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WS-15-419 (2) wM 6-ij-)S Miami Shores Village �7PTN �'� J201 Building Department UN 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 �� Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201 d BUILDING Master Permit Nows PERMIT APPLICATION Sub Permit No. 536ILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING MECHANICAL PUBLIC WORKS ❑ CHANGE OF E] CANCELLATION SHOP � (� CONTRACTOR DRAWINGS JOB ADDRESS: Ir y�1 �—1 oTrccT City: Miami Shores County: Miami Dade Zip: '122)ls�o Folio/Parcel#: 113 101 C5„'4 01 BYO Is the Building Historically Designated:Yes NO Occupancy Type: IL W: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):S)f� ��1Cxz Phone#:�l®� Address: �� NLA.) ` 1'A --nre(T A I X315® City: M 1 4,4m f State: �lo Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: 'YTA hone#: Address ® k I J � . '7 City: State Zip: �, Tc Qualifier Name: RCADLIZ211 //Va L� \` Phone#:,501 —3-7 1 State Certification or Registration#: 66C l0 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ i 3, 7W ?3 Square/Linear Footage of Work:•�� Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work:f-44. f c,t'i ®t,c Li � LoAj 4210-CC YYUA--f �(0 �►24— Specify color �ofcolor thru tile: Submittal Fee$ `�Xl^ •V�v Permit Fee$ CCF$_ �f�� CO/CC$ Senning Fee$ Radon Fee$�_� DBPR$ �-�_Notary$ Technology Fee$ / 2_Z1 Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TATS"Fid NNW AUV r% 2 7z z. � (Revised02/24/2014) Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Jr 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. 1 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. #9k 'ayV, r a.4 s�; Signature igfiatu re XZ OWN wor AGENT ` CONTRACTOR The foregoing instrument was acknowledged before me this The for 1,, instrument was acknowledged before me this day of 20 (S by �,_,pday of t�-(� L- ,20 f by ✓TP r7 rl �I l� .wh is personally kno n to K.((` C11 1 -&1�who' ersonally know 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 PUBLIC: i kEci�v Sign: Sign: Print: Print: Seal: °�Pueuc ARELY BETMMURT Seal: °�. P.,�o ARELY BET4MRT MY COMMISSION#FF 178704 * * MY COMMISSION#FF 178704 * * EXPIRES:January 2,2019 EXPIRES:January$2019 N'4'Fa °��0� Banded Thru Budget Notary Setvkes MB=W Thtu Budget Notary Sanim ss*sssssssssssssssss*ssssss*ss* $ss s*sessssssssss*ss*ss*ss**sas*s$sss**ss*ssssssssssssssssss*sss*sssses$ss* APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Policy Number. Date Entered: '4`C�R®® CERTIFICATE OF LIABILITY INSURANCE P ATE(MMIDDIYYYY, 6/5/2015 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 terns 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). PRODUCER NAMEACaLISON SAId�N INSURANCE ----T_._-___--- 730 3W 4T8 ST. #3 PHONE (866)587-7147 p X (888)542-3507 E-MAIL ALLISON@ SALNMINSURB.COM CAPE CORAL, FL 33991 DDRESS• INSURER(S)AFFORDING COVERAGE_ _ NAIL S INSURER A:PREFERRED CONTRACTORS INS. CO. (RRG) IasuReo FOWLER ENGINEERING CONTRACTORS, INC. INSURER 8: — —--- - INSURER C: 1400 VILLAGE BLVD #1103 INSURER D: WEST PALM BEACH, 33409 ----- --_- --- 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 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. IdSSR TYPE OF INSURANCE DL SUBRT POLICY EFF POLICY EXP - ---- LTR POLICY NUMBER MMIDD/YYYY I MMIDD1YYY LIMITS A COMMERCUlL GENERAL LIABILITY j i EACH OCCURRENCE S ]�Q9910QQ. i DAMAGE TO RENTED CLAIMS-MADE �x OCCUR PCIC5026-PCA77236 6/5/2015 16/5/2016 i-PREMISES Me occurrence i S 0 000.____ -05 j MED EXP(Any one person) Ste,QOQ _ _-------_-PER--: I PERSONAL&ADV _JURY GEN'L AGGREGATE LIMIT APPLIES I GENERAL AGGREGATE_ S 1.QQ �Q� POLICY JECT �_-j LOC I ! PRODUCTS-COMPfOP AGG S 1,000,000 i OTHER: I ------- $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S tea aimident _---- _ ANY AUTO I ! BODILY INJURY(Per person) S ALL OWNED SCHEDULED !! — AUTOS AUTOS I BODILY (Per accident) S NON-OWNED i PROPERTY DAMAGE HIRED AUTOS AUTOS PeraccideEd S I UMBRELLA LIAR OCCUR _ S EACH OCCURRENCE ' _- _— r— _ EXCESS LIAB CLAIMS-MADEI ;AGGREGATE S --- DED RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y fN —___-- ANY PROPRIETOR/PARTNER/EXECUTIVE i E.L.EACH ACCIDENT OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) ❑ i E.L.DISEASE-EA EMPLOYE $ If yes,describe under --- -------- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S i DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached I more space Is required) LICENSE- # CGC1515716 CERTIFICATE HOLDER CANCELLATION Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WLL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NS Second Ave. Miami. Shor®S, VL 32128 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Producedusing Forms Boss Plus sof mre.www.FamsBass- .208.1977 June 4,2015 State of Florida County of Broward Before me this day personally appeared Randall Fowler qualifier for Fowler Engineering Contractors who,is being duly sworn,deposes and says: That he will be the only person working on the project located at: 29 NW 94th STREET MIAMI SHORES FL,33150 Sworn to and subscribed before me this—!i—day of .2015 by &V)�Qll � Personally know O roduced Identification Q Type of Identification Produced o ARELY BumcoURT * * W COMMISSION t FF 178704 ,A F EXPIRES:January 2,2019 p�000,E BON Thru Budget Notary Serft Print,Type or Stamp Name of Notary fit►,51!�,�,�-s unit"anon Miami Shores Village - �� Building Department �i0Rl+pp► 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner— Workers' Compensation Insurance Exem tion tl'W1,11111 Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers'compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: cr State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of M 20 1 s. By who i personally known to me r has produced as identification. Notary: � � SEAL: EUMQUEUDA W COMMISSION#FF 211368 CANRES:Man 10,2019 BondedthruBuWNotarysefto