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PL-15-360 Miami Shores Village Building Department FEB 1S 2015 Q �J 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 I -, ���D Tel:(305)795-2204 Fax:(305)756-8972 -- INSPECTION HONE NUMBER:(305)762-4949 C FBC 20 BUILDING Master Permit No.2 t t, r PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION ❑RENEWAL PLUMBING F-1 MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP p (� �] CONTRACTOR DRAWINGS JOB ADDRESS: ! !� F �®1 City:- Miami Shores County: Miami Dade Zip: 3 Folio/Parcel#: 1/- 3905- QqtP0 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder)* 1 d S S Phone#: Address{:_ l � clo jN e gat � City: h.1 CA,1')''i 1 S/ )r1_P% State: zip:.-3 31 d Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Phone#: 3f)'5- Address: la-3u 4\)wcj City: iilrl r tate• Zip: �� �� t Qualifier Name: ,f Phone#: .X6&'73- 96)02- State Certification or Registration#: J �!�;kC6�L4wetency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 3"M 'KN A6 Square/Unear Footage of Work: Type of Work: F-1AdditionEli--�/Alteration Leg New ❑ Repair/Replace ❑ Demolition Description of Work: 7sn 4 Ct 10\00-9 9( Ctdl-Q t �\) ,n q 0 �' CP c�g 11'&k. �F�Ul CY, w;�-In [��erw,,'�- L !0—lS-- Specify color of color thru tile: Submittal Fee$ Permit Fee$ S6,rr CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ -Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) S Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) w 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 the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to alta ent. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which c rs seven (7) days after the building permit is issued. In nce of such posted notice, the inspection will not be approv d a reinspection fee will be charged. Signature Signature r OWNER or AGENT CONTRACTOR The forggoing instrument was acknowledged before me this The foegoing instrument was acknowledged before me this �d 3� day of 3Gi✓1 vA 020 15 by -day of �✓I unr 20 1.5 by N-44 MAr kv5 .who is personally known to W,l l`A MIA{6)i- who i ersonally know to me or who has produced tAL9,o`L 1116r6-06140 as me or who has produced as identification and who did take an oath. F`71b identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign• Sign Print: uclaln — — — — — — Print: / "'a LAZARO ARIEL FORTUN LAZA ARIEL FORTUN �`1�v P elf, . n��ti.��� Seal: Seal: ;r° Notary Public•State of Florida .,r�.�•: NoUry Public State of Florida '• My Comm.Expires Jul 13,2018 ? My Com.Expires Jul 13.2018 Cammisaion*FF 141358 Comalssion tY FF 141358 NatiarW Assn. „m ##### APPROVED BY 3- S Plans Examiner 4' ( Zoning 44tL -LD.14—- Clerk (Revised02/24/2014) c FbrWa D"rbnent 096WIture and Consumer Services Bureau of Liquefied Petroleum Gas Inspection 2005 Apalachee Parkway Tallahassee, Florida 32389..5500 Master Qualiffer Mailing Address Licensed Location Address CECILIA MARTINEZ BLUE GAS DISTRIBUTION,LLC 1234 NW 79TH ST BLUE GAS DISTRIBUTION,LLC MIAMI,FL 33147-8212 1234 NW 79TH ST MIAMI,FL 33147-8212 Certificate Number 27863 License Number 15520 This Master Qualifier Certificate is Issued pursuant to Chapter 527, Florida Statutes, This c Is valid only for the person and licensed holdeertificate r listed. Any changes to the Master Qualifier status (such as transfer or termination of employment)must be reported to the Bureau of LP Gas Inspection at(850)921-1600 immediately. The Master Qualifier Certificate Is valid only through the date noted on the Certificate. A notice of renewal will.be sent to you In advance of your expiration date. A Master Qualifier Certificate may be renewed If certification of a minimum of 1,16(sixteen)hours continuing education is provided along with the renewal form. If training cannot be documented,an examination must be taken. If there are any errors on the certificate,please submit all changes in writing to: Florida Department of Agriculture and Consumer Services Bureau of Liquefied Petroleum Gas Inspection 20055 Apalachee Parkway Tailahassee� Florida 32399-6500 ———————————————————— cut Here -------------------,...----- State of Florlds Department of Agriculture and Consumer Services Division of Consumer Services Bureau of Liquefied Petroleum Gras Inspection �m�aa c June s,2011 GO (850)921-1660 tssm Date: July 15.2014 Tallahassee,Florida EX0860n DOW: July 14.2017 Exam: Owl MASTER QUALIFIER CERTIFICATE This Certificate Is issued under authority of Section 527.02,Florida Statutes,to: dalM ForCECILIA MARTINEZ Number. I BLUED BLUE t3A5 DISTRIBUTION.LLC 1234 NW TOTH ST ADAM N.PUTN M MAN.FL 33147-$212 COMMINIONER OF AGRICULTURE t Florida Department of Agriculture and Consumer Services Bureau of Liquefied Petroleum Gas Inspection P.O. Box 6700 Tallahassee, Florida 32399-6700 License Number: 15520 Business Mailing Address Licensed Location Address BLUE GAS DISTRIBUTION,LLC BLUE GAS DISTRIBUTION,LLC DBA BLUE GAS PROPANE-BLUE GAS PLUMBING DBA BLUE GAS PROPANE-BLUE GAS PLUMBING 1234 NW 79TH ST 1234 NW 79TH ST MIAMI,FL 33147-8212 MIAMI,FL 33147-8212 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company located at the address on the license. Each business location of a company must be licensed. All LP Gas licenses must be renewed annually. Any license allowed to expire shall become inoperative because of failure to renew. The fee for restoration of a license is equal to the original license fee and must be paid before the licensee may resume operations. IN THE EVENT OF AN OWNERSHIP CHANGE AT THIS BUSINESS LOCATION: This license may be transferred to any person,firm or corporation for the remainder of the current Iicer,§e year upon written request to the department by the original license holder. License transfers must be approved by the department. All licensing requirements must be met by the transferee and a transfer fee of$50 will apply. To apply for a transfer,contact the Bureau of LP Gas Inspections at(850)921-1600. Pursuant to Chapter 527, Florida Statutes, LP Gas licensees must present proof of licensure to any consumer, owner,or end user upon request when engaged in the business of servicing,testing, repairing, maintaining or installing LP Gas systems and/or equipment. For future correspondence, please make any needed corrections or changes to,your business mailing address and/or your licensed location address and return the UPPER PORTION with corrections to: Florida Department of Agriculture and Consumer$,eivieb§ Bureau of Liquefied Petroleum Gas Inspec>taon; ., P.O. Box 6700 r 1- Tallahassee, Florida 32399-6700 Cut Here -- -- — — _-- . State of Florida, Department of Agriculture and Consumer eNices Division of Consumer Services License Number: 15520 Bureau of Liquefied Petroleum Gas Inspection Expiration Date: August 31,2015 850 9211-1600 ',1 fl l T Pate of Issue: September 1,2014 • i 41cense Fee: $425.00 POST LICENSE T'allahasSee, Florida E;r: ,�, T�p�an4-Class: 0601 CONSPICUOUSLY Li ° quefied Petroleum ,Goas License CATEGORY I LP GAS;DEALEP:,.,;: GOOD FOR ONE L.00ATION''ONLY 5'i' !' '6-'I ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license Is Issued under authority of Section 527.02,Florida Statutes;to: i BLUE GAS DISTRIBUTION, LLC DBA BLUE GAS PROPANE - BLUE GAS PLUMBINI 1234 NW 79TH ST:: ,' ADAM H.PUTNAM MIAMI, FL 33147=8212 d COMMISSIONER OF AGRICULTURE ew,ae s� Locat Business;Tae ': Miami-Dade Count y, ?Sta or; -6f` ;FI rids� d -THIS IS NOTA BILL.=`b6l` A 63888214 BUSINESS NAME/LOCATION s* ` I RECfsI BLUE GAS PLUMBING ;tYY { ' y aaEIRE$ ; 1234 NIN 79 ST REN ALS O MBER: Z��J. 50997s wztuai e r MIAMI FL 33147 q gxy rt spy d`et piece of business a � y Pureuiant to county Code Chap3er8A'-ArL98'c,t0 OWNER SEC_TYPE OF BUSINESS BLUE GAS DISTRIBUTION LLC 205 LPG DEALER/MFG PAYMENT R6CEPJEO 15520 By TAX COLLECTOR. '$450.00 08/07/2014 CHECK21-14-046176 This local Business Tax Receipt only centirms Payment of dre Local BusWKw TaX Tia Reeiipt Cam a heenst Permit,Ora cortificalioq of the holder's qualification,to do traalaess Holdar,mnst er aon0overnme�l ragolatory laws aad_roquiremeats wilieh to the bnsi any 9averamaittaf a . apply nes The RECEIPT N0.above Must,be displayed on aU Com atrial vefuctes lAiaati-0sd Code Sec tk-ZI& For more information,vfait ' ' 9� f� I Client#:70001 PROUS ACORD. CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 10/14/2014 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 Ileu of such endorsement(s). PRODUCER E Michelle A.Kallcharan Gulfshore Insurance-Naplesa�"N ,239 435.7143 ac,No): 239 213-2852 4100 Goodlette Road North E-MAIL ; mkalicharan@gulfshoreinsurance.com 239261-3646 Naples,FL 34103-3303 INSURER(S)AFFORDING COVERAGE NAIC i 239 26INSURER A:HDI-Gerling America Insurance C 14343 INSURED INSURER B Propane USA Distribution,LLC INSURER C: Blue Gas Distribution,LLC dba Blue Gas Plumbing(Cont'd.) INSURER D: 1234 NW 79th Street,Miami FL 33147 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 CONTRACTOR 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. RR TYPE OF INSURANCE ADDL SUER POLIC EFF POLL��C I SR WVD POLICY NUMBER MMlD MMID % LIMITS A GENERAL LIABILITY EGGCD000109914 0/15/2014 10/1512015 DpEAAqCMMHgqOEECTCURpREENCE s2,000,00 0 X COMMERCIAL GENERAL UABIUTY PREMISES EaEcixurrDence $100 000 CLAMS-MADE 7 OCCUR MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $2,000 OOO GENERA-AGGREGATE $2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 JECT —1 X POLICY F7 PRO- LOC $ A AUTOMOBILE LIABILITY EAGCD000109914 0/15/2014 10/15/201 COMBINED SINGLE LIMIT Ea aocldent 2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X MCS90 Incl X Pollution Lia $ A UMBRELLA LIAR J( OCCUR EXAGD000109914 0/15/2014 10/15/201 EACH OCCURRENCE $3 000 000 X EXCESS LWB CLAMS-MADE AGGREGATE $3 000 000 DED I X RETENTION$O $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY PR ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) Insured Name Continued:dba Blue Gas Propane dba Consumer Gas Plumbing CERTIFICATE HOLDER CANCELLATION Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE m 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S796148/M795903 MAK ATE Amo r ' CERTIFICATE OF LIABILITY INSURANCE D 0501 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(lss)must be endorsed.N SUBROGATION IS WANED,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(a). PRODUCER CONTACT NAME PHONE AVC No Ext: 1800.277-1620 x4800 FAX A/C No: ffZn 797-0704 FrankCrum Insurance Agency,Inc. E-MAIL ADDRESS: 100 South Missouri Avenue INSURER(S)AFFORDING COVERAGE NAIC0 Clearwater FL 33756 INSURERA:* Frenk Winston Crum Insurance Co. 11800 INSURED INSURER B. FRANKCRUM L(C/F BLUE GAS DISTRIBUTION,LLC dba INSURER C: CONSUMER GAS PLUMBING INSURER D: 100 SOUTH MISSOURI AVENUE INSURER E CLEARWATER FL 33756 INSURER F: COVERAGES CERTIFICATE NUMBER: 303830 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME 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. ILTRR TYPE OF INSURANCE IN� M D POLICY NUMBER ry��,n �Policyy) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIAMITY DAMAGE TO RENTED $ PREMISES commence CLANS-MADE OCCUR MED EXP(Any one Person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ rGENI. .AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ POLICY PROJECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ d snt ANY AUTO BODILY INJURY(Per $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per aWdent) $ HIRED AUTOS NO N'OWNED PROPERTY DAMAGEAUT $ UMBRELLA LMB OCCUR EACH OCURRENCE $ EXCESS LIAR �CLAIMSAME AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AD WC201500000 01/01/2015 01/01/2016 X we srAnrroRv oR RS• A EMPLOYELIABRT y Y/N LIMITS ER ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $1,000,000 (11brdistaryInm0 If yes,desalt order E.L.DISEASE4--A EMPLOYEE $1 000 DESCRIPTION OF OPERATIONS Eelm EL DIS IT 91.000.0m DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks,Schedule,If more space Is requked) EFFECTIVE 11/1712008,COVERAGE IS FOR 100%OF THE EMPLOYEES OF FRANKCRUM LEASED TO BLUE GAS DISTRIBUTION,LLC DBA CONSUMER GAS PLUMBING(CLIENT)FOR WHOM THE CLIENT IS REPORTING HOURS TO FRANKCRUM.COVERAGE IS NOT EXTENDED TO STATUTORY EMPLOYEES. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE MIAMI SHORES VILLAGE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT 10050 NE 2 AVE AUTHORIZED� /s� MIAMI SHORES, FL 33138 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD