PLC-11-1243Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
JUL 12 1011
Permit No. c 11 1 a4
Master Permit No. //- 66-61
Permit Type: PLUMBING n
OWNER: Name (Fee Simple Titleh1olderAA):.. &A' 1 i Lc30 Phone#: 3VS-1119 -305 l�
Address: Ir30 0 1•1 11k! C.
City: ksa.t► SArtS State: Fl- zip: 3316!
Tenant/Lessee Name: ` 34-y 1/lT 44r5 Phone#: :19
J rd
Finail• / ,Jlall. Vkril t tk.
JOB ADDRESS: I -OD 7 L
City: Miami Shores County: Miami Dade Zip: b 1
Folio/Parcel #:
}pd319oc0W
Is the Building Historically Designated: Yes NO Flood Zone:
CONTRACTOR: Company Name: CAN% i240I ..za CA 71/oA) IOC • Phone#: 3o - 25 - Sol 0
Address: • 0 IIox 0-a
City: IM 1 A M ( State: .
Qualifier Name: e* t105 V ia-012.ra
33191?-
Phone#: 305- SOS - Dolcl
State Certification or Registration #: CPC /4/2%34.5 Certificate of Competency #:
Contact Phone#: Email Address: Tit C V (C f CQ A Q0 tj /c 54• • COM •
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ q'o.00� Square/Linear Footage of Work:
Type of Work ❑Address ❑Alteration
Description of Work: talN ' s
421.gew ❑Repair/Replace
MK —IL
❑Demolition
** ** * * **sa* *masse* *svp* *s * *ss**** ****ss* Fps * **r*ss*******ss***sa *�es**s• *****
b
Submittal Fee $ Permit Fee $ a� —?0:749- ''CF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
Technology Fee $
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDmONERS, 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 approve j;� a reinspection fee will be charged
Signature
Signature — • 7 —r
Owner or Agent Contractor
instrument was wledged before , foregoing instrument was acknowledged before me this
,20 11 ,by .: !!� ,�,�;;,yof C110 ,20 it by Carlos V( orcG
or who has produced who is personally known to me or who has produced
n1ek as identification and who did take an oath.
•
NOTARY PUBLIC:
NOT
Sign:
Print:
My Commission Expires:
As identification and who
C:
'd take an oath.
Sign:
Print: Aes C.,
My Commission E
*****Q 1<,A *+A** AFB *** *dti*******oD** Vyk********44************************************
APPROVED BY
Plans Examiner
Structural Review
(Revised 07 /10/07)(Revised 06/10/2009)(Revised 3/15/09)
u' 'r, ;• ISENIE CASTELLANO
;:= MY COMMISSION # DD 713252
EXPIRES: September 14, 2011
Bonded Thor Notary Public Unde '
Zoning
Clerk
SEE OTHER SIDE
DO NOT FORWARD
CENTRAL IRRIGATION INC
CARLOS M VICTORIA PRES
8975 SW 198 TERR
MIAMI FL 33157
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02 °232011
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 02/23/2011 EXPIRATION DATE: 02/22/2013
PERSON:
FEIN:
VICTORIA
208235869
BUSINESS NAME AND ADDRESS:
CENTRAL IRRIGATION INC
8975 SW 198 TERR
MIAMI FL 33157
CARLOS M •
SCOPES OF BUSINESS OR TRADE:
1- REPAIR SERVICE 2- SPRINKLER INSTALLATION
*
IMPORTANT: Pursuant to Chapter 440 . 05(14), F.S., an officer of a corporation who elects exemption from this chapter by tiling a certificate of election finder this
section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certtficates of election to be exempt... apply only within the
scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or
certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person
named on the certificate to meet the requirements of this section.
QUESTIONS? (850) 413 -1609
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW
EFFECTIVE 02 /23/2011 EXPIRATION DATE: 02/22/2013
PERSON: CARLOS M VICTORIA
FEN: 208235889
BUSINESS NAME AND ADDRESS:
CENTRAL IRRIGATION INC
8975 SW 198 TERR
MIAMI, FL 33157
SCOPE OF BUSINESS OR TRADE
1- REPAIR SERVICE 2- SPRINKLER INSTALLATION
IMPORTANT
®Pursuant Co Chapter 440.05(14), F.S., an officer of a corporation who
elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chaster.
Pursuant to Chapter 440.05(12), F.S., Certificates of election to be
H exempt.. apply only within the scope of the business or trade listed on
the notice of election to be exempt
E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt
and certificates of election to be exempt shall be subject to revocation
if, at any time after the filing of the notice or the issuance of the
certificate, the person named on the notice or certificate no longer meets
the requirements of this section for issuance of a certificate. The
department shall revoke a certificate at any time for failure of the
person named an the certificate to meet the requirements of this
section.
QUESTIONS? (850) 413 -1609
CUT HERE
* Carry bottom portion on the job, keep upper portion for your records.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11
07/11/2011 20:06 3052358606
ALL AMERICAN INS
PAGE 01/01
M(DD)Y
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CERTIFICATE 01: LIABILITY INSURANCE 07/12/11
THIS CERTIFICATE A H HE
-
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEG TMELY IMEND, EXTEND OR ALTER THE COVERAGEAFF R AFFORDED BY T 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 ATONAL INSURED, the policy(les) must be Endo• If SUBROGATION I5 WAIVED, subject to
the terms and conditions of the policy, certain policies may require an etrdorsemerd. A statement on this certifit.'de does not canter rights to the
certificate holder In ilea of such endorsement(s).
PRODUCER
All American Insurance
9038 SW 162nd St,
Miami, FL 33151
Phone (305) 233 -0856 Fax (305 235 -13608
INSURED
Central Irrigation
P.O. BOX 970251
Miami FL 33197
(305) 256-5090
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: —
THIS 15 1'O OER1'I 1 T THE POUCIEB OF INSURANCE LISTED BELLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FO—re HE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDiTION OF ANY t NTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THiS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN NAY HAVE BEEN REDUCED BY PAID CLAMS. _
A.. UBR POLiC - • fDI WM." YY�J LIMITS
TYPE OF INSURANCE _ Ids 1M1 0 .?O1 1.N.�BER . t1"A9L^.
EACH OCCUR ENCE i
Tel 2 II )
TMATE000494 1 MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERALAGGREEATB
. I PRODUCTS - c=MPPPP AGO
CCU SANTIAGO BEECH!
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quotGat klnoinsumnco.com
INsURP.g(S) AFFORDING COVERAGE
rtit_rio (3061235-8608
SURER A: LLOYDS OF LONDON
INSURER B :
INSURER O
INSURER D
INSURER`
1NSUR F :
GENERAL LIABILITY
COMMERCIAL GENERAL LiAFIIurf
f ] CLAIMS -twos 17 occuR
02/28/2011
02126/2012
GEN1. AGGREGATE UMIT APPLIES PER
❑ POLICY ❑ Fj ,7. u LOC
AUTOMOBILE LIABILITY
El ANY AUTO
1 AALLUTOSCIWNED J NiW
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L. I UMGRELLA LIAB ❑ OCCUR
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❑ DED „[,LNTION S _
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AND EMPLOYBRS• LWBIUTY Y I N
ANY PROPR RIPARTNER/EXECUTNL
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((tt yea, daaorlbe under
p jjlpTIoN OF OPERATIoNLs pilaw
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OWNED SINGLE LIMIT
a = op di enTZ
BODILY MJURY (Per pm teh)
WDILY INJURY (Per awl
300 000.00 —
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s 5,000.00
s 300 ,0000_00_
600,000.00 _
0 300,000.00 _
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AGGREGATE
DESORIPfiON DP OPERATIONS / LOeNTIONe 'VEHICLES (Aitach ACORD 101. Ark -tIansi Remarks Sensdule, If mare spec la restates)
THE PARTY LISTED BELOW IS RECOGNIZED AS CERTIFICATE: HOLDER.
CERTIFICATE HOLDER
Mlaml Shores Village
Building Department
10060 NE 2nd. Ave
Miami Shores, FL 33138
Fax; 305456 -8972
ACORD 2$ (2010/08) OF
wWLJ.1M • OTpt•
E,L. EACH AOCIDE S .
E.L.DISEASE - £A EMPLOYE S
- .L asEAsE - POUCY LIMIT
CANCELLATION
SHOULD ANY or THE ABOVE THE EXPIRATION DATE THEREOF, NOTICE WiLL POLICIES
BE DELIVERED I CANCELLED BEFORE
ACCORDANCE WiTH THE POLICY PROVISIONS.
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