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PW-14-2376 Miami Shores Village Tr 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 '(F�BC 20 I BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No. F-1 BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL 0 PUBLIC WORKS Ej CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9301 North Bayshore Drive City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):RIGHT-OF-WAY Phone#: Address: City: State Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: TE PEOP Phone#: 954-453-0811 Address: 5101 N.W. 21 AVE., SUITENCK0 city: FT. LAUDERDALE staw: Zip: 33309 Qualifier Name: JESUS VEGA, JR. Phone#: 945453-0811 State Certification or Registration#: E1608 Certific)ofmpetency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$2000 Square/linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑■ New ❑ Repair/Replace ❑ Demolition Description of Work: INSTALL 2" PLASTIC GAS MAIN AND 3/4" GAS SERVICE Specify color of color thru tile: Submittal Fee$ � n Permit Fee$ COO CCF$ 1 ,20 CO/CC$ Scanning Fee$3 (jz:) Radon Fee$ "� DBPR$ 2- Notary$ Q-) Technology Fee$ , (60 Training/Education Fee$ Double Fee$ Structural Reviews$ <2!r-) Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) t 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 of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature J" � - s' OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 ,by L day of° ®G ' 20 f by who is personally known to � � V/��yfi who personally known t me or who has produced as me or who has produced as identification and who did take an oath. identificati an who did take an oath. NOTARY PUBLIC: NOTAR PUB C: Sign: ue,� HUBERT NUNS Print: Print: _ o • '•=My Comm.Expires Sep 11,2017 Seal: Seal: Notary Puhlic-State of Florida ip� oar ,U — Commission#t FF 043679 '''°;�:"`� BwM pwo Natural Notary Assn. APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Aco® CERTIFICATE OF LIABILITY INSURANCE DATE 201'4W' J 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 ALTERTHE COVERAGE AFFORDED BYTHE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,ANDTHE 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 MCGRIFF,SEIBELS 6 WILLIAMS,INC. NAME: P.O.Box 10265 PHONN, 800-476-2211 ILC No: Birmingham,AL 35202 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC S INSURER A Zurich American Insurance Company 16535 INSURED INSURER S:Associated Electric&Gas Ins.Svcs. Peoples Gas System TECO Energy,Inc. INSURER C:LM Insurance Corporation 33600 702 North Franklin Street Tampa,FL 33602 INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:VZWSW6G 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. INTR TYPE OF INSURANCE D R POU CY EFF POLICY EXP LIMITS POLICY NUMBER MM/DD MMIDDIYYYY B GENERAL LIABIUTY XL5129403P 07/01/2014 07101/2015 EACH OCCURRENCE $ 1,000,000 Self-Insured Retention x COMMERCIAL GENERAL LIABILITY $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ X CLAIMS-MADE F—I OCCUR MED EXP Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ POLICY JECTPRO LOC $ B AUTOMOBILE LIABILITY XL5129403P 07/01/2014 07/01/2015 O aBIINNEaD SINGLE IMT $ 1,000,000 Self-insured Retention X ANY AUTO $250,000 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ 1HIRED AUTOS AUTOS Per accident B UMBRELLA LIAB OCCUR L5129403P 07/01/2014 07/01/2015 EACH OCCURRENCE $ 1,000,000 X EXCESS UAB X1 CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ A WORKERS COMPENSATION Excess Workers'Compensation: 07/01/2014 07/01/2015X WCY LATU OE TR AND EMPLOYERS•LIABILITY y/N EWS9318597-03(Statutory limit is ANY PROPRIETOR(PARTNERIEXECUTIVE excess of$35,000,000 Insured by LM E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N/A Insurance Corporation) 1,000,000 (Mandatory In NH) Employer's Liability:XL5129403P E.L.DISEASE-EA EMPLOYEE $ If yee describe under 1,000,000 Dm OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Excess Workers'Compensation EW5-64N-004918-124 07/01/2014 07/01/2015 Each Accident or Each $ Employee for Disease $ 35,000,000 $ $ $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Excess Liability policy provides Insurance in excess of Peoples Gas System's Self-Insured Retention as stated above. C 'IFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. City of Miami Shores AUTHORIZED REPRESENTATIVE 10050 NE 2nd Ave t Miami Shores,FL 33138 V 4Qp ..Qws. Page 1 of 1 ©1988-2010 ACORD CORPORATION. All rights reserved. At-non 99 1on4nrne1 TMe.Arnon —A I---e...—9.4—A—1—-f ArnOn Construction Tre CTOB BUSINESS CERTIFICATE OF'COMPETENCY E1608 PEOPLES GAS SYSTEM INC D.B.A.: VEGA JESUS Is certified under the-PFO*Aons of Chapter 10 of Miami-Dade County VALID -POR CONTRACTING UNTIL 0913012015 North Miami Contractor 11) Number: 160800000 Town of Bay Hirbor Island Contractor ID NUmber-, CONT-06t-.3 .2004-05 QUALIFYING TRADE(S) 0014 FUEL TRANS& DISTRI Crades Oanger P F MCI gi! —1-4t —1'1�dado