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EL-15-789 (2) Miami Shores Village � .77 - Building Department Julo 31. 20 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 BY- Tel: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20,//-/ Td BUILDING Master Permit PERMIT APPLICATION Sub Permit No.e�/ UILDING ELECTRIC ❑ ROOFING EVISION ❑ EXTENSION [:]RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: ALE Gjy $ City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): 4z 2-- e I Z4 41','n Phone#: Address: I"r)r G(a City: AA ,-an i (h e!f C State: Zip: Tenant/Lessee Name: Phone#: Email: � ��1�� CvSt�.M �/e<<�,i S tr✓✓fie CONTRACTOR:Company Name: e o Phone#: Address: i lv17 1 S1,v I�Q t �► ,lc. City: �' C L�/-C� ��• State /�/�-L Zip: fs 7 Qualifier Name: M ' e _r&,-7 Phone#: State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ Z[7 , L7 49D Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration Q.New ❑ Re air/Replace p [:1 Demolition Description of Work: Ati. t— 5-cr y,`r-P Ali �G l�S Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ 03 CO/CC$ Scanning Fee$ -0® Radon Fee$ G . DBPR$ Notary$ Technology Fee$ (b . oz) Training/Education Fee$ 4• Clo Double Fee$ 0 Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ `C ° (Revised02/24/2014) 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. a absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoi 7rument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20_l 5 , by day of k 20 k S—�, by n YlQ ,who is personally known to _ Ic2 h1 `3' who i ersonally known_t� _ - me or who has produced as me or who has produced as identification and who di identification and who did take an oath. �'f�''•• JESSICA MARIA VARCA NOTARY PUBLIC. tr: ,IESSIGAMARUVAFA NOTARY PUBLIC: MY COMMISSION#EE 84e717 My COMMISSION#EE 848717 b;3 EXPIRES:March 2,2017 =' <? EXPIRES:Mauch 2,2017 Banded Thm Notary putt UWwwr tm °� PubAc Undenvrlters ��ya�, Baided Thm Notary Sign: / Sign: Pri �� Q VOLC Seal: Seal: APPROVED BY 3/ J1 A�� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ACC> CERTIFICATE OF LIABILITY INSURANCE DATE M16-0 PRDDUtEIR Galloway Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 17840 South Dixie Highway ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Miami, FL 33157 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (305)255-1661 Fax (786)206-7066 INSURERS AFFORDING COVERAGE NAIC# INSURED Mike's Custom Electric Service, Inc. INSURERA: Federated National Insurance Co. 10871 SW 188th Street,#19 INSURER B:INSURER C: Miami, Florida 33157 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD DATE MM/DDNYYY DATE MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 ❑d COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED GL-29171-00 06/29/2015 06/29/2016 PREMISES Ea occurrence) $100,000 ❑❑ CLAIMS MADE ❑V OCCUR MED EXP(Any one person) $5,000 A ❑ FV� PD:Ded:$500 PERSONAL&ADV INJURY $1,000,000 ❑ GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 0 POLICY ❑PROJECT �/❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS BODILY INJURY ❑ ❑ SCHEDULED AUTOS (Per person) ❑ HIRED AUTOS ❑ BODILY INJURY NON OWNED AUTOS (Per accident) ❑ PROPERTY DAMAGE ❑ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC ❑ AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE ❑ ❑ OCCUR ❑ CLAIMS MADE AGGREGATE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND ❑ WC STATU- ❑ OTH- EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Electrical Contractor/Work..... "Please note that any changes to this policy must be submitted to the Insurance Company for approval"... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Miami Shores Village N/A DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NE 2nd Avenue THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY Miami Shores, Florida 33138 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Attn: Building Dept AUTHORIZED REPRESENTATIVE Fax#305-756-8972 Jose H Romero, Licensed Agent-A225234 ACORD 25(2009/01)QF ©1988-2009 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD