method
Evaluation Repot yarn a Product Evaluation Entity
Evaluation Entity
Quality Assurance Eby
ICC Evacuation Sevtce, LLC
Quality Assurance Contract Exphedot Data
Benchmark Hol*V• LLC.
Validated 8y
12/31/2014
Jeffrey P. Amason, P.E.
® Validation Checklist - Hardcopy Received
CertiSoete of IftlePendence
FLiL-4s5ia P,2 C01_ICC Gert of hvdependence.pdf
Reitet Sneed Stendand and Year (of Standard)
altudard
ASTM D1761
NA SPEC FOR DESIGN OF COLD FORMED STEEL CONSTRUCTION
NATIONAL DESIGN SPECIFICATION FOR WOOD C NVSTRUCi1ON
EquiWence of Product Standards
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FL10d56_R2_Equiv_2010 Seff Affirmation Simpsan.pdf
Sectlons ficin► the Cie
Product Approval Method
Method 1 Option C
Date SuWnttlad
Date Validated 03/14/2012
Date Pending FBC AppmW 04125=2
Date Approved 06/02/2012
06111/2D12
Summaryof Products
Go to Page _
j FLS
Page 113
----•— ( Model, Number or Name
f 10458.1
j Description —
-- � DSP
Umks or use --- --
Doubie stud to Plate tla
Approved for use In NVHZ• Yes
Approved for use outside HVF. Yes
f Imi alladon IrstrutWells
1`1-10 56_RZ
f Impact Resistant WA
Design Pressure. WA
II ESR �fii3.pdf
1 Verified Byr- Rendall Shackeliord P.E. 68675
111 Outs, r. Supplimer� wftn�tms
�:--. may be taclult� to acFrehe 7 upQft i� HVHZ
-----
Created by independent Third
Evaluation PAY Y�
��
—
10456.2 FTA2
FLi0::55 R2 AE -ESR-2613.pdf
U miss of use
I Floor 170 Anchor
i APlroved for use in HVHZt Yes
Installation Irm&,*ons
Approved use outside H1/ite: Y88
impact Resistant WAp
1`1-10456_R2 _If_ESR-2613. df
Design Pressure: N/A
Other.
Ue�� ey a and Third p, P.E. 66675
heated by Hufepatuierd Third Party: Yes
t Evaluation Reports
110466.3
FL 104 56_R2_A E_ ESR -2613. p df
FrAS
Limits of Use
Floor Tie Anchor
! APProvad for use in HVHZ Yes
for rrse outside HVHZ Yes
hmtailation instructions
FL'0456
IApproved
Impact Resi=nt: WA
Design Pressure: WA
R2 X ESTI-Z613.pd
' Verified By: Rar>daB Sh w&elford P.E. 68675
Other
Crested by trctepertderd Third P Yea
Evaluation Reports
FL10456
1045.4 — --
R2_AE_ESR-2613.pdf
�— FTA7
Umtls of Use —
, + Floor Tie Anchor
Approved 1br use In "We Yes
APProved for use outside f1UHe Yes
Impact Resistant: WA
i 1-ift stun tnsouclion
FL10456 R2-11 ESR-2613.pdf
Design Pressure: WA
Other.
Verified By: Randall Shackelford P.E. 68675
mated by independent Third Party Yes
Evaluation Reports
10456.5 T
--- ` H1
FI10456- P.2_AE -ESR-2613,pdf
—
j Lhnita of use
Humc ene na
Approved for use in HVFM Yes
APProirod for use outside MMM- Yes
Installation Inatructlors
FL10456_112_II
Impact Resistant WA
Dsalgn Pressure: WA
Other. 2connectoua
ESR-2613.pdf
Vied By-- Randall Shackel&ud P.E. 66675
Cts W by traiependattt Third Party: Yes
must be used to achene 7W# uplift for HVM
Evaluation Reports
FL 10456_R2_A E_E S R-2613. p d f
10456.6 f 1110
Units of Use
IHurricane Tie
Approved for use in HVHZ Yes
Approved for use outside Hwa. Y,,
InaWletion Inatructions
FL10456_R2_Il ESR-2613.pdf
Impact Realstant WA
Design Pressure: WA
Verifed By: 01 i" U Shackelford P.E. 68675
Created by ktdependerd Thhd Petty: Yes
Other.
Evaluation Reports
L
FL10456_RZ_AE_ESR-2613.pdf
10456.7 H10-2 —
Limits of Use
Humic lie
Approved for use in HVHF- Yes
Instatietion Irtstructiorts
APP►oved for use outside HVHZ Yes
Impact Resistant WA
FL10456_R2_II_ESR-2613.pdf
Verified By: RGI -W Slucke fwd P.E. 5675
Design Pressure: WA
Other. 2 connectors must be used to achene 7005 upWt fpr Me when using5PF/i Hadar.
Created by Independent M*d Party: Yea
I Evaluation Reports
!
FLY0456 Ft2 AE_E5R-2613.pdf
10458.8 1116
Umns of u
1 Hu"Icime Te
Approved for use in Wit Yes
I Installation Instrutctiom
F L 10456_R2_iI_E S R-2613, pdf
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Vests Cmstruction SO-4ces Mall - F4s PFirdltlis atltfor NW 101 St perntffing
1 Approved for use outside HVHZ Y
InPact Resistant WA
ODoellin Pressure: WA
10455.9
HIS -2
Umus of ulse
Approved for use in "Wim Yes
Approved ter uss outside HvFm Yes
Impact Redicat WA
Oceign Presque: WA
Other
10456.10
H2
Units of Use
Approved for use in HVM Yes
Approved for use outside HVH2: Yes
impact Resistant WA
Design Premnue: WA
Other. Supplmeri rxnn8ct0M must be � to
- salleive 7001E UPM far HVHZ
10456.11
H2.5
Umitsof Lisa —
APPnored fbr nee in HVM6 Yes
Approved for use outside HVF2 Yes
Impact Resistant WA
Design Pressure: WA
Other. 2 conneacn; must be used to achahe
700q far HVHZ
10456.12
Units of Use
Approved for use In HVHm Yes
APProved for use outside HVHZ Yes
Impact Resiatant WA
Design Pure: WA
H2.5A
Other. 2 connectors must be used to nmh dw 700p to* hy. WHZ
10456.13
0
Units of Use
Approved for for use In HVHZ Yes
APProved for use outside twin Yes
Impact Resistant WA
Design Pressure: WA
Other. Suppiimerdal connecters must be used to achene 700# Will forHVHZ 2 H3S may be used
In DF/SP lump to sect the 7�t req
uiremeM
10456.14 j
— --_. H4
Units of Use
APProved for use in HVH2: Yea
Approved for use outside I. H Yes
Impact Reslsmnt WA
Daslgn Pressure: WA
Other 8eerp r corer Cts mbe used to 60holm 70M L0111 for HVHZ 2 We may be �
In DF/SP I—b r to me. the 700#n'0yaremeft
10456.15
Umits of Use
Approved for use in HVIM Yes
APProvad for use outside mm Yes
Impact Resistant WA
Oceign Pressure: WA
H5
Other. 2 connedors must be used to
admw700d upfiftf
OrHVH7
10456.16 -- FH -6
Limits of Use
APProvod for use in HVHZ_ Yes
Approved for ase outdda HVHZ_ Yes
Impact Resistent WA
Design Pressure: WA
Other
10456.17 j H7Z
Units of Use
Approved for use In HVHZ Yes
Approved for use outside HVHZ Yes
Impact Restslaet WA
Design Pressure: WA
Ober.
10456.16
HOT -2
Verified W- Ramtaff Siackelfctd P.E. 68675
ErB
Created
oby Re Third Party- Yea
FL10456_R2_AE ESR-2613.pdf
FHurricane lie
Installation Instructions
fi FL10456 R2 1! ESR-2613.pdf
VwflW By: Randa6 Shm*ettaud P.E. MM
Created by Iadopendeni Third Partly: Yes
Evaluation Reports
FL10456 R2 AE_ESR-2613.pdf
Hurricane lie
Installation instruction
FL10456 P,2 II_ESR-2613_pdf
Verified By: Randall Shandcelfmd P.E. 68675
i ideated by tsleMtderd Third Party; Yee
Evaluation Reporte
FL10456R2_gE_ESR-2613.pdf
j Hymficane Tie
�j I—rstallation innrudlone
FL10456_R 11_ESR-2613.pdf
VORW Sr- Rarda6 Shackelbd P.E. MM
Created by idem lhbd Party- Yes
Evaluation Reports
FL10456_R2_AE_ESR-2613.pdf
Hardcore Tie
Inslallatlon Instructions
F L 1041-6_RaR2_}I_E S R-2613. pd f
Verified By: ndall Sh,*Wfmd P.E. SSM
CreEvaluation
dby � by Mft party: Yes
pww
I FL10456_R2_AE ESR-2613.pdf
Hurricane Tie
Indallation Instructions
FL10456 R2 1LESR-2613,pdf
Verified By: F7ande0 Shackeflbud P.E. 66675
Created by Independent lidrd Party: Yes
Evaluation Reports
fFL10456_R2 AE_ESP,-2613.pdf
Hunk�rle Tie
kWdbution hnatructiors
{� FL10456 R2_11 ESR -2613. pdf Veded By: Randall ShwAarad P.E. 68675
fEvaluationi
Created by ds ant Thhd Party: Yaq
r'L10456_R2_AE_ESR-2613.pdf
Hurricane Tie
Installation Instructions
FL10456_R2_I! ESR-2613.pdf
Hewed By: Randall Shackelfod P.E. 66675
0eated by bxWpendeM ThLd party: Yes
FL 10456_R2_AE_ESR-2613.pdf
Hunlr� 71e
Installation Instrohctons
FL10456_R2_11 ESR -2613. pdf
VeMed By: Randall Sheckstord P.E. 68675
Created by kWsp wWent ThW Party: Yes
Evaluation Repots
FL 10456_R2_AE_E S R-2613. pdf
Hurricane lie
Installation Instructions
F L 10456R2_ll_ESR-2613, pdf
V-Msd Oy: iilrrdae Stmrxcettd P.E. MUM
Created by krdepmrdem Third Party: Yes
Evaluation Reports
FL10456 R2_AE ESR-2613.pdf
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ti7M4
Vista Cm itrtictimn Ser -ices Mail - PIs print INS W for NW 101 St plirniiting
L.b jts of use --- _
IApproved for use in Wam- Yes Irrststiation Insdrue8ora
AAprOad Outside FIVI$ Yes FL10456 R2 11 ESR-2613.pdf
imP8ct Resistant WA' VeltOed By: Shackd P.E. 68675
t Design Presaure: WA
Other. Cry by Ndett Thbd Party: Yes
10456.19
omits of use
Approved for the in HM- Yes
APPraved for use outside mm. Yes
Impact Reshunt: WA
Design Preastne: WA
10468.20
Units of use
APPrwmd for use In HVH& yes
APPfMd for use outside HWM Yes
4npactResietarrt WA
De gn Pressure: WA
Evaluation Reports
FL 10456_R2_AE_E SR -2613. pdf
HGT3
Heavy Glider 7ledown
Ire;oallatlon 1� —'
FL10456 RZ_II_ESR-2613.pdf
Vertfed By. RBtdag Shackelford P.E. UM
Gmw
Evaluationby Rerog wt ftt �d Party; Yes
FL10456 R2_AE_ESR-2613.pdf
Ht37-q
"`--- Heavy Ginter Ttedo m
insbllatlon Instmellone
0456_R-9 II_ESR-2613.pdf
Veld By- i2anda6 Shacketfixd P.E. 68875
Cued by kdatdent 7hW petty: Yas
Evaluation Reports
II FL10456_R2_AE_ESR-2613.pdf
Joseph C. Chan, PE, PSM, CGC
B. A, 6 K Group, inc.
120(10 SW 92 Street
Mt -1, FL 33188-2018
Phone; 786 488 1000
Fax: 888 448 6511
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