12-2044Miami 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
Permit Type: BUILDING
JOB ADDRESS: � () '5 ft U 0 9,,AA"`
City: Miami Shores County:
Folio/Parcel#
Is the Building Historically Designated: Yes
NOV 19 2012
exp
FBC 201D
Permit No. %
Master Permit No.
ROOFING
// OWNER: Name (Fee Simple Titleholder): L
Address: la 3 30 d t
City: t (I I AV /-r ¢ 3 State:
Tenant/Lessee Name:
Email: — %r
s
lood Zone:
'Phone#: J
/Z,f
Zip: /
CONTRACTOR: CompanyName: -�✓�� Phone#: 'to C 3 r- 1P Cl j 1 U
Address: 0 0 0 v- 6 9 Co S
City: M le c State: v Zip:
Qualifier Name: V ✓. o Yv c,- c% ^ Phone#:
State Certification or 6gistration #: e&**'C. / r 1 j ZT"1 Certificate of Competency #:
Contact Phone#: V /1 7j c Email Address: & 11c o,,u "t/ .� �) 4,4 j, L c--�
DESIGNER: Architect/Engineer: Phone#:
Color thru tile:
Submittal Fee $ Permit Fee $ _ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $ oe
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
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 notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attac t. Also, a certified copy of the recorded notice of commencement mu be posted the job site
for the first inspection which oedreinspection
seven (7) days after the building permit is issued�isenc of such po ed notice, the
inspection will not bA�gro_ved fee will be charged.
V L/ I v CJ
OmWE o gent 4 Contractor
The fore"g instrument was acknowledged before me this The foregoing instrumnt was acknowledged efore me this %
day of X2i' �Z20 ✓`r� ; by day of _ , 20 .L&y ,
o iis�personal� 1�kn,Q me or who has producedwho is personally kno o me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
A ACEL
Sign: '%tate of Elodda
►L+ 15, 2016
Print:
My Commission E " " Bonded Through Rational hotary Assn
Sigr
Prin
My
APPROVED BY Plans Examiner Zoning
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Clerk
ACVRtf CERTIFICATE OF LIABILITY INSURANCE
`...M"'•
DATE(MhUDDWYYYY)
I IAS112
THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, TH19
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOIWED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING UIISURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certNicate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, sutgect to
the terms and conditions of the porky, certain policies may rare an intlorsemint. A statement on this certlMeste does RM coMer rights to the
certificate holder M Neu of such endorsement(s).
PRODUCER
WACT GRETELL GONZA F7
USA General Insurance Corp/USA Insu
PHONE(30.5) 3813-3305 Fox (3DS) 388-M8
E-MAIL gretell�usagelteralimaurancs.com
5841 S.W. 137th Ave.
INSURERtal AFFORDMKi COVERAGE NAIL!
Miami, FL 33183
INSURER A: ACCIDENT INSURANCE COMPANY
Phare (305) 386-3305 Fox 388-8778
INSURED
INSURER 0:
INSURER C:
All Construction & Develo"MffiC.
INSURER o :
1000 51h St #200
INSURER E:
Miami Beach, FL 33139- (788) 7004M
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
CERTIMCATE 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 CLAW.
TLT�
TYPE OF INSURANCE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
10050 NE 2ND AVE
NUMB
POLICY EFF MONYM
MPO�ICY ta(P
LIMITS
A
GENERAL LIABIUTY
R CDMMERGAL GENERAL LIABILITY
❑ ❑ CLAIMS-MAOE ❑ OCCUR
❑
❑
GEN'. AGGREGATE LIMIT APPLIES PER:
PODGY ❑ PRO- LOC
N
N
CP P- OW2991
05!16!2012
05/IVM13
OCCURRENCE
Li�1„-, 1,0,000,00
DA�AC
n� s 100,000.00
MED EXP ('Y one "mn) s 5,000.00
PERSONAL&ADV INJURY S 1.000,000.00
GENERAL AGGREGATE S 2.000,000.00
PRODUCTS. COMP/OP AGO 3 2,000,000.00
S
AUTOMOBILE LIABILITY
❑ ANY AUTO
❑ ALL OWNED ❑ SCHEDULED
AUTOS
NON OWNED
❑ HIRED AUTOS ❑ AUTOS
El
COMBINED SNiGLE LIMIT S
BEOeaaLOCY INJURY (Par peraw) S
BOMY "Ry pw accidwA =
PEE $
er
S
❑ UMBRELLA A LIAD ❑ OCCUR
EJ EXCESS LIAR CLAIMS.MADE
SACH OCCURRENCE S
AGGREGATE S
❑ DED ❑ RUENTION S
S
WORKERS COMPENSATION❑
ANDEMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNENEXECUTIYE
OFFICERIMEMBER EXCLUDED?
(MandMely IN NN) ❑
M deswibe under
DESCRIPTION OF OPERATIONS belov+
ri / A
WC STA ElOTH-
---
E.L. EACH ACCIDENT S
E.L. DISEASE • EA EMPLOYE S
_
EL DISEASE, POLICY UWr, S
DESCRIPTION OFOPERATIONa i LOCATIONS! VEHICLES (AMNh ACDRD 109, AddiManai Remarks Schedule, If more space Is rogWme)
Apt 1803
CERTIFICATE HOLDER CANCELLATION
®1988,2010 ACORD CORPORATION. An rights reserved.
ACORD 26 (2010106) t x. . The ACORD rtlrlre dnd logo are registered rmdm of ACORD
SHOULD ANY OF THE ABOVE DnCPJBED POLICIES BE CANCELLED RWORt3
MIAMI SHORES VILLAGE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
10050 NE 2ND AVE
ACCORDANCE WITH THE POLICY PROVISIONS.
MIAMI FLORIDA 33138
AUTHORIZED -REPRESENTATIVE
®1988,2010 ACORD CORPORATION. An rights reserved.
ACORD 26 (2010106) t x. . The ACORD rtlrlre dnd logo are registered rmdm of ACORD
NOTICE OF COMMENCEMENT
A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION
PERMIT NO. % Z d W -TAX FOLIO
STATE OF FLORIDA:
COUNTY OF MIAMI-DADE:
THE UNDERSIGNED hereby gives notice that improvements will be made to certain real
property, and in accordance with Chapter 713, Florida Statutes, the following information
is provided in this Notice of Commencement.
1. Legal de cription of roperb
Of, t�l.
2. Description of improvement:
3. Owner(s) name and address: C-00
Interest in property:
Name and address of fee simple titleholder:
4. Contractor's name. address and Dhone n
OR Bit 28363 Pq 4087; (1p9)
RECORDED 11/19/2012 13,446-00
HARVEY RUVINY CLERK OF COURT
MINIT-DADE COUNTYr FLORIDA.
LAST' PAGE
Space above reserved for use of recortling office
5. Surety: (Payment bond required by owner from contractor, if any)
Name, address and phone number:
Amount of bond $
6. Lender's name and address:
7. Persons within the State of Florida designated by Owner upon wl
Section 713.13(i)(a)7., Florida Statutes,
Name, address and phone number:
H,
J/;
or other documents may be served as provided by
8. In addition to himself, Owners designates the following person(s) to recei e a copy of the Lienor's Notice as provided in Section
713.13(1)(b), Florida Statutes.
Name, address and phone number:y y
9. Expiration date of this Notice of Commencement:
(the expiration date is 1 year from the date of recording unless a different date is specified)
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED
IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR P PERTY A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE
FIRST INSPECTION. IF YOU D TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK
OR RECORDING YOUR Nr14F COMMENCEMENT.
Signature(s) o Own et(s)' Authorized Officer/Director/Partner/Manager
Prepared By Prepared By � (/X / (, / 0 ' � /� � Ste'
Print Name Print Name
Title/Office r Title/Office
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
The foregoing instrument was ac knor4ldpSo before me this 1( day of
C I.dividually, or ❑ as for
ersonaliy known, or ❑ produced the following type of identification:
Signature of Notary Public:
Print Name:
(SEAL) �4PpV °, OLGA VALCARCEL
e Notary Public -State of Fl�ida
VERIFICATION PURSUANT TO SECTION 92.525, FLORIDA STATUTES • 5 My Comm. Expires Feb 15, 2t)f 6
Under penalties of perjury, I declare that I have read the foregoing and - , �;
that the facts stated iWita true, tothe best of m knowled a and belief. „;,�Commission ti EE (4ary AY 9 Rnnded Through National Notary Assn
Signat e(s) of Ownewner(s)'s Authorized Officer/Director/Partner/Manager who signed above:
B By
123.01-52 PAGE 3 X10
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