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EL-14-1182 r Miami Shores Village Building Department JA( � 2 °0)5 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 20 10 Master Permit No. PERMIT APPLICATION Sub Permit No. Z ❑BUILDING A ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING [-] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP 2! � e� CONTRACTOR DRAWINGS N((U) o S JOB ADDRESS: / ! City: Miami Shore//�s , County: Miami Dade Zip: / / � Folio/Parcel#: 10` �r 2 2 0- ?, "(� Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: aLl � l n OWNER: Name(Fee Simple Titleholder): ©� l nC Phone#: 2 0` S. -n07 Address: City: State: Zip: 3 __?/50 Tenant/Lessee Name: Phone#: Email: Z CONTRACTOR:Company Name: X00 ! I«� C Phone#: - 0 Address: LA /2- �Ez-a- City: /� // State: �l Zip: Qualifier Name: C L /J/�v/`+ L Phone#: State Certification or Registration#: EX 0(!:)0 D ZS Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Additio ❑ Alterattion / ❑ New ❑ Repair/Replace ❑ Demolition Description of Work:_ � ��a CIE(�-lze � �2/' f � L� �y- I/e 2- Specify color of color thru tile: Submittal Fee$ Permit Fee$ „I3�� A CCF$ ' . CO/CC$ Scanning Fee$_� '_A_j Radon Fee$ DBPR$ L—Notary$ Technology Fee$ 1 ^ �� Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) Atv V 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 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 ,Such posted notice, the inspection will not be approved and a reinspection fee will be charged. l Signature � lY' / � ignat 1 OWNER or AGENT CONTRACTOR The foregoing instrment was acknowledged before me this The foregoing instrument was acknowledged before me this 7 day of 20 �`7 by 2110dayof 20 / by y ; ��4 �d��( 1( ;�� who is personally known to who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: P rpt: '" j FE-AU i Seal: yy ROSEM4RYF.WAR SOW! * y Cr MISSION FE Bo E-Xf-RES-Geptember 6.2U i 6oucec Thru Notary Public Unrcrs,,i!:r s ********* ********************************************************************* APPROVED BYPlans Examiner Zoning Structural Review Clerk (Revised02/24/2014) DEPARTMi:NT SWINE pROFESSlONAL REGULATION ELECTRICAL CON RS L#CENSING BOARD The ELr:c'TR1CA�.cOf o 1'RACTbR Natrmd bel*w HAS REOSTER Under the pr y+ C tr"489 FS, Wn Explradsts A� 1 6 4 d€?I �AL MUST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) AMENGUAL,SERNAR© c AMENGUAL ELECTRIC,iNO. 38 11 NW 12TH TERRACE MIA AI FL 33 tSst o: 4 bi p", ASR QUIRED BY LAW SEQ L�4t>a2 C► 33 r Y 4 s+-ktg:i0s5�+ig4k^+ $ 1�1 6A N9 NI t SUS ■-i-�S ■ U'"'iN9iI'�:XI�h�' ' 5 i 195 S. Wd ;1# �. - F :�.B@rclats,FL 33301-985—954-$3140 VAUH Cds t3 4 THROUGH SEPTEMBER ,1 Receipt#;1f ��-"�'RjCALIAhAi2Mfi/cC121i'R14C`�C}k + Sr ow t dspa/lMH09/20`007 y4I1 r ,,,� i, �� fix. ��.�'�>�Y.�� 2 �� t r iq •+i i �;�d� �> FfOf@swOfl81S a tl �.�A 2�� 'k °'M 'E{ '� Y :AS.i �� x•'14' lOk��#- � cy. 8 i I 3 1or- Cbw h" u k 5�f ADS,, o�" OR Q WAY&O, o x + _ .I -- r 'i(r`x se'y y '- `aa ' °.�idkj� '001, b � �m ' �w a 4 a �G w _ in my; n; too i -g- -A. n — a �a " = -T- Iwo' C� - i T ., ymi(" b anew mM ~K r '! AW * a' e ti. Wanmvwx a alin � ' �,�' - `' �'-�-s �" r ��a£•, a I� ' �k DATE"'"fflO""Y" I F LIABILITY INSURANCE CERTIFICATE O 01/21/15 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 WANED,subject to the terns and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate folder in lieu of such endorsement(s). PRODUCER NOM ACT GRETELL GONZALEZ Usa General Insurance PHONE . (305)386-3305 _ A xo: (888)330-1123 5841 S.W.137th Ave. j A�RESS, GRETELL@USAGENERALINSURANCE.COM Miami,FL 33183 j INSURER(S)AFFORDING COVERAGE NAIC# Phone (305)386-3305 Fax (888)330-1123 INSURER A: INTERNATIONAL INSURANCE CO OF HANNOVER LTD INSURED ! INSURER 8: _ 1 AMENGUAL ELECTRIC INC INSURER C. 3851 NW 12 TERR ± INSURER D: _ Miami,FL 33126 (954)410-6364 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 SHOW_N MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE UBR POLICY NUMBER A POLICY /D Y EFFPOLICYEXP — LIMITS LTR GENERAL LIABILITY i EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED 1 OO,000.00 0 COMMERCIAL GENERAL LIABILITY ! PREMISES Ea oxunence $ A 0 ❑ CLAIMS-MADE Y] OCCUR I N N IG06CO02214-01 12/18/2014 12/18/2015 MED EXP(Any one person $ 5,000.00 PERSONAL&ADV INJURY $ 1,000,000.00 ❑ I GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: j I PRODUCTS-COMP/OP AGG $ 2,000,000.00 © POLICY [:] PRO- [J LOC ` $ JFCT AUTOMOBILE LIABILn'Y COMBINED SINGLE LIMIT Ea accident i ❑ ANY AUTO { BODILY INJURY(Per parson) $ ❑ ALL OWNED ❑ SCHEDULED ; BODILY INJURY(Per accident) $ AUTOSAUTOS ❑ HIRED AUTOS ❑ AUTOS D i PPLO d�DAMAGE $ ❑ UMBRELLA LIAR ❑OCCUR ? EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION $ WORKERS COMPENSATION ❑WC STATU- rl OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) GENERAL CONTRACTOR#CGCO03704&#EROW4025 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE AUTHORIZED REPRESENTATIVE MIAMI SHORES FL 33138 _ FAX 305-756-8972 --- ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010f05)OF The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE 1/211//2015 per; Plymouth Insurance Agency This Ca Wlo to Is issued as s msttw of kdWmadon only and confers no 2739 U.S. Highway 19 N. rialft or shred ka This C do by ths Unca aoas rwt amen4 e>mm+a Holiday, FL 34691 (727) 938-5562 Insurers Affording Coverage NAIL# Insured: South East Personnel Leasing, Inc. &Subsidiaries Insular A: Uo`mma"0e OMPar y 11075 2739 U.S. Highway 19 N. Insurer B: Holiday, FL 34691 Insurer G: Insurer D: Insurer E: CrOY neposeftorin—rasped b which this Isted el may vabler;lamed issued a b Oarlod rW sequi arrest termor srq coract or oto meld 0th with drown cosy have trees reduced may pertain,the Insurer"afforded by the policies described herein is atbJBCt b allto tetims sadusions,and conditions of such policies. Aggregate by pails darns. INPolicy P alloy E>ox8ffon LTR INSSRRD Type of Insurance Policy Number Date Data Limits MM/DD/YY) (MM/DD/YY) ENERAL LIABILITY Each,Occurrmce Commercial General Uability Danielle to rented prernlses(EA Claims Made 13occur ) Med EV al aggregate limit applies per: Personal Adv In]" Policy 13 ed 13ftiLoc Deneral Apgregete Product!-Con+a+ov Agg AUTOMOBILE LIABHJTY Corrbrved Siroe Lira Any Aub (EA Aoadent) AN Owned Autos Bodily Injury Scheduled Autos (Per Pef—) Hired Autos sway rqury Non-Owned Autos (Per AoddwQ Property Drupe (Per A EXCESWUMBRELLA LIABILITY Each occurrence Occur ❑Claims Made AWegate Deductible A WOrkKv Compensatlon and WC 71949 01/01/2015 01{01/2016 x WC$fortis OTH- EmployerW Liability toryLimits ER Any proprietw/partrw/executive offkosthnember E.L.Each Acclrtent $1.000.000 excluded? No E.L.Disease-Ea Employee $1,000,000 0 Yes,describe tinder special provisions below. E.L.Disease-Policy Limb $1,000,000 Onar Lion Insurance Cmwny Is A.M.Bad COMOMY ratiad A-(ftCQN6nt1, AMB 12616 Deecrtpdons of open aftnevLocallilonwWWdes/Exclustons added by Pftotrbiom.s: Client IIT: 92-W589 Coverage only applies to active employee(s)of South East Personnel Leasing,Int.&Subsidrarles that are leased to the following"Clielt Company": AnmVuW 1111stbic,I= sollomm asE7roo0torts Coverage only applies to injuries Incurred by South East Personnel Leasing,Inc.&Subsidiaries alive emp**s),while woridrg in:FL. Coverage does not apply to statutory employee(s)or independent mrrtractor(s)of the Client Company or any other entity. A 0A of the active employee(s)leased to the Client Company can be obtained by Bring a realest to(727)937-2138 or by raft(727)938-5562. P.0ject Name. ISSUE 01.21-15(AF) TE[i0L0ER CITY OF MIAMI SHORES VILLAGE Should any of On above described policies be shied before the expiration data thereof,the Issuing rawer will endeavor to well 30 do"often notice to the certiRra s holder named to to Wk but failure to do so dull inyose no obligation or is0iay of my kW upon to trusser.Its agenda or representatives. 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 OAF