RC-15-678 (2) J .
Miami Shores Village - -
Building Department FEB Z 6 o1e
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY'
INSPECTION UNE PHONE NUMBER:(305)762-4949
FBC 201 -r s�
BUILDING Master Permit No.?(--I ( —4S2-2-
PERMIT
-'4SZZPERMIT APPLICATION Sub Permit No. G IS Co-7d
BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 6,44 WE ,' 95 %t
City Miami Shores County Miami Dade Zip:
Folio/Parcei#: Is the Building Historically Designated:Yes NO ,
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
19 OWfNER:Name(Fee Simple Titleholder): -!l A X.4 M eso d� Phone#:
Address:
City: 7J �i,�.i� A" "�Q State: Zip:
Tenant/Lessee Name: Phone#:
Email: / f`
CONTRACTOR:Company Name: /,a o ba/2C CI ,' Z*V,1,611Y& 60 Phone#: 305-z47
Address: 1840 SW, Ef d A vo.
City: / ,/,AM/ P.A 00 State: /OrW ---ZIP: ��l �
5�
Qualifier Name: /®4 0 lkA~AN 4902 Phone#• u-ns' 241 Z-446
State Certification or Registration#: C JW C 10 732 6 7/ Certificate of Competency#:
DESIGNER:Architect/Engineer: H"A Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ cj<; •c:s� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ® New [:a Repair/Replace ❑ Demolition
Description of Work: tSu?RZy .BYO IN-571.44" A oVa W llgrygA Z. GAS
LS;YS T�'� is7 634 4 VA!4 A11 r r .77wo t- -t M A a'.®IY.F'G asS
Specify color of color thm tile:
Submittal Fee$ S(3'0-3APenmtt Fee$ CCF$ 0 "'(0 6 CO/CC$
Scanning Fee$ Radon Fee$ ,�s DBPR$ -2'V3 Notary$
Technology Fee$ Training/Education Fee$ Double Fee$ 0
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
'32/24!20141
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$25w, the applicant must
promise in good falth 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 certifled 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 proved and a reinspection fee will be charged.
Signature Signature
WNER or AG CONTRACTOR
The fore oing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 1 .by `iZ3 day of FdFAeu�g�@ l .20 /(a .by
whol(& ally kn n to P�'DRO )6 EIWJV ar)-be g,who is personally known to
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 PUBLIC: ;j�stu; NOTARY PUBLIC:
Sign• Sign: 1
Print: 07 C V` X7e = Print: i��ka E'`e d e-5
Seal: �FF� � �: Seal: Pl UWAF1.EM3
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APPROVED BY �� Plans Examiner Zoning
Structural Review Clerk
(ReVISW02/24/2014)
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LICENSE NUMBER 4`�
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cQ CERTIFICATE OF LIABILITY INSURANCE °"'M' "
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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 MOLDER.
IMPORTANT: N is esrttkats holder Is an ADDITIONAL INSURED,the polky(tes)must be endorsed.N SUBROGATION IS WANED,subject to
is teres and conditions of the policy,certain policies may require an endorsement.A stat nwnt on tris certificate does not confer rights to the
certifleale holder In iku of such
PRODUCER Xan*Baneres
Temax Insurance 539-5989 LAIWk
(305)356.1235
7990SWI17m#113E-9mm
Amxm&. xmret@ft=Wrmmww.com
AFPDRKIINRi COVERAGE N=0
Miami Fl. 33183 INSURERA: CAPACITY INSURANCE COMPANY 32930
RURINIM I B•
Henna%i PlurnbIng ConWW BSC:
1840 SIN 83 Ave I D:
IN E
Miarrd FL 33155 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 POUCY 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,
-EXCLUGONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED 13Y PAD CLAMS.
am gum L TYPE of aRRJR POLL NLumuJ1 EFF Lam
X ri AL LIALidLT11 EACH OCCURRENCE $ 1,000,000
RERrEU-
CLAWS-MADE FX OCCUR $ 100,000
MED EXP one $ 5,000
A CLM01009098C 09/1812015 09h8/2016 PERsoNAL&mwiN,luRy $ 1,000,000
GEML AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2.000,000
X POLICY ED JECT ❑Loc PRoDucTs-CoMPIoPAw $ 2,000,000
OTHER: $
A1/7101N1MA UAD&W CONNINED
$
ANY AUTO BODILY INJURY MW pm" $
AMEDULED
O � BODILY INJURY(Per ao W" $
HIRED AUTOS 1AUTOS
444 I Z=MMAGE $
$
UM JA LIAR OC" EAW O� NCE E $
EXf UAB CLAWSaADE AGGREGATE $
H11IORlum ITXIN
AND EMPLOYE W LJABOdrY YIN E E
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E.L.EACH ACCIDENT $
it�e,, IPkmddwyln t er E.L.DISEASE-EA EMPLOYEE $
DEBCRIPTIOHI OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
008CRIP1w/1 OP OPERAIMM I LACAIMM I VeIUCLES(AOORD 101.Addmone1 RemeA®solndd%mey be e>e 0 sae se
Plumbing Contractor
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN
M1mw Shotes vmage ACCORDANCE VATH THE POLICY PROVISIONS,
10050 NE 2nd Avenue AUTHORIZEDREIMSEMATNE
Meld d Shores FI 33138
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