REV-16-2617 Miami Shores Village
Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY,
INSPECTION LINE PHONE NUMBER:(30S)762-4949
FBC 20 t4
BUILDING Master Permit No. — �
PERMIT APPLICATION Sub Permit No. 19)CV —9—
❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL E]PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
Q /( CONTRACTOR DRAWINGS
JOB ADDRESS: ®�0 (� �� ""'I'�J A?e
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 1132060135_101 Is the Building Historically Designated:Yes NO— if'
Occupancy Type: P= Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): erbaxl a/ r2 Phone#:
Address: --C-64& 0 2-0'f Ali
City: aAo 5'. State: rl Zip: S
Tenant/Lessee Name: Phone#:
Email: 1 s .�]
CONTRACTOR:Company Name: �/ '�[°� 'i Phone#: /ti's
Address: lD
City: BNS S State: 42 Zip:
Qualifier Name: ltJi&AM Phone#:
State Certification or Registration#: Z_" /������ Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition
Description of Work: 1�,V(70/7 (PSP
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ —4_115 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
r
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or tallation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all la s 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 2 Signature
OWNER or AGENT CONTRACTOR
The fore going instrument was acknowledged before me this The foregoing instrument was acknowledg d before me this
2-2 day ofr�S' C*0-Vy1. V ,20 L6 by 1 .,�.12 , day of rn�Y 20 l� by
(C�r�l GI*��1`�Y ,who is personally known to W W%cxv�n (Y"? who is personally known to
me or who has produced Drt'"Y ;C%tYO !Q as me or who has produced nr Iy`tr L%ctcAs%( as
identification and who did take oath. identification and who did to an oat .
NOTARY PU LIC: NOTA Y PUBLIC:
Sign: C Sign: U. 45
Print: Print: h 1`e
Sea yANADYPR"' Seal: 1�,,, YANADYPRIETO
r ltY,e. l
*. MY COMMISSION 0 FF 214031 : ;y MY COMMISSION#FF 214031
. :; EXPIRES:March 2 �D1� �:, _.•. s EXPIRES March 25,2019
o:
F IN. Bonded Thru Notary P4" ifr4AP'yet(fF :A �l/of�yqe� Bonded Thru Notery Pubft Undervmters
#ffi�k�k
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYY1)
�..../ 09/22/2016
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 policy(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 endorsement(s).
PRODUCER CONTACT
NAME: Priscilla Chirino
Equiinsurance PHONE , (305)557-5578 A No): (305)557-5197
6839 Main Street ADDRESS: ffernandez@equiinsurance.com
INSURER(S)AFFORDING COVERAGE NAIC#
Miami Lakes FL 33014 INSURER A: FEDERATED NATIONAL 10790
INSURED
INSURER B
WIICon CO. INSURER C:
9636 NE 5th Ave Road INSURER D:
INSURER E:
Miami FL 33138 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.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER M D M D
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAGE TO
CLAIMS-MADE Fx_1 OCCUR PREMMA
aEoccurrence) $ 100,000
MED EXP(Any one person) $ 5,000
A GL-0000030371-01 09/03/2016 09/03/2017 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY[:]JE O- 7 LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
UMBRELLA LIAR HOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDEI �N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
CGC 1512642
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
AUTHORRED REPRESENTATIVE
10050 NE 2nd Ave.
MIAMI SHORES FL 33138
@ 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
EFTAWHASSEL 32399-0783
CRUZ,WILLIAM
WILCON CO
9636 NE 5TH AVE RD
MIAMI FL 33138
Congratulations! With this license you become one of the nearly
one million Floridians licensed by the Department of Business and
Professional Regulation. Our professionals and businesses range STATE OF FLORIDA
from architects to yacht brokers,from boxers to batheque DEPARTMENT OF BUSINESS AND
restaurants,and they keep Florida's economy strong. PROFESSIONAL REGULATION
Every day we work to improve the way we do business in order CGC 1512642 ISSUED:- 07/06/2016
to serve you better. For rnfonnation about our services,please
ionto.www.myflorldalicens8.com. There you can find more CERTIFIED GEN M- AL CbNTR#tCTOR
on about our divisions and the regulations that impact CRUZ,WILLIAM--;
you,subscribe to department newsletters and loam more about WILCON CO
the Departments Initiatives.
Our mission at the Department is:License Effichently,Regulate
Fairly.We constantly strive to serve you better so that you can
serve your customers. Thank you for doing business in Florida, IS CERTIFIED under the provisions of Ch.489 FS.
and congratulations on your new license! E +deW:nuG31,tare L1607050000967
......---------- DETACH-HESE -
RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD o
CGC1512642
The GENERAL CONTRACTOR '
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31,2018 -
CRUZ,WILLIAM
WILCON COt
9636 NE 5TH AVE RO ,=,,v
MIAMI
ISSUED: 07/06/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1607060000967