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PL-14-1053 (2)
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 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING kAY 21 FBC 20 (L---> Master Permit No. IL4 407,y Sub Permit No. Y L.I L4— f o'5 2> ❑ REVISION ❑ EXTENSION ❑ RENEWAL N PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS �y JOB ADDRESS: (500 OE & C:�reeA- City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11 b20 (0 01 4 Qt()C) Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): .I. Mn S 2a�.` Phone#: C9� 5ng (go Address: 50D 0 e- 4 Co- 15�r e ei M City: � 110-m ( (5 � oras State: �C. Zip: C58/31; Tenant/Lessee Name: //�� Email:) � e,�Q, (J o co CONTRACTOR: Company Name Address: 17 C) " I City: P'1 R M Qualifier Name: R` o e e� , one#: &Q5501 IV? State: ` Zip: 63/i l U t � Lt-, -2- Phone#: 3U51531 300 State Certification or Registration #: Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Value of Work for this Permit: $ 1 t t�i&ems 4 Square/Linear Footage of Work: Type of Work: ❑ Addtion Alteration ❑ New ❑ Repair/Replace Description of Work: o vi h eC 1-4s OIVI C1-- �j s �% W Cis k e -A " Zip: ❑ Demolition rem Px. t 1 re 6 l h t oW 75 No--- Low a4 - Specify color of color thru tile: Submittal Fee $PAAC�.Permit Fee $C� X CCF $ r CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee Structural Reviews $ (Revised02/24/2014) Training/Education Fee $ Double Fee $ Bond $ �r p 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 Zip 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, 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 arRinspection fee will be charged. Signatu OWNER The foregoing instrument was aclehowledged before this day of 20 ( by �IGYI S�9a' , who i ersonally know to me or who has produced identification and who did take an oath. NOTARY PUBLIC - Sign: Signature CONTRACTOR The foregoing instrument was acknowledged before me this day of QC 20 —' --F- by (t l6e r4 E l �a.2 , who is oersonally known to as me or who has produced qnc712 R6* eZ— Print: Y Seal:�,� �ApEREZ 1• t CarerMM#FP069154 vy r, Expas March 7, 2018 aondedih9T Ftln 138&701p identification and who did take an oath. NOTARY PUB* Y"IRASOTO *.° MY COMMISSION # FF 055M EXPIRES: December 21, 2017 Bond adT►wM-9-8 WNW Undowk e.; Print: Seal: 5��D as ************************************************************************************************************ APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. X COPY OF QUALIFIER'S STATE LIC CARD B. X COPY OF LOCAL BUSINESS TAX RECEIPT C. X COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. X COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33133 ■■oemeeeeeeeaeeeeeeeeeeeeee®eeeeemoe®®aeeemeee■e®aeaeomm®a®eeeveeeeoeeeeeeoseeeeeeeeeeeeee� COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: Empire Plumbing Company BUSINESS ADDRESS: STATE FL ZIP CODE 33139 BUSINESS PHONE: (305 ) 531-7017 CELL PHONE () QUALIFIER'S LIC NUMBER: FAX NUMBER (305 ) 531-7044 CFCO27516 E-MAIL ADDRESS (IF APPLICABLE): Created on 3119109 BY MLDV 1 RV 3126109 MLDV % "V gg Witt F BUSINESS AND PROFESSIONAL REGI iWUSTRY LICENSING BOARD ONROE STREET FL 32399-0785 TLBAZ, ALBERT V ENP7RE PLUMBING COMPANY 1754 BAY ROAD MIAMI BEACH FL 3 313 9' DETACH HERE (850) 487-1395 AMC -,:;$8 .6 2:8, 69 4 STATE110F FLORkDA Con alulations! With :his license you become one of the nearly one million g liccnse Floridians J by 6e Department of Business and Professional Regulation. F ON US MA Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. qFCO2751-4,S Every day we work to improve the way we do business in order to serve you bene For information about our services, please log onto www.myflorldallcense.00M. 12 C There you can find more information about our divisions and the regulations that : Vained below IS CERSIFTED impact you, subscribe to department newsletters and team more about the f de e provision - of C: apt-, qQ Department', initiatives. iration date: im d-,:: 203,4" vl Ourmi,,sV)n! the Department is: License Efficiently, Regulate Fairly. We L Rt i_ w constantly i y e ti serve you better so that you can serve your customers. fDr ?'IT-ING*.�C .MI;OMPA�� Thank you doing business in Florida, and congratulations on your new license! KIZ1,41 BEACH FL ,33139 DETACH HERE (850) 487-1395 AMC -,:;$8 .6 2:8, 69 4 STATE110F FLORkDA 13 'DEP -BY INESS F ON US MA 21120 2, 1280484 24 1 1 ?the, PLT 7:7;7,:7nm CONTRACTOR : Vained below IS CERSIFTED f de e provision - of C: apt-, qQ iration date: im d-,:: 203,4" vl L Rt i_ w ?'IT-ING*.�C .MI;OMPA�� r 7 5 1 4 BAY ROAD KIZ1,41 BEACH FL ,33139 a.LCK SCOTT,. GOVERNOR Ole al P. AS REQUIRED,$Y LAW I=. EMPIR-3 OP ID: LL CERTIFICATE OF LIABILITY INSURANCE DATE(Mn'vrY► 05/1133D/14 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 pollcy(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 305446-2271 Kahn -Carlin & Company, Inc. 3350 S. Dbde High 305148-3127 Miami, FL 33133-9984 CONTACT �E' PHONE FAX No): M11-0 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL# INSURER A: Hanover American Insurance Co. 36064 INSURED Empire Plumbing Company 1754 Bay Road Miami Beach, FL 33139 INSURER S:Associated Industries Ins Co 23140 INSURER C: INSURER D: INSURER E INSURER F 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 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. TR LTR TYPE OF INSURANCE DL SU13R POLICY NUMBER POLICY EFF MID POLICY EXP LEM A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx—I OCCUR LZJ930629202 09/23/13 09/23/14 EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTED PREMISES CEO cogmence $ 100,00 MED EXP (Any one person) $ 5,00 PERSONAL &ADV INJURY $ 1,000.00 GENERAL AGGREGATE $ 2,000,00 GENIAGGREGATE LIMIT APPLIES PER: POLICY PRO X LOC PRODUCTS -COMPIOPAGG $ 2,000,00 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Me ecdderd BODILY INJURY (Per person) $ BODILY INJURY (Per acddeM) $ PROPERTY DAMAGE $ PeracddeM UMBRELLA LIAS EXCESS LIAR HCLAIMS-MADE OCCUR CH OCCURRENCE $ [AGGREGATE$ DED I I RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIEfORMARTNERIEXECU7IVE YIN NWC1024523 OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) Kyes describe under DESCRIPTION OF OPERATIONS below N / A 09123113 09123114 X WCy TA U- ETH - E.L EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT I $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more space is -1W--Q Contractor's License Number: CFCO27516 CERTIFICATE HOLDER CANCELLATION MIAMS-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Building & Zoning THE DATE OF, NOTICE ACCORDANCEOWITH THE POLICY PROVIS ONS. WILL BE DELIVERED IN 10050 NE 2nd Ave Miami Shores, FL 33138 AUTHORQED REPRESENTATIVE 1� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD