EL-16-923 RE,CPT-VT 77—
Miami Shores Village MAY 04 2016
Vi at Building Department BY:
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 ,O
FBC 20Ms
BUILDING Master Permit No. R6-3 (a"` 3
PERMIT APPLICATION Sub Permit No. �-IU d q` �
❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
F]PLUMBING [:] MECHANICAL ❑PUBLIC WORKS CHANGE OF ❑ CANCELLATION [:] SHOP
JS_+ _q CONTRACTOR DRAWINGS
JOB ADDRESS: � ��6 ® " q
City: Miami Shores County: Miami Dade Zip: 3,3113
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: fF�loQod Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): ®b e r�- Qe �v Vt Phone#:
Address:
City ® b State: � Zip:
,-33
Tenant/Lessee Name: Phone#:
Email: (�
CONTRACTOR:Company Name: Coti e L e- �r P Phone#: �� 6 q q—z4
Ad 1 /U L
City e b r® L, State* Zip:
QualiRer Name: no Phone#: ,5—33 d —
State Certification or Registration#: EC_ J'A Q®5 IF�Z Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ q-, Square/Linear Footage of Work:
Type of Work: ❑ Addition 23 Alteration ❑ New ❑ Repair/Replace ❑ Demolition /�
Description of Werk: Z__ �� C ® I� h e_n 0('e �
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ �_4✓00 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)
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. Asa ondition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith tha a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection wl4ch occurs seven (7) days after the building permit is issued. In the absence of s ch posted notice, the
inspection will not be appy ed a reinspection fee will be charged.
t
Signature Signature
OW R or AGENT CONTRACTOR
The foregoing I ent wa acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 by day of .20 IG by
�� who is personally known towho 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 PUBLIC:
Sign: Sign:
Print: Print:
��� Y P ••,
A3.0
�P" �s�% JUAN ALBERTO BRUGO o�"" e,% JUAN ALBERTO BRUGO
Seal: 3�' �? Notary Public-State of Florida Seal: 3?? ° Notary Public-State of Florida
f By Corton.Expires Jul 15.2017 %"'. My Comm.Expires Jul 15,2017
%;oFF. •• Commission#FF 195 %.;aF. :' Commission FF 195
nnna n lot
* aa��s�sx� ss�x�a*
APPROVED BY t{/&y Plans Examiner Zoning
Structural Review Clerk
(RevisedO2/24/2014)
gBo, m y ! 714"
AY4 016 1
BY: _ Miami shores Village_
"" p"'� Building Department
10050 N.E.2nd Avenue
R Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR/ARCHITECT
-�ermitNAC-.3 -I (o-6351
Owner's Name(Feesimple 71de Holder): 46"q– /A/6Tq/^1 Phone#:W
Owner's Address:__/ �cIP i?
City: - State Zip Code::; /3
Job Address pf where work is Ding done):
City: Miami Shores State:—Florida Zip Code:
Contractor's Company Name: 4(251 L Z�72 6W71VMi,1Phone#:
Address: Ste. 67-
City: State: �,2�6- Zip Coded
Qualifier's Name : Lic. Number:
Architect/Engineer of Record Name: IV940 Phone#:(-78aX11 7-36/0
Address: 'ells 'e2d 131,11- &P-Wag-1 j(9r
City: titState: Zip Code:
Describe Work:
I hereby certify th the work has been abandoned and/or the contractor/architect is
unable or unveil ng to complete the contract. I hold the Building Official and the
i Shores harmless for all legal involy7e ..
Signature '
Signature
erorAgen to
The foregoing i trume was dged bef, me The foregoing instrument was akno Wedged before me
thisd o 01 thiQ'f dayof G 2 b
r ' Y
Who is personally known to me or who has produced who is personally known to me or who has produced
as indentiflcation. as Indenti ication.
Ota. 'y. JUAN ALBERTO BRUGO NOte U �"A � •,.� JUAN ALBERTO BRUQO
Notary Pubk-Stye of Florida Notary Public-State of Florj Came. res Jul 18 2017 Ig ; y Comm.Expires Jul 15,2
•a�„ ��;`;'� Commission#FF 195 .,M� r
al: Seal:
t
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
EC 13005821 ISSUED. 08/28/2014
CERTIFIED ELECTRICAL CONTRACTOR
CHALJUB, PEDRO
CONELEC USA CORP,
IS CERTIFIED under the provisions of Ch.489 FS.
Expiration date:AUG 31,2016
L1408280003287
J
May. 04.2016 09:21 AM CONELEC USA 9544996654 PAGE. 1/ 3
Lace : s es T- ax Receip
.Miami--Dadetoonty,•State of Florida -L.-BT
-THIS IS N&ABILL-DO NOT PAY
S10Y7t38
1349mr,,"mojww ocArm RECEIPT NO.• -I~XPIR'ES
CONELEC USA CORP. REWWAL : S PTEMBi=F� 30
.DOINC3sualkess IN DADS 5335591 , r20i6•
COUNTY Must 6 dlsp14 d.I,t place of huslrwss
Purauai1t,to County Code
Chapter M.-Art SALT 0. .
QWNER 6r;*.TYPE OF t3N81NXXO
CONELM USA CORK198 ELECTRICAL PAYMENT RBCEIVEC
BY TAX COLLECTOq
CONTRACTOR. 76.00 09130/2015
Weuker(9) 1 EC13OM21 0227-15-00am
This Laval Bwiross rax Reodptoaly 0mum mmem of tlw Local Madam Tat.The Receipt b am s Ikeoee..
Pena%or a tltwlBl Wqm,bo dobarinew Holder must Cox*with any 9avermwow
ar IrMsvaraa* ml regulatory laws sad,,sq*onalits W ibb apply to the IlaslmL
11W RECEIPT NC.skew rmgt bo disol"an all eommamw vemmu-MimoNDadb Cade Sm Sa-M,
For ones infordm i"vhdt
nr,.
May. 04.2016 09:22 AM CONELEC USA 9544996654 PAGE. 2/ 3
4
i
CERTIFICATE OF LIABILITY INSURANCE /2/2'°'°6
�.•� s/3/201s
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOL09R. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERA43E AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sh AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polloy(ies)must be endorsed. If SUBROGATION 15 WAIVED, subject to
the tarns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
Certificate holder 1n lieu of such endorssmen s).
PRODUCER UUNTAUT AMUZI a Chase
Rick Gibbs, P.A. Insurance Agencry (950581-7740 FAX (954)584-9875
1000 S. State Road 7 Mag,amandaf ick ibbs .vote
Ins AFFORDDdGCOVEMC.E NAX;e
Plantation IF L 33917 INBUPMA:Evanston Xns Co
INKNIBD ImuR6R01.2vanston ]Cas Co
Conelec USA, Corp. INSURER C o
1422 NIR 139 Avenue INS URER D
IW8t1RER E
Pembroke Pines )PL 33028 F.
COVERAGES CERTIFICATE NUMBER:CLI012300431 REVISION NUMBER:
THIS 13 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 WfTH RESPECT 70 WHICH THIS
CERTIFICATE MAY HE ISSUED OR MAY PERTAIN, THE INSURANCI: AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE LIM rr3
GENERAL L1A91Lnv
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LV1 LITY $ 100,000
#, COMMSM ADE Q..CUR MED EXP WW one Deacon) 5,000
[1321862 /6/207.6 /6/2017 PERSONAL&ADV INJURY $ 1,000,000
GENIFRAL AGGREGATE $ 2,000,000
GEN'L AG I.I-MIT APPLIF.$PER: PRODUCT'S-COMP/OP AGG $ 1,0001000
zi POLICY PR Loc $
A V FQMeele.6 UAV ILM V
ANY Alan BODILY INJURY(Per person) $
ALL OWNED bCHEUULED
AUTOS AUTOS BODILY INJURY(Par awidwd) $
HIRED AUTO5 NOW-O%NEDPROPEqTY
AUTOS P BCG M A $
UMBRELLA LiA9X OC90ft EACH OCCURRENCE $ 2,000,000
a X EXCESS LIAR CLAIMS-MADE V20121138293 2/16/2015 /6/2017 AGGREGATE $ 2,000,00
RFT ION 9 $
VMRVJMCOMP04BATION PTU•• 0TH•
AND EMPLOYERS'LiBUTY
ANY r�Ro1°RIE'TOR/PARTNERVIECUTIVE YIN E.L.EACMACCIDENT $
0MC.ER1Mt:Mt�TI E)QCI.U]ED4 EI N/A
f(fMyyaeencceater#r In NM) E.L.DISEASE EA EMPLOYE 9
I17NSCR CMN OFO AERATIONS below
E.L.p19EAb'E••POLICY LIMIT $
DHSCRIPTION OF OPERATIONS/LOCATIONS I VEHICILES(AtMeh ACORO 907,Ad4ltlona!Remark$Seraduis,Irmare$Pace Is required)
Llechrlcai Contractor License T =bftr 2=3005821
CERTIFICATE HOLDER CANCELLATION
(305)756-B972 SHOULD ANY OP THE ABOVE DESCRIBED"LICIM 11119 CANC&LLDANORC
THE EXPIRATION PATO THMtMW, NOTICE WILL as DELIVERED IN
Village of ban i Shores ACCORDANCE WITH THE POLICY IsROVIS1ON8,
Building Department
10050 NS 2 Ave AUTHOPJZEDREPRESENITATIVB
Miami Shores Villag, LPI, 333.38
Rick Gibbs/ACHAM - � t_„r�. - % BGG .=rc
ACORD 25(201 NO) Cot 1911119-010ACORD CORPORATION. All rights reserved,
INS02512OUX+6w The ACORD name and logo are registered marks of ACORD
May. 04.2016 09:23 AM CONELEC USA 9544996654 PAGE. 3/ 3
CERTIFICATE OF LIABILITY INSURANCEDATE(MMI MW n
016
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: N the certificate holder is an ADDITIONAL INSURED,the pollcy(ies) 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 lieu of such endorsement(s).
PRODUCER CILTf]Laura Rogaapra.ore
Mack Insurance Group PHONE (561)674-0774 .(561)674-0775
7251 W. Palmetto Park Rd ADM
IeLRoccapriorelmackinaq�rou�_c:om
Suite 206 INSURER(S) AFFORDINQ COVERAGE MAIC$
Boca Raton FL 33433 IN$uRERA:Sraishfield Ansoeiates
INSURED INSURER 8
Conalec USA Corp. INSURER C
1422 NW 139th Avenue INSUMb:
INSURER R• _
Pembroke Pines FL 33028 INSUIMFi
COVERAGES CERTIFICATE NUMBER.-CL159433100 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
LTR im POLICY NUMBER M M LIMffS
C40MMEROIAL GENERAL LIABILITY EACH OCCURRENCE $
CAAIM6 M OE U OCCUR — --
MW EXP(AnY eno person) f
_mow...........,r— —_ PERSONAL&ADV INJURY $
GERLAOGREGATELIMIT APPLIES PER; _ GENERAL AGGREGATE $
POLICY ----_ .....,.....�......r..
JECOT- ❑LOC PRODUCTS-OOMROPAOR f
OTHER! $
AUTOMOBILE LIABILITY �
ANY AUTO BODILY INJURY(Perperson) f
AU7DS�D SCHEDULED BODILY INJURY(Peracclden<)
HIREDAUTOS AAUUTTOOS 6D PROPEL $
H 41
UMBRELLA U mit EACH OCCURRENCE $
EXCESS LIAR OLMM&MADF — —
AGGREGATE
$
WO RETEbMON 2 S
WORKERS COMPENSATION
AND EMfPLOYMIS,LIABILnYTU OERTH
ANY PROPPoETOWPARft4LqfflX2OVTIVYINE E.L.EACH ACOWNY $ $OO OOO
A CFMCERIMEM13ER EXCLUDED? N I A
i(frr Inasadba ter IM40-0026976-2015A 9/8/20],5 9/8/2016 E.L.DISEASE-EA EMPLOY s 500 000
DEiGRIPTIONOFOPM6 DebW E.L.DISEASE-POLICY LIMIT f 500.000
DESCRIPTION OF OPERATION$I LOCATION&I VEHICLES(ACORD 107,Addin mel Ram wm Schedule,may he Muhsd If mon vows Is r"Wro y
Electrical Contractor License Numbev Ec13005821
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Village of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Building bepartment: ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2 Ave
Miami ShorGaVillage, FL 33138 AUTHORIZED REPRESENTATIVE
Jay Maok/DELLA !
®1988 2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD
INSD25 t�014011