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REV-16-701 4 Miami Shores Village RF, Building Department MAR 17 Uts 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BYlIk"Ck . Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 pF�By (Cr (20 BUILDING Master Permit No.-- PERMIT o. —PERMIT APPLICATION Sub Permit No. d1J IC - 7)_0 []BUILDING ❑ELECTRIC ® ROOFING REVISION ❑EXTENSION ❑RENEWAL PLUMBING ❑MECHANICAL MPUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP t Q,, .-��CONTRACTOR � DRAWINGS JOB ADDRESS: 13 D� J"� Z Kd i "C tll[6-G � 3 0 OW: Miami Shores County Miami Dade Zip: FaHo/Parcel#; the Building Historically Designated:Y NO t/ Occupancy Type: Load: Construction Typl: Flood Zone: BFE: FFE: ER:-Name(Fee Simple Titleholder): yi"w VNl .-4i U 'hone#: 3 �cmt:--- ,��nn ► �klv Q.�s —State: ^-�'_t. —--� � 3.3 l� 1 TenantJLessee Name: �— Phone#: Email: CONTRACTOR:Company Name: HOV17414 ��WrA Phone#: 'yoS 5`i Z•_(�38R Address: l ��'l I 4�w �- City:. ��A M� �1 State: Zip: Qualifier Name: oVty r�44�tin Phone#. 1K CerlftCtoq�i R�gictratien# ��G b2 Certificate of Competency#: 0 DESIGNER:Architect/Engineer. Phone#: Address: City: State Zip: Value of Work for this Permit:$/ 56o Square/Linear Footage of Work: Type of Work: ❑ Addition ® (Alterationde ❑�I NeNew �I ❑ Repair/Replace ❑ Demolition Description of Work: �Iw,,I.tia-1'i ova b f G01^ l a{Z 0 21�ti^ Specify color of color thru tile: Submittal Feet Permit Fee$ '7s' CCF$ CO/CC$ Scanning Fee$ 3 Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ • TOTAL FEE NOW DUE$ � ` C (Rev1seW2/24/2014) Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Nacre(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 YOOR 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$2500,the applicant must promise in good faith that a copy of the notice of commencement and construction lien low brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. A &Z Signature A &0/4Signature r OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of .20 _,by day of t.R-/l .20 Z by who is personally known to QQ%3 G 1�T Ch !:l j t` .who is personally known to mime or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Ste: Si Prin P Print• Jelffry J Yao NASANI 0.EOMINI� Seal: AMY commission FF ISMi Seal: '' E)gli►es 11/12/2018 Notary Pabiic•State of F� • C #FF 925542 my Comm.Exon Oct 7,2019 wwsswr�art•*�•�*a.*+�etta*��+�*wt*ria+r�+�wss�rr�r$+��+�s��eafe�:�� a+�*BbBs�iat�b�� APPROVED BY 7-.�—��_ Plans.Examiner Zoning Structural Review __ Clerk (Revised02/24/2014) ACCORDO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDrrrYY) 4/6/2016 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 Sharon R. Myers, AAI, CRIS Frank H. Farman, Inc. PHONE ,,. (954)943-5050 1 jFAAfX.No:(954)942-6310 1314 East Atlantic Blvd. AE-MAIL sharonm@furmaninsurance.tom P. O. BOX 1927 INSURER(S)AFFORDING COVERAGE NAIC# Pompano Beach FL 33061 INSURER A:Endurance American Ins Cc 10641 INSURED INSURER B.-National Trust Ins Co 20141 Horizon Plumbing & Mechanical Contractors, Inc INSURER Commerce & Industry Insurance Co 19410 10871 SW 188th Street INSURER D:FCCI Insurance Co 10178 Suite #1 INSURER E: Miami FL 33157 INSURER F: COVERAGES CERTIFICATE NUMBER:2016 Master w/o end 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 BR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMMD MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ANAUE TO—RENTED A CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence) $ 50,000 CBC20001259800 4/1/2016 4/1/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Fe accident $ 1,000,000 B I AM.AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED CROOIS2886 4/1/2016 4/1/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident PIP-Basic $ 10,000 X UMBRELLA LWB X OCCUR EACH OCCURRENCE $ 4,000,000 C EXCESS LIAR CLAIMS-MADE AGGREGATE $ 4,000,000 DED I X I RETENTION$ 10,000 1 141566811 4/1/2016 4/1/2017 $ WORKERS COMPENSATIONI PER AND EMPLOYERS'LIABILITY X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 D OFFICER/MEMBER EXCLUDED? FN—1 N/A (Mandatory In NH) OOINC16A66548 4/1/2016 4/1/2017 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500.000 D Inland Marine CM00067965 4/1/2016 4/1/2017 leased&Rented $ 100,000 Contractors Equipment Deduclible $ 1,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Plumbing Contractor CFC056992 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Dirk Dejong/JA ' Y ©198&2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS02512m4n1i