REV-16-913 - Miami Shores Village . �Y_ - ,__
Building DepartmentAPR daj
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 Y,
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20N
BUILDING Master Permit No.RC 6-15-1499
PERMIT APPLICATION Sub Permit No. Va VQ-(—?t3
CF-IBUIL � ELECTRIC Ej ROOFING REVISION ❑ EXTENSION RENEWAL
MECHANICAL ❑PUBLIC WORKS CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1399 NE 104TH STREET , MIAMI SHORES , FL 33138-2661
City: Miami Shores County Miami Dade Zip:
Folio/Parcel#:11-2232-032-0040 Is the Building Historically Designated:Yes NO X
Occupancy Type: RES. Load: Construction Type: RES. Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):ANGELA KELSEY F/K/A/ANGELA WICHMANN Phone#:(954)444-2156
Address: 1399 NE 104TH STREET
City: MIAMI SHORES State: FL Zip: 33138
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: MASTER MECHANICAL Phone#: (305)825-3004
Address:15181 NW 33RD PLACE
City: MIAMI State: FL Zip: 33054
Qualifier Name: WILLIAM FLOWERS Phone#: (305) 825-3004
State Certification or Registration T. - 2&179 Certificate of Competency#:
DESIGNER:Architect/Engineer: JAO ARCHITECTS & PLANNERS Phone#: (561) 391-4115
Address: 300 NW BOCA RATON BLVD, SUITE 115 C; BOCA RATON State: FL zip: 33432
Value of Work for this Permit:$ IM,, Square/Linear Footage of Work:
Type of Work: 0 Addition 0 Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: KITCHEN AND BATH RENOVATION &ADDITION OF 1/2 BATH
Specify color of color thru tile: `t--1 S
Submittal Fee$ Permit Fee$ � CCF$ CO/CC$
Scanning Fee$3 C9J Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ �s "�
(Revised02/24/2014)
y
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.
�.
SignatureV Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was(acknowledged before me this
day of 20 ` V ,by day of �j Ir( / 20 .by
who is personally known to t 1,l e(� -R t5kAJ6,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: NOTARY PUB
Sign: r • a Sign
e Of Fionds
Print �- Print: w e Lucrecia Guerrero
t Gomm? ul 1705
4 wq, REAYMlA L.90RN Expires'0Z—OG617
Seal: Seal:
Notary Pubflo-State of Florida
•
Commission+►FF 934043
My Comm.Expires Feb 4.2020
on I Notary Assn.
APPROVED BY q;F- t J 6 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Apr. 5. 2016 12: 57PM Master Mechanical Services No. 1286 P, 2/2
MASTE-2 OP ID:Sb
CERTIFICATE OF LIABILITY INSURANCE °A0313112016'
03/31/2016
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 13Y 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 polieylles)must be endorsed. If SUBROGATION 13 WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A alatement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s),
PRODUCER CONTACT
Kahn-Carlin&Company,Inc. NAMG:
3360 S.Dixie HI hway PNON,o :306-446-2271 FAX
A,c H,:30548-3127
Mldml,FL 3313 9884 L
,&mavimt rocessln kahmcarlin,com
INSURER(S)AFFORDING COVERAGE NAK:B
INSURERA:National Trust Insurance Co 20141
INSURED Master Mechanical Services Inc INsuRER9.North River Insurance Co. 21106
Nl-33 Place
Miami,
INsuRERc:FCCI Insurance Company Mlaml,FL 33054 p y 10178
INSURER D:Federal Insurance Company 20281
INSURER E.'MAPPRE Ins Co of Florida 34932
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1
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, THF- INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITION$OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTNR TYPE OF INSURANCE MaL POLICY NUMBER b7MrD LIMITS
A X COMMERCIAL GENERAL LUIBILI7Y EACH OCCURRENCE S 1,000,00
CLAIMS-MADE []X O=R GL00118388 03/31/2016 0313112017
F9ZEMISES Ea00aeteil03 $ .300,00
X PER PROD-PER LOC MED EXP(Any one wn) 6 10,00
PERSONALaADVINJURY S 11000,00
GEN'LAGGRWATE LIMIT AFPIJGSPfiR: GENERALAGGREGATE y 2,000,00
POLICY❑JECT LOC PRODUCTS,COMPIOPAGG S 2,000,000
OTHER S
AUTOMOBILE LIABILITY Efl EIfl�N L LJMI S 1,000,00
E X AM q�0 160140010422 03/31/2016 03/31/2017 BODILYINJURY(perwson) 6
D9tSCHEDOMLED BOD LYINJURY(per=dderd) S
HIREDAUTDS $X UMBRELLA LIAR z
B EXCESSLIAO 581-104700.1 03/3112016 03/31/2017 EACH OCCURRENCE g 4,000100
AGQREOATE S $,000,00
DEO I X I RETENTION 0
WORKERS COMPENSATION3
AND EMPLOYERS'LIABILITY X R
C ANY PROPRi6TORIPARTNERIFXECUTIVE YIN 001-WC16A72087 03/31/2016 0313112017 ELEALHAWDENT s 11000,00
OFFICERd,IQdBER EXCLUDED? FI NIA
(Mende6orylnNH) 6L.OISFASE-FAEMPLOYE S 1,000,00
If yea,i�e�epfpe WF
DESCRIPTx?N OF OPERATIONS M. E.L.DISEASE-POLICY LIMB S 1,000,00
D Equipment Floater 06642183ECE 03/37/2016 03/31/2017 Limit 100,00
Leased/Rented Dad. 1,00
DESCRIPTION OF OP11RATIONS/LOCATIONSIVEHICLES(ACORD 701.AdcMiensl Remerb SNiedul%MRY Leaaaghod Irmue 9paeo is raWrod)
LiCanse Numbor: CFC1426279
CERTIFICA7I.HOLDER CANCELLATION
MiAM-04
SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE VALI, FIE DELIVERED Irl
Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2nd Avenue
Miami Shores,FL 33138 AUTHORIZED R9FRBsENTATIvk'
®1086 2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
Apr. 7, 2016 10:56AM Master Mechanical Services No. 1299 P. 1
.......... . .........................................................................................................................................................................................................................._......................
Local Business Tax Receipt
Miami—Dade County, State of Florida
THIS IS NOTA BILL-DO NOTPAY
5380513
BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
MASTER MECHANICAL RENEWAL SEPTEMBER 30, 2016
SERVICES INC 5646427
15181 NW 33 PL Must be displayed at place of business
MIAMI GARDENS,FL 33054 Pursuant to County Code
Chapter 8A-Art.g&10
OWNER SEC.TYPE OF BUSINESS
MASTER MECHANICAL SERVICES 188 PLUMBING PAYMENT RECEIVED
INC BY TAX COLLECTOR
CONTRACTOR 4.5.00 07/15/2016
Worker(s) 4 CFC1426278 CHECK21-15 094969
Tuts Local Business Tax Receipt only confirms paymantof the Local Business Tax.fie Recelpt Is not a IIcenso,
Permit,or 8 Cerlif e.1tios of the holder's qualifications,to do business.Holder mustcomply with any governments[
or nongovernmental regulatory laws and requirements Whiolt apply to the business.
The RECEIPT NO,above must b e displayed on all commercial vehicles-Miami-Dade Code Sec 8a-218,
MIS For mare lnfotmation,Visit WWW miamidada.govAaxcolle rear
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