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FW-14-5 t � Miami ShoresVillage Building Department JAN 0 3 ^013 l 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY:— Tel:(305)795.2204 Fax:(305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 FITC 20 LO BUILDING Permit No. PERMIT APPLICATION Master Permit No- '` I H �S Permit Type: BUILDING ROOFING JOB ADDRESS: 1490 NE 101 STREET City: Miami Shores County:_ Miami Dade Zi . 33138 Folio/Parcel#: 057 63:9:° —00_&O Is the Building Historically Designated:Yes NO Flood Zone: � OWNER:Name(Fee Simple Titleholder): QlQ r+ 5t Phone#: Address: City: State: —zip: �� 0 a. Tenant/Less Name: Phone#. Email: �2 Ct - CONTRACTOR:Company Name: GOmeZ &Son Fe',CB Phone#: (305)471-$922 Address: 10805 NW 22 Street City: Miami State: FL ` zip. 33172 Qualifier Name: Caridad GomezPh : �305 471-8922 one# } State Certification or Registration#: Certificate o ompetency#. 000016587 Contact Phone* (305)471-$922 Email Address: a tmez ezfence.com DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$1,000.00 Square/Linear Footage of Work: IS O .*N= Type of Work: ©Addition ❑Alteration ❑New DRepair/Replace ODemolition Description of Work: Fence 60f li� .rn Ak ee_ Color tht'u tile: �a�a ������������aa>xx�x.>x•��x�x+a�>��x�M����>uFees���a>��>x��ux���>u�a�aw�+u>x>�x��*��m���x�sk�>�>������x Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL,FEE NOW DUE$��„ e 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 the notice of commencement and constniction lien law brochure will be delivered to the person whose property is sttb'e . Also, a ceniji r ' sped copy of the recorded notice of commencement must be posted at the job site for the ection which occlirs seven 7} dans after the building permit is ' ed. In the absence of such posted notice, the in rnon wit nt b pprov a a reinspec n fee will be charged. Signa ire Signature er or Ag C acro T Parc )ng instrument was acknowledged before me this The foregoing instrument was acknow ged before me this 30 day of J e ,20LA by_7IB/!!,5-,- ��tcce�sir�s� day of December '20 by Caridad Gomez who iseisonally known to me or who has produced who is ersonally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOT Y PUB Sign: Sign: O Cis prat. Isabel Pane e cot�uas de -2a a o 17 My Commission Expires: ��p�aYPjje®°° Isabel Paneglle CW :�A��- � %COMMISSIONOEE21€1755 o JULY 23,2016 lz APPROVED BY I ( Plans Examiner �L Zoning Structural Review Clerk (Revised3/12/2012)(Revised07/11)/07)(Revised06/10P-0 9XRevised3/)5/09) l Policy Number. CPS1708424 Date Entered: 02/25/2013 ACORO® CERTIFICATE OF LIABILITY INSURANCE PATE(MWDDNYYY) 2/5/2013 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 CONTACT KEY KNOWLEDGE INSURANCE, INC. NAME: 9101-C S. W. 19TH. PLACE954)382-5259 FAX No: (954)382-0080 PHONE E-MAILEAs: mryals@keyknowledgeins.com FORT LAUDERDALE, FL. 33324 ADDRE INSURERS AFFORDING COVERAGE NAIC 0 INSURER A: SCOTTSDALE INSURANCE COMPANY 41297 INSURED Gomez & Son Fence Corp. INSURER B:SCOTTSDALE INSURANCE COMPANY 41297 INSURER C:SCOTTSDALE INSURANCE COMPANY 41297 10805 NW 22 ST INSURER D: MIAMI, FL 33172 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. INSR TYPE OF INSURANCE ADDL BR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD GENERAL LIABILITY EACH OCCURRENCE $2,0 00,000 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY CPS1708424 02/24/2013 02/24/2014 PREMISES(Ea occurrence) $100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PE a LOC $ AUTOMOBILE LIABILITY Ee acccl idem SINGLE LIMB $ ANYAUTO N/A BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ B UMBRELLA LIAB OCCUR EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS-MADE XBS0028530 02/24/2013 02/24/2014 AGGREGATE $4,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N/A E.L.DISEASE-EA EMPLOYEE $ Hdescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Contractors Equipment CPS1708424 10/24/2013 02/24/2014 LIMIT 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) 14-029R Supply, Install and Repair Chain Link Fencing " This policy contains blanket additional insured and waiver of subrogation " CERTIFICATE HOLDER CANCELLATION Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Avenue Miami Shores Village, FL. 33138 AUTHORIZED REPRESENTATIVE MARIA A. RYALS ADEN ea— @ ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Produredusing Forms Boss Plus software.www.FormsBoss.comimpressivePublishing 800-208-1977 i Y lJSII+C as ctr►+ r ICATIE of C&PiTErbM 000016587 MEZ,&-,vr?4,FEN gg wMA 9 a", CARIDAD Is�iJ11tl2[!f� From:3054718925 01 /08/2014 13:52 #127 P.003/003 062b38i` tti a-t'Ev.r<:'ll'i<A,;s„......... �. :.',•rfi,: "i?' :d A:'i�::\. �':> ..j,a2 +1'Ll.':u":h:,'.x::,asn..;. c";ia..j: .�.:i�t� .5*'•'�"'� S"'i, a a'%'.+�}.,%t"'`'':.,j�;', :: -.a?�. 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