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REV-16-420 UNITED STATE l VW%8E First-Class Mail Postage&Fees Paid USPS Permft No.G-10 • Sender Please print your name, address, and ZIP+4 in this box• MIAMI SHORES VILLAGE BUILDINGDEPARTMENT 10050 N.E 2 AVENUE MIAMI SHORES, FL 33136 COMPLETETHIS SECTION • . DELIVEPY ■ Complete Items 1,2,and 3.Also complete A. 9nature item 4 If Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. g, Ned by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailplece, or on the front If space permits. �-A D. Is delivery address different from Item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No UL7(1rrnMiL kM(ftV-%ffWT:S 3. Service Type Certified Mail ❑Express Mail ❑Registered Al Rehm Recei CC � 1 � ❑Insured Mail [3C.O.D. ✓ — 1 4. Restricted Delivery?Pft Fee) ❑Yes 2. Aft 7011 0470 0000 8985 5522 ffhar • Miami Shores Village -- t 'S\ 0 e Building DepartmentFEB zoos 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 9 FBC 20 BUILDING10':mVIS1Rw t f rmit No.RC-6-15-1499 PERMIT APPLICAT O - - Sub Permit No. r2,' r\r 1 - '-i z� rM—IBUILDING ❑ ELECTRIC ❑ ROOFING *REVISION ❑ EXTENSION E]RENEWAL OPLUMBING F-1 MECHANICAL ❑PUBLIC WORKS [] CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1399 NE 104th Street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-22320320040 Is the Building Historically Designated:Yes NO X Occupancy Type: R-3 Load: Construction Type: Enclosed Flood Zone: AE BFE: 9 FFE. 8.3 OWNER:Name(Fee Simple Titleholder):Angela Kelsey Wichmann Phone#:954-444-2156 Address: 1399 NE 104th Street City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: n/a Phone#: Email: CONTRACTOR:Company Name: Ultimate Environments, Inc. Phone#: 561-998-3643 Address: 1742 Costa Del Sol City: Boca Raton State: FL Zip: 33432 qualifier Name: David Habeck 561-985-4033 Phone— State Certification or Registration#: CGC 1510686 Certificate of Competency#: DE SIGNER:Architect/Engineer: Jose Obeso Phone#: 561-391-4115 Address:3100 NW Boca Raton Blvd, Suite 115 City: Boca Raton State: FL Zip: 33431 Value of Work for this Permit:$+32' �? Square/Linear Footage of Work: 2065 Type of Work: ❑ Addition N Alteration ❑ New ❑■ Repair/Replace ❑ Demolition Description of Work: See attached. Interior renovation. Specify color of color thru tile: Submittal Fee$ Permit Fee Q3 CCF$ 2 �� CO/CC$ Scanning Fee$aq • QZ) Radon Fee$976c—:1 DBPR$ Notary$ Technology Fee$ Ko • oz� Training/Education Fee$ - 03 Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 2 , (41 (Revised02/24/2014) t Bonding Company's Name(if applicable) n/a Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) n/a 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—Jtq& Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this _I_day of I . 20 10 ,by 1 (� -day of�e b�✓may 20 1b by _4(-l'rLMI A V, k4 kq.400 Is personally known to Da.0'Lp-�ra bJ�� who is personally known to ` me or who has produced as me or who has produced TL- ()�,VQ3S kAk, as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY P IC: Sig "�L�l� Sign: Print: Print: AFATIM L.BORN Seal: f!lohry Risk.81190 of Florida Se "jk" JEENA NELSON COMMI 8lon#FF 934043 i .MY COMMISSION#FF0537so +, Illy Comm.Ellphes Feb 4,2020 EXPIRES:Sqx be 1s,2017 !=No Nab"Notary Assn. APPROVED BY PI) Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) CERTIFICATE OF LIABILITY INSURANCE 4/5;016"'"' THIS CERJ'IFICATE 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 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(s). PRODUCERA NAME: Fan3. Cebert CBIZ Weekes & Callaway PHONE . (561)900-1639 1 Lock .(561)900-1939 3945 West Atlantic Avenue £cebert@cbizwc.com INSU S AFFORDING COVERAGE NAIC# Delray Beach FL 33445-3902 INSURER A.Cap1tol Specialty 10328 INSURED INSURER B 40wners Insurance Co. 32700 Ultimate Environments, Inc. iNsuRERcFCCI Insurance Co. 10178 1.742 Costa Del Sol INSURERD:SCottsdale Insurance Corp 41297 INSURER E: Boca Raton FL 33432 INSURER F: COVERAGES CERTIFICATE NUMBER-CL1633107810 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 TYPE OF INSURANCE POLICY EFF PO EXP LTR POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREmisEs(En A CLAIMS-MADE �OCCUR X X 1/10/2016 1/10/2017 2016079301 MED EXP( onen5 person) $ 5,000 X BLANKET ADD'L INSURED PERSONAL&ADV INJURY $ 1,000,000 X BLANKET WLTVER OF SUBRO. GENERAL AGGREGATE $ 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PR LOC EMPLOYEE BENEFITS LIAR. $ 1,000,000 AUTOMOBILE LIABILITY C O a ED SINGLE LIMIT 11000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALLLTOC OWNED OS X X 0-236998-00 1/10/2016 1/10/2017 BODILY INJURY(Per accident) $ X HIRED AUTOS X AN(OjTON OWNED PROPER DAMAGE $ $ UMBRELLA LU1B X OCCUR EACH OCCURRENCE $ 2,000,000 D X EXCESS LIAS D X� CLAIMS MADE AGGREGATE $ 2,000,000 DED I X I RETENTIONS 0000660 1/10/2016 1/10/2017 $ C WORKERS COMPENSATION X B WC STATU- 8 OTH AND EMPLOYERS'LIABILITY 81 ANY PROPRIETORIPARTNEWEXECUTIVE YIN 73400 4/01/2016 4/01/2017 OFFICERWMBER EXCLUDED? F-1 N I A E.L.EACH ACCIDENT $ 1'-000'000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If pes,d s-ftPTION under E.L.DISEASE-POLICY LIMIT $ 1,000,000 IT I DESCRIPTION n OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Rentaft Schedule,B more space Is required) CG# CGC1510686 Florida statute requires 10 day notice of cancellation for non-payment of premium and 45 day notice for non-renewal. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS. Building Department CG# CGC1510686 AUTHORIZED REPRESENTATIVE 10050 NE 2nd Ave Miami Shores, FL 33138 Leon A. Weekes/MSADER ACORD 26(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 onin 1.F1 ni Tho Ar npn nwna anti Innn aro,ro,niafarati marlra of AMRn