RFV-16-844 --� I Miami Shores Village
Building Department MAR 1 0 2016
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949 VA
FBC 20114
BUILDING Master Permit No. r)1C6_o�;PQ
PERMIT APPLICATION Sub Permit No.� 1(, -"s-,
❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING Ea MECHANICAL [-]PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: J061 Z A/C I�f�`C?d
City: Miami Shores Countv: Miami Dade Zia•
Folio/Parcel#: I I !S-)®-2 W500 Is the Building Historically Designated:Yes NO.---
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): L l�D>1 Phone#: �
Address:
City: All- State:. f' L Zip:
Tenant/Lessee Name: _ Phone#.
Email: su m ` fid �N► � � i-L
CONTRACTOR:Company Name: r1ri oT l'20J Alc__4c Phone#: t_iG! ALt-1L() d
Address: j7Sn/Sq_: CaFg�,;�< Gtr j3
City: b%rA , IJ State• I L Zip: j3yi
Qualifier Name: SV+/<a 0^46K Phone#: so-1047 14,d
State Certification or Registration#:Ca e-l 91- S14 Certificate of Competency M
DESIGNER:Architect/Engineer: Phone#:
Address: rq City: State Zip:
Value of Work for this Permit: I, Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New 0 Repair/Replace ❑ Demolition
Descrip0d4 bf Work: Ajew S g zyt S x
Specify color of color thru tile:
SubmittalFee$ Permit Fee$��� CJQw CCF$ CO/CC$
Scanning! :$. Radon Fee$ DBPR$ Notary$
Technolog fi Training/Education Fee$ Double Fee$
_
Structurar _ Bond$
TOTAL FEE NOW DUE$��
(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. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature -:S
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
25 day of -V_k 20 1 ,by 2 _day of 0C Yod r .20 /S ,by
who s personally known to Sty ICK ]0.g /A who is personally known to
me or who has Vroduaced A as me or who has produced OL as
identification and w7/)/an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC: ...
Sign: � Sign: i2 f
1 g .
Print j J Print:
THOMAS M. KANN
Seal: sf� - Commission 4 EE 181909 Seal: W #
My Commission Expires g�r �
April 11, 2020
APPROVED BY his Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
C R® CERTIFICATE OF LIABILITY INSURANCE °� *=NM
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(%AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the holder Is an ADDITIONAL INSURED,the poles)must be ended. It SUBROGATION 18 WAIVED,subjaat 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 entforsonerd,s
PRODUCER T Noel Brown A032583
Brown Insurance Inc. PIImtE 941493-1886 941497-6325
111111101*
1872 Tamiami Trail S. Uftme, noembrownins.net
Suhe G
Venice FL 34293 INIIKIRER A: ARCH SPECIALTY INSURANCE CO 21199
IIID INIIIURER 8:
FRIENDLY ROOFING AND A/C,INC.
19515 CAROUNA CIRCLE D:
BOCA RATON FL 33434
CERTIFICATENUMBER:
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,TELA 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.
ADM sum
TYPE OF INSURANCE FaLrymumm LIIm
X COMMERCIALGENERALLUMILITY 1,000,000
Cly M OCCUR UPJM S 100,E
MED EXP(AM one Perm) 10,000
A AGL0019779-01 12/06/2015 12M612016 PERSONAL aADV KAM S 500,000
A LNITAP ft 1,000,000
X POLcY JE& LPELoc PRODUCTS_COMPJOP AGG 5 500,00
$
AUTOMCBILELUUNLITY SINGLE LIMIT $
ANY AUTO
BODILY NJURY(Per Person) S
�
OWNED AEDULED UTOS
BODILY INJURY(Per accident) $
OS
NON-OWNED PROPERTY
HIRED AUTOS AUT S
S
ILA LIAR OCCUR EACHOCCURRENCE
EXCESS LIAR CLAIMS-MADE AGGREGATE S
WORKERS COMPENSATION WPER
YIN IA ER
PROPRIETORIPARTNEPjExEcuTivE 7N/A EACCIDENTH
in NM) EXCLUDED? L O
E.L.DISEASE-POUCY LIMIT 16
de�ersWer
OF OPERATXNIS/LOCAT /YEHKXM(ACOM 101, Renmrios Sahe*De,mey be eM1taolmd H fnaro aPaee req ed)
ROOFING S AIR CONDITIONING CONTRACTOR STATE OF FLORIDA.SVIXIA ELMALAH LICENSE#CCC1327680 AND CACIS15584
X&BIMMMUMM CANCELLATION
SHOIILD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BIS
THE E04PATION DATE TIEREOP,NOTICE WILL BE DELIVERED IN
Mlami shores village Bid Dept ACCORDANCE WITH THE POLICY PROS
10050 No 2Nd Ave
AUrlqAIRED NTATNE
Miami Shores FL 33138'2304 Noel Brown I A0325S3 er f
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014/01) The ACORD name and logo are regisb mW maNcs of ACORD
.��v .
JEFF ATWATER
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
**CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 2/20/2016 EXPIRATION DATE: 2/19/2018
PERSON: ELMALAH SVIKA
FEIN: 205395576
BUSINESS NAME AND ADDRESS:
FRIENDLY ROOFING&A/C, INC.
19515 CAROLINA CIR
BOCA RATON FL 33434
SCOPES OF BUSINESS OR TRADE:
LICENSED ROOFING HEATING,VENTILATION,
CONTRACTOR AIR-COND
Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section
may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only
within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Nofices of election to be
exempt and certificates of election to be exempt shall be subject to revocation If,at any time after the filing of the notice or the issuance of the certificate,
the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609