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PL-14-1426L BUILDING 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 FBC 2010 Master Permit No.2p/— A/- j y PERMIT APPLICATION Sub Permit No. ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL CLIMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP a CONTRACTOR DRAWINGS JOB ADDRESS: 1S I le q-7 3- Com: Miami Shores County: Miami Dade Zip: 3:313 9 Folio/Parcel#: �3Z(b -0i 3 — I-oap Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholddeer)aL)e iof c SS LA.I Phone#: -if Address::1-6s iQe 9-7 Is- ] City: �" l B Oj-vii ghtAs State: Zip:. / Tenant/Lessee Name: Phone#: Email: 0Y-)C�P&Qif�``Jaa6, 61 V CONTRACTOR: Company Name: _4u. -n *fie it" :50hAt4S_S Phone#: -1 SY &f eg4p u Address: [ 6+_ City: State: Zip: -3340 Qualifier Name: 21AP t���AAinnG'`. Phone#: State Certification or Registration #: Certificate of Competency M DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 0 O O . QQ Square/Linear Footage of Work: Type,of'Work: , ID Addition ❑ Alteration [ New ❑ Repair/Replace ❑ Demolition Description of Work- 1 L1 Specify color of color thru tile: Submittal Fee $ Permit Fee $ . CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) 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 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 iss In the bsence ch posted notice, the inspection will not be approved and a reinspection fee will be charged. Si gnatur Signature ..... • A OWNER or AGENT CONTRACTOR The•fore,ppg,trl� umer�� was acknowledged before me this The foregoing instrument was acknowledged T7efor� me this day of U 20 ✓`9 • by�day of G(A20 _%�, by who is personally known to P(f�d C who is personally known to me or who has produced ,E?M[5'692L)as me or who has produced identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign:` 2T, • P � int JP Print: / _ • 51 Seal. e n Notary Public State of Florida : Joanna M Feliciano Seal: �;� ' iwy Commission FF 082753 ��,oGe•;�few 4,;SS A` ro Expires 01112/2018 /��//�, STATE //���I1111111111���� APPROVED BY 7. 2 • fy� Plans Examiner Structural Review (Revised02/24/2014) Zoning Clerk 0710112014 08:59 WMAL PAX}305407W P.0021009 Miami shore's Y Building Department NTRACTORS' REGISTRATION 10050 N.E.and Avenue Miami Shares, Florlde 33938 Tel: (305) 788.2204 Fax: (305) 766.8972 CONTRACTORS EK OVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT 18 SUBMITTED. IF COM!•RAC 1STATE C CONTRACTOR: COPY OF QUALIF R'S S ES COPY SINES8 TAX RECEI F LIABIL INSURANCE* COPY OF WOR S COMPENSATION INSURANCE' CONTRACTOR HAS A CERTIFICATE OF COMPETENCY: °"' COPY OF A. CERTI E OF COMPETENCY OF QUALIFIER B. E:-�COPY OF LOCAL I IUSINESS TAX RECEIPT �j d B. COPY OF STW REGISTERED CONTRACTOR LICENSE 'OR IAMI DADE COUNTY MU PAL CONTRACTOR': TAX RECEIPT. c C. COPY OF LIARILI INSURACE* OF WO S COMPENSATION INSURANCE' BUSINESS NAME: BUSINESS ADDRESS: BUSINESS PHONE. (,_ CELL PHONE (. QUALIFIER'S LIC NUMBER: Certificate Holder. MIAMI SHORS8 VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33938 aPe¢KY the desodplon of operedone or ooraetor Ik*m number_ S� ■sss'osass# �i'n GNU &tee I 'ODE Fg C� 6 l0 y�La l��d FAX NUMBER( QUALIFIER'S NAME: 10.PI) 00a9� �0v 1 d -1 �S bi CK�.�/ B 5 /T *atwd wa ST=ZT vToz,To*Tnr CTQB Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY 10P000277 ALL AMERICAN SPRINKLERS INC .B.A.: ZBICAAV'1DARON Is certified under the provisions of Chapter 10 of Miami -Dade County VALID FOR. CONTRACTING UNTIL 09/30120/5 10 JEFF ATWATER CHIEF FINANCIAL OFFICER * * CERTIFICATE OF CONSTRUCTION INDUST!! This certifies that the EFFECTIVE DATE; 07 PERSON: y FEIN: 2 BUSINESS NAME AND ALL AMERICAN SPRIWI-BRS 8155 SW 2 STREET MARGATE FL SCOPES OF BUSINESS OF 1- IRRIGATION OR DRAINING IMPORTANT: Parsaant to Chapter 440 . Dail sectlea may am recover b000tns or compom scope of the business or trade listed on tar election to be exempt shell be suh)eet to r Certificate no toner meets the requirements named ea the toniffoato to mom the ragafri OWC-252 CERTIFICATE OF ELECTION TO E 07-10-2012 STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION MI TO BE EXEMPT FROM FLORIDA WORKERS' COMPNIISATION LAW listed below has elected to be exempt from Florida Workers' Compensation taw. EXPIRATION DATE' 07/03/2014 DAVID A F.S., an officer of a corporation who elects exemption from this chapter by filing s certificate of election under this 10 sellar INS adapter, Paribas! to Chapter 440.061121. F.S., Certificates of olatllss 10 be axempt... apply only wfmis Ike Ince of election to be exempt. Pursuant to Chapter 440.08113E F.3., Notices of election to be exempt and cartNicates of cation it, at any time after the filing of the notice at the Issuance of the certificate, the person homed on the notice or this section for issuance of a certificate. The depar meat shall revoke I certificate at nay time for failure of the person his of this Swiss. QUESTIONS? (850) 413-78D9 EXEMPT REVISED 01-11 PLEASE CUMI OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATI:OF FLORIDA DEPARTMEW OF FINANCIAL. SERVICES DIVISION OF VIMEW IMPORTANT COMPENSATION Pursuant Pursuant to Chapter 440.05!14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY 9 elects exemption from this chapter by filing a certificate of election CRIMPICATE OF ELECTION TO BE EXEMR wORKf'W COMPENSATION LAW I FROM FLLORIDAL under this section may not recover benefits or compensation under this D chapter. EFFECTIVE: 07/03/2012 EXII113ATION DATE: 07/03/2014 Pursuant to Chapter 440.061911, F.S., Certificates of election to be H PERSON: DAVID A YESSICK exempt.. apply only within the scope of the business or trade listed on FEIN: 272888522 E the notice of election to be exempt. R EIUSINESS NAME AND ADDRESS, E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt ALL AMERICAN SPRUSIGLERS INC and certificates of election to be exempt shall be subject to revocation 6159 SW 2 STREET If, at any time after the filing of the notice or the issuance of the MARGATE. F7. 33068 certificate, the person named on the notice or certificate n0 longer meets the requirements of this section for issmice of a certificate. The department shall revoke a certificate at any time for failure of the SCOPE OF SUSINESS OR TRADE: person named on the certificate to meet the requirements of this 1• IRRICAYION OR DRAINING SYSTEM section. QUESTIONS? (850) 413-1604 w Carry CUT MERE portion on the job, keep upper portion for your re0ords. OWC-Z52 CERTIFICATE OF ELECTION TOEXEMPT REVISED 01-11 5 /Z 'a0vd Wd ST:ZT VTOZ'TO'Tnr Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, You maybe, personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. LTi State of Florida ) County of Miami -Dade ) Sworn to �ano subscribed before me s /�dh`V� day of , 20 . g. ON ��,•�..... �oil,� •`c"Z7.2Byjamhfa Nk&# Au zJ ipp (SEAL) %* 'Ott &MV0c Type of Identification produced p 11AW • , pi••` 4o�-4 Print Nam Signature: State Of r ivuua County of Miami -Dade } Sworn to and subscribed day of J4I11 of Identification before me this W!"111 "of ��z1. Zo�� '•.: �c __ ._._�•��rv�rr�u-��ury r.�-t-t�rvr�t--rsu�rrv���. _ 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2013 THROUGH SEPTEMBER 30, 2014 DBA: ALL AMERICAN SPRINKLERS INC Receipt #.PLUMBING/LWN SPRNK Business Name: Business Type: (SPEC PLUMBER LAWN Owner Name: DAVID A YESBICK Business Location: 6.55 SW 2 ST MARGATE Business Phone: 954-818-4754 Rooms Seats Number of Machines: Employees _1 Business Opened:o5/03/2005 State/County/Cert/Reg:1 o -CLS -12 8 69 -X Exemption Code: 6 °Machines Only. .. Vendinn Tvee: Professionals Taut Amount Transfer Fee NSF Fee: Penalty • Prior YearsCollection Cost Total Paid 27.00 0.00 Q,.QO' -'6.75 0.00'. 25.00 58.75 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not Indicate that the business is legal or that It Is in compliance with State or local laws and regulations. Mailing Address: ALL AMERICAN SPRINKLERS INC Receipt #02B-13-00004788 732 NE 2 ST Paid 01/27/2014 58.75 POMPANO BEACH, FL 33060 2013 -2014 07/2/2014 08:02 TO:13054079007 FROM:8778240964 Page: 1 aI vr CERTIFICATE 4F LIABILITY INSURANCE /2/20 ' 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 The Fairway Insurance Group, LLC 5461 North Federal Highway Fort Lauderdale FL 33308 CONTACT Annette Griffin NAME: PHONE (954) 772-9819 FAXElft (AM,roo (954)772-9564 ADDRESS: Anne ttea@TFIGIN3.COX INSURERS AFFORDING COVERAGE NAIC A INSURERA.ESSeu Insurance Company INSURED All American Sprinklers, Inc. 732 NE 2 Street Pompano Beach FL 33060 I(SURER 8 INSURER C: INSURER D: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER:14 -15 GL COI 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 ADUL im SUBR WVD POLICY NUMBER POLICY EFF WDOMM POLICY EXP fMM[MDNYYY1 LIMITS A GENERAL LIABILITY MERCIAL GENERAL LIABILITY NcLAjms-mADEFx-1occLR Edward Brown/AG D&1661 /16/2014 /16/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ee axurrem $ 100,000 MEDS one pmwn) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN1- AGGREGATE LIMIT APPLIES PER POLICY x JECT�a MLOC PRODUCTS - COMP/OP AGO $ Include $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS MIBINED SINGLE LIMIT IF BODILY INJURY (Per person) $ BODILY INJURY (Pe acckied) $ PROPERTY DAMAGE raccident $ UMBRELLA LIAROCCUR EXCESS LIAR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ OED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPWETORIPARTNEWD(ECUTIVEEL OFRCEWMEMBER EXCLUDED? ❑ (Mandatory in MOT) It yes, describe under DESCRIPTION OF OPERATIONS beta N f A WC STATU- I OTH- TORY LIMITS E EACH ACCIDENT $ EL DISEASE - EA B61PL $ EL DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) Contractor's License Number: IDP000277 - Certificate is Subject to Policy Forms & Endorsements. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010105) INS025 rmi m ii m ©1888-2010 ACORD CORPORATION. All rights reserved. Tiro arnian nomo onA Inns or* ronlclororl mor1ra of arnonl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Avenue AUTHORIZED REPRESENTATIVE Miami shores, FL Edward Brown/AG ACORD 25 (2010105) INS025 rmi m ii m ©1888-2010 ACORD CORPORATION. All rights reserved. Tiro arnian nomo onA Inns or* ronlclororl mor1ra of arnonl 'r.mP Meru: :�-: T X : to 81�f° . Qa d 4 W%KOW .T N.B. 07th S et APS g u e DEQ, rj J--�DA77-Ep EpT PAGE 1 OF 2 S UBJECr O CC,I�I PfOpwW Ad�ss: I rlCE VVI F 85 N.E. 97 STUF- r �fJ All FEUERq� MrAM1 SHOMS, FL 33138 --.L REc rionIs I lit. z� o• ` .& TmTTiEI' m .� SSr4nOFA PS1LL Alfl SI01 %V.V0�fRwIIkG11o4a.Aet0ne'AaL�COmIFm�VQ.WA�e,�D, RdLO�'yes �encA, sae .r ALiCOY�oapaVy.p.,ep.� Accepted By: 11 �GU�,� ,is�,�,i'X�►OS.9l LAND SU,RY;EI?NG,1N� 3311 SW: BW SMET, StM262 M"W RLO.i A 33134 PHONE. (305) 144:3319 FAXO: ($05) 669 319U LB 0 6463 oa LIN -r— 7 / .01=r. A MIAMI SHORES, FL 33138 Fox TFC PMM A(fGllBL,pp1MOSf —P-Im AdO. stat SUnOff-c ACDA °u`�+mss"�armn*amri`,�u�►a�me�°re�e�� ago o.'�e^� ,ee.a�a Accepted By: ATiG&Wl.,trSPRVO$A LAND SVRLWMG, PVC 5511 S- W. SwSMUT, SLM202 A1L4AW. FLOR DA .33134 PHONE: (385) 740-3319 FAX #.- (SITS) "94190 LB 0 6463