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MC-17-17Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. MC -1-17-17 Permit Type: Mechanical - Commercial Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date:1110/2017 Expiration: 07/09/2017 Parcel Number Applicant 415 NE 105 Street Number: CHURCH BLDG 1122310430010 Miami Shores, FL Block: Lot: ST ROSE OF LIMA CATHOLIC CI Owner Information Address Phone Cell ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD MIAMI FL 33138-2970 (305)758-0539 Contractor(s) MODERN MIDWAYS Phone (305)234-7776 CeII Phone Valuation: Total Sq Feet: $ 400.00 0 Tons: Additional Info: AMUSEMENT RIDES FOR TEMPORARY CHURC Classification: Commercial Approved: In Review Comments: Date Denied: Scanning: 3 Date Approved:: In Review Type of Work: AMUSEMENT RIDES FOR TEMPORA Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $7.50 $7.50 $0.20 $500.00 $9.00 $0.80 $525.60 Pay Date Pay Type Amt Paid Amt Due Invoice # MC -1-17-62520 01/03/2017 Check #: 11714 $ 50.00 $ 475.60 01/10/2017 Check #: 10719 $ 475.60 $ 0.00 Available Inspections: Inspection Type: Ventilation Final Rough Rough Duct Duct Detector Test Review Mechanical In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS 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. Futhermore, I - uthorize the above-named contractor to do the work stated. uthorized Signatur- Ow Applicant / Contractor / Agent Building Depa ment Copy January 10, 2017 Date January 10, 2017 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 nspection Number: INSP-274077 Permit Number: MC -1-17-17 Inspection Date: January 27, 2017 Inspector: Perez, JanPierre Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Job Address: 415 NE 105 Street CHURCH BLDG Miami Shores, FL Project: <NONE> Contractor: MODERN MIDWAYS Permit Type: Mechanical - Commercial Inspection Type: Final Work Classification: Addition/Alteration Phone Number (305)758-0539 Parcel Number 1122310430010 Phone: (305)234-7776 Building Department Comments AMUSEMENT RIDES FOR TEMPORARY CHURCH CARNIVAL JAN 27-29, 2017 Infractio Passed Comments INSPECTOR COMMENTS False --7 17 Passed Inspector Comments rt..4, , Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled re -inspection fee is paid. until For Inspections please call: (305)762-4949 January 27, 2017 Page 1 of 1 ADAM H. PUTNAM COMMISSIONER INVOICE TO: MODERN MIDWAYS 22901 SHERMAN ROAD STEGER, IL 60475 Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection INVOICE Section 616.242(8), F.S. Rule 5J-18.0012, F.A.C. Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com INVOICE #: 2880866 EVENT NAME: ST. ROSE OF LIMA EVENT ADDRESS/LOCATION: 415 NE 105TH STREET EVENT CITY/COUNTY: MIAMI SHORES/DADE OPEN DATE: 01/27/2017 INSPECTION #: FR17-39971 COMPANY INSPECTION FEES AND COUNTS - 001142 FAIL TO CANCEL LATE NOTICE REINSPECTION GOKARTS 0 - $0.00 0 - $0.00 $0.00 0 - $0.00 TOTALS: Date $0.00 $0.00 $1,260.00 DTN: 2880866 I Org Code: 42101002000 Object Code: 002060 Object Code: 001142 $0.00 $0.00 $1,260.00 Grand Total: $1,260.00 c ��.5 Check Number: � $1.260.00 Run Date: January 26, 2017 4:59 PM Page: 1 of 1 PERMIT FEES - 002060 INSPECTION FEES - 001142 RIDE TYPE I USAID PERMIT NO. IC NO. RIDE LOST USAID RIDE HOLIDAY TOTAL K 1 12392 14457 190568 $35.001 $35.01 $35.00 $35.00 K ( 190567 NK 00765 J 190565 $70.01 $70.09 NK ; 07009 190575 $70.01 $70.00 $70.00 NK 07203 190576 $70.01 NK 11521 i 190578 $70.01 $70.00; NK f--- -- NK 12423 i 190580 $70.01 $70.00. 13989 ! 190569 $70.01 $70.00. NK 14397 i 190564 $70.01 $70.00 NK _ 14893 ; 190581 $70.01 $70.0 NK - 14894 { 190566 $70.0 $70.00 SR SR SR '09690 11131 L- 190574 $140.0 $140.00 I 190577 $140.0 $140.09 11852 j 190579 $140.0 $140.00 SR 13153 f 190570 _ $140.0121 $140.00 TOTALS: Date $0.00 $0.00 $1,260.00 DTN: 2880866 I Org Code: 42101002000 Object Code: 002060 Object Code: 001142 $0.00 $0.00 $1,260.00 Grand Total: $1,260.00 c ��.5 Check Number: � $1.260.00 Run Date: January 26, 2017 4:59 PM Page: 1 of 1 ADAM H. PUTNAM COMMISSIONER Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection FUN FOR EVERYONE SHOWS 7509 SYMMES RD GIBSONTON, FL 33534 # Rides: 3 EVENT REPORT Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFrom Florida.com INVOICE #: 2907814 EVENT NAME: ST. ROSE OF LIMA EVENT ADDRESS/LOCATION: 415 NE 105TH STREET EVENT CITY/COUNTY: MIAMI SHORES/DADE OPEN DATE: 01/27/2017 INSPECTION #: FR17-39971 # Rides Passed: 3 # Rides Failed: 0 # Go Karts: 0 # Go Karts Passed: 0 # Rides Not Ready: 0 # Go Karts Failed: 0 USAID Theme Name fl053f8 RAIDERS 09798 ROK N ROLL 14305 HURRICANE Status ' IC/RT # Pass 190573 ' Pass 190572 ' Pass j 190571 T— # Go Karts Not Ready: 0 Deficiency OST # I Unit 0 I acknowledge that all identified rides issued a stop operation order (RT #) and/or carriers or components issued an out of service (OST #) are not in compliance with Florida Statute 616.242 and/or Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a su•sequent inspection by the Department. //Zion 7 Date Run Date: January 26, 2017 5:02 PM Page: 1 of 1 • 94\ Miami 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 S FBC 20 Permit No. V\ 1 + 1 Master Permit No. BUILDING PERMIT APPLICATION Permit Type: MECHANICAL JOB ADDRESS: 415 SIE 105 Street City: Miami Shores County: Miami Dade Zip: 33162 Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami Phone#: (305)727-6243 Address: 9401 Biscayne Blvd. City: Miami ShoresState: FL Zip: 33138 Tenant/Lessee Name: St. Rose of Lima Catholic Church Email: Phone#: (305)758-0539 CONTRACTOR: Company Name: Modern Midways, Inc. Address: 10420 SW 115 Street Phone#: (305) 234-7776 City: Miami Qualifier Name: Brian L. Morrissey State: FL Zip: 33176 Phone#: (786) 586-9568 State Certification or Registration #: Certificate of Competency #: Contact Phone#: (305) 234-7776 Email Address: bmorri9495@aol.com Phone#:, DESIGNER: Architect/Engineer: Value of Work for this Permit: $ 400.00 Type of Work: DAddress ❑Alteration Squate/Linear Footage ONew ORepair/Replace • ❑Demolition Description•of Work:. Amusement -rides for temporary Church Carnival Jan. 27-29, 2017 1 I .CIS f.S tau;.•?A %3r r"IkS ,411: I Submittal Fee $ Scanning Fee $ Notary $ 150 Permit Fee $ Radon Fee $ es**.****************************************** CCF $ . ca° CO/CC $ DBPR $ • S© Bond $ •S0 Training/Education Fee $ • Z °Technology Fee $ o 8,0 Double Fee $ Structural Review $ ,](oO TOTAL FEE NOW DUE $ y 5'. 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 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 n g approved and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this (l It day of as ,,20 1G ,by 441._ Ge.,xcE (�j►crcu►lGTr►ii;AKt1 who is rsonally known t me or who has produced A NOTARY PUBLIC: Sign: Print: c .t 1 .1 .' 1 . J :l, • .1 \ . . i.. y Public State of Florida B74i L Morrissey .nmission FF 187178 d' E.•. s 01/04/2019 g1L►Avv L.. !"t v scal My Commission Expires: Signature Contractor The foregoing instrument was acknowledged before me this/ 3-11 day of who is Ofd-orn cit, 201 L , by 13l hN rn vn-K.1.5sc, to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: J2:/( Print.rs , ,1 I At Ar CATHERINE EL H NYLUND My Commissiotfx MY COMMISSION # GG023712 EXPIRES August 23, 2020 *************************** .3 *** ************************************************************************ APPROVED BY Plans Examiner Structural Review Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Zoning Clerk • 1 Miami Shores Viiiage Building Department CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 A. COPY OF QUALIFIERS STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTORS TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION -must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: / o0(4/7P7 NO'8 2 c. BUSINESS ADDRESS: /, VZO Sw O/5 - .tee{ CITY /yaw/ STATE /2 ZIP 33/7, BUSINESS PHONE: (05 ) .23`/'7776 FAX NUMBER (___) CELL PHONE (.7?6) -% - r5 68 QUALIFIER'S NAME: ssPy QUALIFIER'S LIC NUMBER: A Local Busi ness Tax Recei pt Miami -Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY 5708137 BUSINESS NAM E/LOCATION MODERN MIDWAYS @ ST ROSA LIMA CATHOLIC CHURCH 418NE105ST MIAMI SHORES, FL 33138 OWNER MODERN MIDWAYS Unit(s) RECEIPT NO. RENEWAL 5953303 SEC. TYPE OF BUSINESS 191 CARNIVAL - SPONSORED LET] EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 PAYM ENT RECEIVED BY TAX COLLECTOR 352.50 12/29/2016 15 0230-17-002079 This Local Business Tax Receipt only con"rots payment or the Local Business Tax. The Receipt is not a license, permit, or a certi "cation or the hol der's guali "cations, to do business. Hilder mut comply with any government or norgovernnent regulatory laws and regui rerrentswhich apply to the business. The RHS PT NO. above oust be displayed on all comrercial vehicles - Miami -Dade 03de Sec 8a-276. For more information, visit www.nianidade.gov/taxcollector ACORD CERTIFICATE OF LIABILITY INSURANCE 11/1/2016 DATE D/YYYY) 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(ies) 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 Arthur J. Gallagher Risk Management Services, Inc. 777 108th Ave NE, #200 Bellevue WA 98004 CONTACT Joanne Manion NAME: PHONE 425 45q_3386 FAX 425-451-3716 E F:t) (A/C. No): -MAIL. ADDRESS- INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :T. H.E. Insurance Company 12866 INSURED BRIGTRA-01 Briggs Transport, Inc. Modern Midways, Inc. 22901 Sherman Road Steger, IL 60475 INSURER B : CPP010090206 INSURER C: 4/3/2017 INSURER D: $1,000,000 INSURER E : INSURER F : X COVERAGES CERTIFICATE NUMBER: 1297121151 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 LTR TYPE OF INSURANCE ADDL INSD SUER WVD POUCY NUMBER POUCY EFF (MMIDD/YYYY) POUCY EXP (MM/DDIYYYY) OMITS A x COMMERCIAL GENERAL UABILITY CPP010090206 4/3/2016 4/3/2017 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO PREMISES (EaENTED occurrence) $100,000 MED EXP (Any one person) $Excluded PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PER: PRO JECT LOC PRODUCTS - COMP/OP AGG $1,000,000 $ A AUTOMOBILE X UABILITY ANY AUTO AUTSSVNED HIRED AUTOS X X SCHEDULED TOS NON -OWNED AUTOS CPP010090206 4/3/2016 4/3/2017 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLA LIAB EXCESS UAB X OCCUR CLAIMS -MADE ELP001021007 4/3/2016 4/3/2017 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 DED X RETENTION $0 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A WCP0004670004 10/29/2016 10/29/2017 x E STATUTE OTH- ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) St. Rose of Lima Catholic Church & School; The Archdiocese of Miami; Archbishop Thomas Wenski and Village of Miami Shores, Florida are included as additional insureds but only as respects the operation of the named insured per policy terms and conditions - policy form CG133C 07/95. Event Dates: January 27 - 29, 2017 CERTIFICATE HOLDER CANCELLATION Village of Miami Shores c/o Building Dept 10050 NE 2nd Avenue Miami Shores FL 33138 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE W1LL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE tgt1"e, ZttialA - ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD