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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 �ar��aaal�araaf�oirlalarrf�aala�alaea� lar�r�arlarrla�rta�1'r�f 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 c Dare (M YYY) 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! -P (05L33 -o8s5 go E. 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 1:3 HIRED AUTOS J q AJ TO3 NED TZ-7 . .. • L. I UMGRELLA LIAB ❑ OCCUR LI. excess ❑ DED „[,LNTION S _ WORKSRS COMPENSATION AND EMPLOYBRS• LWBIUTY Y I N ANY PROPR RIPARTNER/EXECUTNL OFFi EXCLUDED? (MendMery in N ((tt yea, daaorlbe under p jjlpTIoN OF OPERATIoNLs pilaw E OWNED SINGLE LIMIT a = op di enTZ BODILY MJURY (Per pm teh) WDILY INJURY (Per awl 300 000.00 — s 50,000.00 s 5,000.00 s 300 ,0000_00_ 600,000.00 _ 0 300,000.00 _ S S E g EACH OCCURRENCE 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. 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD