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RC-10-1935Miami 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 Permit Type: BUILDING Permit No.q-c, CO — 10, &5— Master Permit No. OWNER: Name (Fee Simple Titleholder): �1 /� = %� ��= J�1 Phone#: Zk • 5K7 .5 -/ate Address: G S N G City: State:Zip: 33X33- z 33 C Tenant/Lessee Name: Phone#: Email: ( U E Cd (/Cha 0 • CC JOB ADDRESS: � 6 S 04 • E. _q 8 S r. City: Miami Shores County: Miami Dade Zip: 3 3 138 Folio/Parcel#: I' - 3206 - 0 13 - 2.33 Is the Building Historically Designated: Yes Zone: CONTRACTOR: Company Name: 6,m 4 e2 4v Icy�- ✓�109Pe.:rS 24 Phone#: 9-("1- 24 1- 12 2 4 Address: _ 9 f 2® f4,-;, Z L A N 1D Dl2 City: 60C4 A-i'.0N State: FSC. Zip: 33 4 91 Qualifier Name: /2 I C /-AAD C. C/q L i FA N o Phone#: State Certification or Registration #: C &C 05 -� 8 4 y Certificate of Competency #: Contact Phone#: 30S - 4 5 i - O 2 9 9 Email Address: a %1212d i 124 ty tcl ATek 14 ^4 GJr DESIGNER: Architect/Engineer: Phone#: Ca'�eDa nF441=(Q& }9-029,c Value of Work for this Permit: $ 2. Olio 6v Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace of Work: COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by. Submittal Fee $ 5D - (XD Permit Fee $ o, Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO/CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE VE54aaa 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. identification and who did take an oath. My Commission Expires: Signatu e 6z�� Contractor he foregoing instrument was acknowledged before me this 20 / U, by vho is personally known to me or who has Cg1S'7FSq Vo7-0 as identification and m APPROVED BY flak) flak) Plans Examiner Structural Review (Revised 07/10/47)(R&ised06/10/2009)(Revised 3/15/09)(rev6/4/10) NOTARY PUBLIC: My Commission Expires: Clerk ANNE M. G AAT N O N P.O. Box 3353, West Palm Beach, FL 33402-3353 *"LOCATED AT** camnin nom us COLL MM www.taxcollectorpbe.com Tel: (561) 355-2272 sffvft t coswy 1120 HOLLAND DR Ste 1 BOCA RATON, FL 33487 TYPE OF BUSINESS OWNER CSMRCATION # RECEIPT #/DATE PAID AMT PAID BILL # 23-0153 BUILDING CONTRACTOR EMERGENCY SERVICES 24 INC . CBC057844 U10.1018440 -10/19110 $17.50 840002007 This document Is valid only when receipted by the Tax Collector's Office. EMERGENCY SERVICES 24 INC EMERGENCY SERVICES 24 INC 1120 HOLLAND DR STE 1 BOCA RATON, FL 33487 ullnrllnlullult�nr STATE OF FLORIDA PALM BEACH COUNTY 2010/2011 LOCAL BUSINESS TAX RECEIPT LBTR Number: 201037051 EXPIRES: SEPTEMBER 30, 2011 ae This receipt does not constitute a franchise, agreement, permission of authority to perform the services or operate the business described herein when a franchise, agreement or other county commission, state or federal permission of authority Is required by county, state of federal law. ACO RD,� 7CERTIFICATE OF INSURANCE ISSUE DATE 10/28/2010 PRODUCER MCGRIFF, SEIBELS & WILLIAMS OF GEORGIA, INC. 5605 Glenridge Drive - Suite 300 Atlanta, GA 30342 PHONE: 404 497-7500 This certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the policies below. COMPANIES AFFORDING COVERAGE Comlpany Wausau Underwriters Insurance Company INSURED Professional Employer Resources, Inc. 500 N. Maitland Avenue Suite 201 Maitland, FL 32751 Company B Company C Company D Company E This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated. Notwithstanding any requirement, term or condition of 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, conditions and exclusions of such policies. Limits shown may have been reduced by paid claims. CO LT TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS OF LIABILITY GENERAL LIABILITY ❑ Commercial General uabllity ❑ Claims Made ❑ occurrence ❑ Owners' and Contractors' Protection ❑ ❑ General Aggregate Umit applies per. ❑ Policy ❑ Project ❑Location EACH OCCURRENCE $ FIRE DAMAGE $ MEDICAL EXPENSE $ PERS. AND ADVERTISING INJURY $ GENERAL AGGREGATE $ PRODUCTS AND COMP. OPER. AGG. $ AUTOMOBILE LIABILITY ❑Any automobile ❑ All Owned Automobiles ❑ Scheduled Automobiles ❑ Hired Automobiles ❑ Non -owned Automobiles ❑ COMBINED SINGLE LIMIT $ BODILY INJURY Per erson $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ COMPREHENSIVE COLLISION A WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY WCJ-Z91-446156-010 WCJ-Z91-446156-020 WCJ-Z91-446156-070 07/01/2010 07/01/2011 WC Statutory Limit I % I Other EL EACH ACCIDENT $ 1,000,000 EL DISEASE Each employee) $ 1,000,000 EL DISEASE (Policy Limit $ 1,000,000 EXCESS LIABILITY ❑ occurrence El claims Made EACH OCCURRENCE $ AGGREGATE $ $ Coverage is extended to the leased employees of alternate employer shown below Emergency Services 24 Inc. CERTIFICATE HOLDER �n i re �"� I r " @� tr. � Miami Shores 10050 NE 2nd Ave. Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Authorized Representative 114 Pae 1 of 1 Certificate ID # YCYTS4WJ A ^^f2rl "%.F%ww"AITM CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDNYYY) WSR LTR TYPE OF INSURANCE 10/28/2010 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 Insurance Office of America, Inc. 4223 South Pipkin Road Suite 200 Lakeland, FL 33811 CONTACT NAME: Teresa Moss HONE x,407-788-3000 acNo:407-788-7933 ADDRESS: PRODUCER CUSTOMER ID $: INSURER(S) AFFORDING COVERAGE NAIC# INSURED Emergency Services 24, Inc. 3715 Northcrest Road Suite 34 Atlanta, GA 30340 INSURER A: Century Surety Co 36951 INSURER B: Deep South EXC WSURERC: INSURER D INSURER E : INSURER F: GENERAL AGGREGATE $ 2,000,000 COVERAGES CERTIFICATE NUMBER: 2010-2011 Master 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. WSR LTR TYPE OF INSURANCE ADDL WSR SUBR WVD POLICY NUMBER POLICY EFF M/DD POLICY EXP WDD LIMBS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR Mi mi Shores, FL 33138 David Hendrick/TERESA CCP66Z03 06/15/2010 06/15/2011 EACH OCCURRENCE $ 1,000,000 DAMAGE —TU—RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ S'000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT r LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ B AUTOMOBILE X X X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS PICFL000120 06/15/2010 06/15/2011 COMBINED SINGLE LIMB $ (Ea accident) 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CCP66203 06/15/2010 06/15/2011 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,00 DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If Yes, describe under DESCRIPTION OF OPERATIONS below N/A 1 1 1 WC STATU-OTH- TORY LIMITS ER 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 space Is required) Re: Permit alid in the State of Florida CERTIFICATE HOLDER CANCFLLATInN ©1986-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Miami Shores AUTHORIZED REPRESENTATIVE /1 <//� g 10050 NE 2nd Ave. Mi mi Shores, FL 33138 David Hendrick/TERESA ©1986-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 6 7tI r^ 9 8 7)_ M� ori ter► �2 a M�� •moi X14 A.F S — FG - 33138 _... Bye ►. 6666..:.: -1Az o.F Day UJ4" ASD rw •. 9966.• • •.. . Pifzjt 4T -)6d (1 APPROVED 3y DATE 666:6. eat �.'r14t�r \` 9999 9999 i•� i ZONINGA/0 • 9999 9999 ••• BLDG DEPT ��0see 0 '" '�•-. : . 9906 • SUF3.IFCT TO COMPLIANCE WITH ALL FEDERAL ♦ �• STATE AND COUNTY RULES AND REGULATIONS � 6 6 0 .' ,9ir• 0 Cl 4,e4 C .= 101 ' Fo-fCAL 11, � X29 P rte=