REV-16-656 Miami Shores Village =Y:
Building Department10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 111 �
BUILDING Master Permit No. CC- ! ('06Co5
PERMIT APPLICATION Sub Permit No. vz-yl�o — QST
❑BUILDING ❑ ELECTRIC ❑ ROOFING 0 REVISION ❑ EXTENSION RENEWAL
QPLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 11300 NE 2 Ave Bucky's Cove i Ar6q ()o j4A L_
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):Barry University Phone#:
Address: 11300 NW 2 Ave
City: Miami Shores State: Florida Zip: 33161
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Go Plumbing, Inc. Phone#: 954-554-1780
Address: 7927 NW 38th Court
City: Davie State: Florida Zip: 33024
Qualifier Name: Mark Gasch Phone#: 954-554-1780
State Certification or Registration#: �� ����7 Certificate of Competency#:
DESIGNER:Architect/Engineer: Gallo Herbert Architects Phone#: 954-794-0300
Address:1311 W Newport Center Dr. Suite C city. Deerfield Beach State: FL Zip: 33442
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition—A Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: As Built Plumbing
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ > 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: 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.
Signatur Signature
OWNER or AGENT CONTRACTOR
The for strument was acknowledged before me this The foregoing instrume t was acknowledged before me this
e) day of d d a % 20 IZ ,by 4 day of CA l� ,20 1 6_____,by
N v /7 O/jv rF who is personally known to Mark Gasch who is perms son�lly known to
Ar
�me or who has produced as me or who has produced as
identification and who did take an oath. ,ly�llll identification and who did take an oath.
NOTARY PUBLIC: ��� `,1R,S TAii, NOTARY PUBLI .
A,
" 28?o :e
Vig9•
— y• — Sign:
IC
Print•--'G .4-A6 �A"r i #tr220397 *� Print
fiN
Seal:
i��•. p`
'°(�•: C1A :' Q\��. Seal:
/�I O
"'il,,Ic 11 I td ``\\` Commission#FF905054
MY Commission Expires
Au ust 25 2019
*x�m�x�****xx***•*����****�*xx **�*�***�***xm�x*��x�xmx**x*�**x*���*�+x*x���*�x���*x****�*���r�����x�***xx�x
APPROVED BY � Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
AcoR® CERTIFICATE OF LIABILITY INSURANCE DATE(AAAAtDD/YYYIf)
/11/2016
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 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 poticy(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 lieu of such endorseme s.
PRODUCER CONTACT
NAME:
Bateman Gordon and Sands PHONE FAx
3050 North Federal Hwy NO
Lighthouse Point FL 33064
INSU S AFFORDING COVERAGE NAIC 0
INSURER A
INSURED GOPLU INSURER 13:
Go Plumbing,Inc. INSURER C:
7927 NW 38 Court INSURER D:
Hollywood FL 33024
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER:960595712 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.
INSLTR TYPE OF INSURANCE POLICY NUMBER AUDLISUOR POLICY EFF POLICY EXP LIMITS
A GENERAL LJABit rrY Y Y CBC20001167100 3/5/2018 3/512017 EACH OCCURRENCE $1,000,000
DAMAGE TO RENTEIY—
X COMMERCIAL GENERAL LIABILITY
PREMISES(Ea occurrence) $100,000
CLAIMS-MADE F OCCUR MED EXP(My one person) $5,000
PERSONAL 8 ADV INJURY $1,D00,000
GENERAL AGGREGATE $2,000,000
GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
POLICY X PRO-_]JECT F7 LOC $
AUTOMOBILE LIABILITY COMBINED 9nqGM-CIIMT—
Es accident)
ANY AUTO BODILY INJURY(Per person) $
AUTOS
OOYSYNED AUTOS
SDULED BODILY INJURY(Per accident) $
NON-OWNED PPe�i'PPEERLDAMAGE $
HIRED AUTOS AUTOS
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR HCLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION WC STA
TU I OTH
AND EMPLOYERS'LIABILITY Y I N
ER
ANY PROPRIETORIPARTNERIEXECUTIVE= E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? N/A
(Mandatory In NH) E.L.DISEASE-EA gmpioyEd$
If yes describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more apace Is r"uhed)
General Liability:
Additional Insured-Blanket Contractors:as required by written contract or required in writing from a municipality as a condition of issuing a
permit-per E00071110.
Primary&Non-Contributory where required by written contract,or required in writing from a municipality as a condition of issuing a permit
per M-231-B 1110.
Waiver of Subrogation-Blanket as required by written contract,per E0008 1110.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS.
Miami Shores FL 33138
AUTHORUM REPRESENTATIVE
001-0
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD