RF-15-881 (2) Miami Shores Village F g 7F,
Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 rBY.
�° Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 `r
FBC 20 l`4 �
BUILDING Master Permit No.c`f-4- lW
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [CHANGE OF ❑CANCELLATION ❑ SHOP
AA � f J� CONTRACTOR DRAWINGS
JOB ADDRESS: �_ L�G 10� �f.
City: Miami Shores County: Miami Dade Zip:33161
Folio/Parcel#:J 0 1I_36®o a o,33® Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name Fee Simple Ttleholder : w4 Proeavas oPhone#:
Address: .350 O iu a) ;L rXWAA'
City: 11QA,4 State: Zip: Jam! 271
Tenant/Lessee Name: Phone#:
Email:
��,�CONTRACTOR:Co , 1 r Phone#:_:30S S �"�,�os
Address: `7 4AF14'//7w ¢ �7.
City: c 1 /1 —State: _1�' l� Zip:1�� f
Qualifier Name: lC�°�u c.�ir Q�� Phone#:
State Certification or Registration MQCL-13a"133 0 G:> Certificate of Competency M
DESIGNER:Architect/Engineer: Phone#:
Address: "' Ci State-
Zip:
Value of Work for this Permit:$ r a l< Square/linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New [RepairjjReplace ❑ Demolition
Description of Work: to O CA P S K—yT— <</C"i VA
c L� L A� I 1
o F _11VE: Sy_s1-6
Specify color of ic& th u tile: 71.
( �}
Submittal Fee$ Permit Fee$ ":�J5 CCF$ CO/CC$
Scanning Fee$'"� ` Radon Fee$ DBPR$ NotaryS,
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$$ � Bond$ 0
IN`'` Ql tO rj' !�&' N TOTAL FEE NOW DUE$ I��
(Revised02/24/2014)
Bonding Company's Name(if applicable)
Bonding Company's Address
City State if 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
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged beforemethis
5 day of 1015 120 IG by1 � dayof � 020 �ha ,by
�IMA-A �..�1oL4001F ,who i personacn to W00 467-- . ,who i ersonally know o
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 PUBUQ NOTARY PUBLIC:
Sign: Sign• u'
Print: Print:
Seal: PEDRO A QODOY Seal:
7An
PEDROA COMMISSION N EEIMn = ' • • M'COMMOMN 6 EE196673
********* **** 15*ss *** ******************** ***EXPMES May
* * *** ***********
r� L1oom .oan
APPROVED BY ' IT` 17b- Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami' Shores Village
Building Department
ys 10050 N.E.2nd Avenue
RtDA Miami Shores.. Florida 33138
Tel: (305 ) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR/ARCHITECT
�Vermit N. ., )
O
LST
YI1er'S Neme.( ee<simpie Title Hoider):O � � � �Phone#: di� 3Y 7g
Owner's Address: f S �I� a
City: _ l 16 State: L- Zip Code:--
.,t
Job Address.,(of where work is being done):_ E� N c
City: Miami Shores State:—Florida Zip Code: 33161 .
Contractor's Company Name: � tC�- W 6 Phone#:
Address: 32�� 345T 1
City:— tAA I AtAA I State: V�Z Zip Code: 3
Qualifier's Name: frOD A Lic. Number._dO&
Architect/Engineer of Record Name: Phone#:
Address:
Al 1100-1,e-
City: State. Zip Code:
RIAE' P kw4:a "tom
Describe Work: t -AAj b,
WiJ cr `tom` r- 'T%Ljw 3Y8_ 36
1 hereby certify that the work has been abandoned andfor the contractor/architect is
unable or unwilling to complete the contract. I hold the Building Offici and the
Miami Shores harmless for all legal Involve
Signature Signature
~ Aged .s rorArchkt
The foregoing instrument was aknbwledged before me The foregoing instrument was ak I wedged before mQ
this k day of ,20/�,by WilubXW this ( day of �I / .2014by tjCjjLL
Who i rsonally know o me or who has producedpersonally known to me or who has produced
as indentification. as indenti8cation.
Naftry'Pub0b.,� Notary Pubi
Sign: Woo `meg' Sign: e
Seal: Pwa�A iso OY Seal: P� A OOD Y
�� W GOMM�fBi lar+ O EE19M � MY��M#EEIM73
EXPING Map".2M O"Es May 15.Me
ai+s� ooa+ o,s�aOWN
+
STATE OF FLCWd*A
DEPARTMEW, Of BUSPUM AND PROFESSM)NAL
CONSTRUCTION W40USTRY LKSMISING BOARD
w
190 NORTH MONROE STREET
TALLAHASSEE FL3=94MM
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CERTIFICATE OF LIA ILI`TY INSURANCE DAT 02/1 021151DIYYYY)98
_..._�__._..__...•_..._........ _-
THIS CERTIFICATE IS ISSUED ASA 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 pollcy(les)must be endorsed. If SUBROQA71ON 1$WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A Statement oh tlits•cortificats does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER C ACT _...._
First Class Insurance Market E . (305)441-2997 arc No; (305)441-6443
4101 NW 91h Street D I as: .. .11011 c0SOLCom_.._ .
Miami,FL 33125 1NSUItER(S)AFFORDING COVERAGE _.. _ NAIG S
Phone (305)441-2997 Fax X305 441-6443 INSURERA: GOTHAM INSURANCE COMPANY
.... .....
INSURED ....... ... _
SURER S:
SKYLINE ROOFS CONTRACTORS INC. uasq(sErlc.;..,
9841 SW 4 STREET INSURERD:
MIAMI,FL 33174 Irl qMR 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 ADD'SUB'_..._._._. PO EFF POLICY EXP
LTR TYPE OF INSURANCE _. .MM� POLICY NUMBER & MM1D LIMITS
GENERAL LtAeILITY _.._ .._. EACH OCCURRENCE $ 1,000,000.00
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000.00
Fl3E.ih1i$f$.lEe 000urrenos $
E-) ElcLA1Ms4mm ® occuR CBC100001930701 MED EXP(Anyo��arao _ $ 5,000.00
A 04!30/2015 04!30/2096 -
❑ PERSONAL 8 ADV INJURY $ 1,000,000.00
_..__.__........_._.._.__..._.-__._..__.. GENERALAGGREGATE $ 2,00000.00
GENT.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 9,000,000.00
❑ POLICY_CI_JJEC.T.PRC- 0 IOC_.__. _.r.._. _. ---
$
AUTOMOBILE LIABILITY CEOBMBI DD SINGLE LIMIT
❑ ANY AUTO BODILY INJURY(Per person) $
❑ AUTOS ED [] SCHEDULED BODILY INJURY(Per accident $
❑ HIREDAUTOS ❑ ANUT SWNED PRbag YOAMAGE ' — $ --
D ❑ P s
❑ UMBRELLA LIAB ❑OCCUR
--------
--_____. EACH OCCURRENCE $ -
EXCESS UAB _..__..-.0 CLW84MOE AGGREGATE $
O OED ❑ RETENTION$ _ 3`
WORKERS COMPENSATION yYC3TATU•� ❑OTH-
AND EMPLOYERS`LIABILITY Yin -
ANY PROPRIE74R/PARTNERIEXECUTIVE E I fAGH ACCIDENT $
OFFICERIMEMBER IXCLUDED? N 1 A
(Mandatory in NH) � E.L DISEASE-EA EMPLOYE $
Byes desabe under
DESG�RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DtiBCRIPTION OF OPERATIONS/LOCATIONS r VEHICLES(Attach A00RD 101,Additional Remark Schedule,If more space to required)
DESCRIPTION OF OPERATION:
ROOFING CONTRACTOR
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
VILLAGE OF MIAMI SHORES AW6,111PIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
BULDING DIVISION ACCORD NCE WITH THE POLICY PROVISIONS.
10050 NE D AVENUE AU ED RE RESENTATNE
MIAMI SHORES,FL 33138 -All
-' - — -®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105)OF The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIABILITY INSURANCE 2/9 2016
Producer: Plymouth Insurance Agency This Certificate is Issued as a matter of information only and confers no
2739 U.S. Highway 19 N. rights upon the certificate Holder. This Certificate does not amend,extend
Holiday, FL 34691 or alter the coverage afforded by the policies below.
(727)938-5562 1 Insurers Affording Coverage NAIC#
Insured: South East Personnel Leasing, Inc. &Subsidiaries Insurer A: Lion Insurance Company 11075
2739 U.S. Highway 19 N. Insurer B:
Holiday, FL 34691 Insurer C:
Insurer D:
Insurer E:
Coverages
The policies of insurance listed below have been issued to the Insured named above for the policy period Indicated. Notwithstanding any requirement,tern or condition of any contract or other document
with reaped 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 ADDL I Policy Effective Policy Expiration Limits
LTR INSRD Type of Insurance Policy Number Date Date
(MM/DD/YY) (MM/DD/YY)
ENERAL LIABILITY each Occurrence $
Commercial General Liability Damage to rented premises(EA
Claims Made 13 Occur occurrence)
Med Exp
Personal Adv Injury
neral aggregate limit applies per:
General Aggregate
Policy ❑Prood ❑ LOC Products-Comp/Op Agg
UTOMOBILE LIABILITY Combined single Um@
(EAAccident) $
Any Auto Bodily Injury
All Owned Autos
(Per Perron)
Scheduled Autos
Hired Autos
Bodily Injury
Non-Owned Autos (Per Accident)
Property Damage
(Per Accident)
EXCESSAJMBRELLA LIABILITY Each Occurrence
Occur ❑Claims Made Aggregate
Deductible
A Workers Compensation and WC 71949 01/01/2016 01/01/2017 X wC statu- OTH-
Employers'Liability I tory limits ER
Any proprietor/partner/executive officer/member E.L.Each Accident $110001tmo
excluded? NO E.L.Disease-Ea Employee $1.000,000
If Yes,describe under special provisions below.
E.L.Disease-Policy Limits $1.000.000
Other Lion Insurance Company Is A.M.Best Company rated A-(Excellent). AMB#12616
Descriptions of Operations/AmUons/vehlclestExclusions added by Endorsement/Special Provisions: Client ID: 36-65-151
Coverage only applies to active employee(s)of South Fast Personnel Leasing,Inc.&Subsidiaries that are leased to the following"alert Company":
Skyline Roofs CoMractors,Inc.
Coverage only applies to Injuries incurred by South East Personnel Leasing,Inc.&Subsidiaries active employee(s),while working in:FL.
Coverage does not apply to statutory employee(s)or Independent contactor(s)of the Client Company or any other entity.
A list of the active employee(s)leased to the Client Company can be obtained by faxing a request to(727)937-2138 or by calling(727)938-5562.
Project Name:
ISSUE 02-09-16(TLD)
Begin Dabs 12/212015
CERTIFICATE HOLDER CANCELLATION
VILLAGE OF MIAMI SHORES Should any of the above described policies be cancelled before the expiration date thereof,the Issuing
Insurer will endeavor to mail 30 days written notice to the certificate holder named to the left,but failure to
BUILDING DIVISION do so shall impose no obligation or liability of any kind upon the Insurer,its agents or representatives.
10050 NE 2ND AVE
MIAMI SHORES, FL 33138