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PL-14-802BUILDING PERMIT APPLICATION Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 F 20 Master Permit No. L� " �J Sub Permit No. BUILDING F-1 ELECTRIC ® ROOFING REVISION EXTENSION RENEWAL PLUMBING MECHANICAL J-]PUBLICWORKS [:] CHANGE CONTRACTOR CANCELLATION SHOP DRAWINGS JOB ADDRESS: '5' P N 9 %b 14 City: Miami Shores County: Miami Dade Zip: 33i6k 0 Folio/Parcel#: IA -3;)L - ®16- b) - 10 51D Is the Building Historically Designated: Yes NO ii Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 1�/l.6 p'le" aaek� Phone#: 30�'�%�-��® Address: aoye- ) l n City: M a P''1 State: � 1 Zip: Tenant/Lessee Name: At Email:�Fked rn , A i r f �� rM CONTRACTOR: Company Name: Address d _'ep City: &-7 Phone#: ?4 ��- t te• 2� Zip:' r� Qualifier Name: Zle C 1 Phone#: State Certification or Registration #: ®� �.��%% Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: Type of Work: ❑ Addition Description of Work: "y VON 99-04 City: L� d a li Sq ❑ Alteration ❑ New ru HIP -- State• Zip: Footage of Work: _ Repair/Replace ElDemolition - , zzejew Submittal Fee $ Permit Fee $ U�1 CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Struura evew ct 1 R i $ 4(5-,40 TOTAL FEE NOW DUE $ `1V_ 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 COMMEIIIWCEMENT 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 her'P)6w 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 issues. in the absence of such posted�tice, the inspection will not be approved and a reinspection fee will be charged. �'� Sig nature Owner or Agent The foregoing instrument was acknowledged before me this this day of /L!% 20by /'yl�P� who is personally known to me or who has produced r-! 1,35 7.3 ?Z 3066 )' As identification and who did take an oath. Contractor The foregoing instrument was acknoowwledge beff e mg da of alt 20 b / 9 '' .0 t a/Ll�� Y f4. Y who i personally known m tor who has produced as I entification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Zon)n 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) A I'® CERTIFICATE OF LIABILITY INSURANCE °A�' 712013 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 WSURER(Sh AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: If the certMcate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. U SUBROGA71ON IS WANED, subject to the terms and conditions of the policy, certain policies nmy require an endorsement A statement an this certificate, does not confer rights to the certificate holder In ilea of such endorsement(ag PRODUCER A ALL SOUTHWEST INSURANCE INC 1827 NE MIAMI GARDENS DRIVE MIAMI FL 33179 305-692-9212 CONTACT NAM MIAMI SHORES FL 33138 AFFOR>arts NAS c MSURF.RA: GRANADA INSURANCE COMPANY INSURED DPAUL PLUMBING 21005 NW 14TH PLACE MIAMI FL 33169 IT B: a Et c UQPJREaD: INSURER E: 06107/2014 r_AUT=RAIMPA f'91MMf ATC MrrMRFR- 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. NOTVMTHSTANDING 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 SHOVMV MAY HAVE BEEN REDUCED BY PAID CLAIMS. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TYPEOFINSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1050 NE 2ND AVE POLICYNUMBER MIAMI SHORES FL 33138 STsGENERALUABILI rA Y COMMERCIAL GENERAL LIABILITY a OCCUR F7,11 1_71MEDEXP FL -36779 06107=3 06107/2014 EACH OCCURRENCE $ 1 000 DAMAGE $1CLAIMS-MADE OrePRIMM $5 000 PEmNAL&ADVINAw $ 1 001) GENERALAGGREGATTE $ 2,00Q0W GENLAGGREGATEUMITAPPLIESPER: X POLICY PRO LOC PRODUCTS -CDWIDPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO OMIED SCHEDULED � H[REDAUTOS p OS AMOS OS coNABIREDUIRGLEURIT �dMI BODILY INJURY (PO I) $ BODILY IN URY (PO' aaldOm $ S UMLA LIAB1R EXCESS LL49 CLAMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ INORKERS COMPENSATION AND EMPLOYERIr LIABILITY ANY PROPRIETORtPARTDE'D? W RVE YIN SER DICLUD� ( m NH) It yes, desap3e under N / A NC STA Mr I EJ- EACH ACCIDENT, $ E.L. DISEASE - EA EMRDYEE $ EL DISEASE -POLICY LIMIT I $ DESCRIPTION OF OPERATIONSI LOCATIDNBI V9RR.M ~ ACORD 101. AdIEEO W Renes SdMduf , Hamre m R9uivad) PLUMBING CONTRACTOR #-=Cm=lr-A re UM r%= !`ARIr`Gr I ATH11M THE VILLAGE OF MIAMI SHORES -BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES FL 33138 AUTHORIZED REPRES13UATM 305 75FrS972 VVKENNEDY 97911114201ULIULRDWliVUMiHJP& wnngrnsreserves. ACORD 25 (20101 The ACORD name and logo are registered marks of ACORD PAUL,.DEC3310B - DPAV-12 TIM' 1710 NE 139 STREET FL 33181 i vEapACS 11.1- :ongratidallonsl Wills ttft kense you become one of the newly one iu�TVMMMIHown OF Ada Fforfft-- Ur-- �RfVftffovL ixashif'sa" Otw putess- IM*Jul a"faaft 4" boxersto bwbequsmftW8nh4 andOW keep Florida's economy sftvj. 41' 82S9�-: -r# -/2,. 1193.91485 Every day we work toimpravache way we do business In order lo serve you befter.� For Wor-T `:-%n, -PA There you can *W more Inibraudlonaboi aw&,kftWiiat-he UL- flud Impad YOU. subscribe to department newslelters and learn more the PI InIfialtuM OLW ra6mijan ai aia UazAi&,; �xy, d Fah4 we coruftay drivefaserve ym beftrso#Wyou can serve yatirajdamem Xg;:VERTXFnMk- Aha Mw* you for doing budness In Pmdia6 and on your new Ncensel AT= 0 r14 26s4 58 i D F T"r I OR E STATF�LOWA-.. C# 6141524. DwAR STFP%O S9102M MULATION _y DT BOA L12052600359 73W -T 72 SEQ# ��MIIIWLXCSS' W NBR list i* 2-# 414is.- lit"I 4 so KM LAWSON SECRETARY - der t2ie2-gr JLCMZ 0 PtA8 0�. Kxpiraktic= dater WYO. 3i,--2014 AN&L DR B ORK ------1710 Nr- 13§W 2 WMAKI Fftt 33181 -V MC AR PLA RE F:?Eb'BYiAW"-* KM LAWSON SECRETARY ,acc��`'�®• CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) INSR LTR TYPE OF INSURANCE 04/21/2014 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 CONTACT NAME: Automatic Data Processing Insurance Agency, Inc. PHONE Ext : a No E-MAIL ADDRESS: 1 ADP Boulevard INSURER(S) AFFORDING COVERAGE NAIC d MED EXP (Any one person) $ Roseland NJ 07068 INSURER A: NorGuard-InterGuard Insurance Company INSURED INSURER B DPAUL PLUMBING INC INSURER C: 21005 NW 14TH PL APT 146 INSURER D: INSURER E MIAMI GARDENS FL 33169 INSURER F: GUVERAGE5 CERTIFICATE NUMBER: 225449 RFVISInN 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 ADOLSUOR INSR WVD POLICY NUMBER POLICY EFF M/DD POLICY EXP M/DD LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F7OCCUR EACH OCCURRENCE $ D)!kMAGE TO REN PREMISES Eaoccunenca $ MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMB APPLIES PER: POLICY PRO- LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE ar accident $ UMBRELLA LIAB EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILnY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If describe under WeOF OPERATIONS below N/A N DPWC444417 05/25/2013 05/25/2014 xWC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Ia required) Plumbing Contrator L,rK I IrIL.A I C rIULLICM GANGCLLAT IUN THE VILLAGE OF MIAMI SHORES BLDG. DEPT. 1050 NE 2ND AVE MIAMI FL 33138 ACORD 25 (2010/05) 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 ©1988-2010 The ACORD name and logo are registered marks of ACORD rights reserved.