REV-16-2885t.
‘2,\C\CI9
BUILDING
MIT APPLICATION
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
RECEIVED
OCT 2 4 2116
BY
FBC 20H 5
1-4
Master Permit No. - .A(0'" 4-1
Sub Permit No. 'EV I `+' a-8-5
❑ EXTENSION ❑RENEWAL
BUILDING ❑ ELECTRIC ❑ ROOFING 1REVISION
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS:
City:
Folio/Parcel#:
Occupancy Type:
R5c1
1q2, c
❑ CANCELLATION ❑ SHOP
DRAWINGS
Miami Shores
County: Miami Dade
zip: 33\ 5.3
Is the Building Historically Designated: Yes
Load:
NO
\� JConstruction Type:
1Ix1Flood Zone:BFE: FFE:
0e�(N AGIs'lOt Phone#: -7C0' "422 • -g
OWNER: Name (Fee Simple Titleholder
20 1 (A.� qG
Address: � n ' ,(
City: a� I� Off( lit State:
Zip: i 3 V _
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: �1 .� G &TA CC.► t VL.CA i �V
23C ¶
Address:
Phone#: CP -I ' 0 ' ✓5 .
City: Kt c l i State: 'n . Z : / JG�7 • �]
Qualifier Name: Vt /1L "�P & Phone#: 6J`c '0 ✓3 ( .
State Certification or Registration #:CX)C�Li [CIO*. Certificate of Competency #:
g
DESIGNER: Architect/Engineer: Phone#:
Address:
Value of Work for this Permit: $ Square/Linear Footage of Work:
City: State: Zip:
Type of Work: ❑ Addition ❑ Alteration
Description of Work: eJISt C1N-1
❑ New
❑ Repair/Replace ❑ Demolition
e c--1- ?ou rt k -
Specify color of co r thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUE $
Structural Reviews $
(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
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 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 issuebsence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
The faregoin:"instrument was acknowledged before me this
2d day ofp ,20/6 ,by
P`Qc<4. 69x.ea 'i ` who is personally known to
,me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
cf-Lc—Nev-az
;40'4;; ELIZABETH ELORRIAGA
it: •'c MY COMMISSION 0 FF953536
EXPIRES January 25. 2020
NO/) 3A8 -0'b.1 Flandallos ySwv ca ear
*************************
APPROVED BY
(Revised02/24/2014)
***
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of (� , 201 6 , by
/02117/— 'e r�i9— , who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
***************************
Plans Examiner
ELIZABETH ELORRIAGA
MY COMMISSION # FF953535
EXPIRES January 25.2020
********
14.e.‘
DATE /U —"L I —, 6
THIS IS CERTIFICATION OF COMPLIANCE WITH
THE CITY OF MIAMI'S "BUSINESS TAX RECEIPT"
IT IS IN EFFECT WHEN DATED, NAME OF CITY
PERSONNEL STAMPED AND INITIALED, AND
UNTI T E PERM ENT "ONE" IS e CEIVED.
INANCE D
PARTMENT OFF
Please, note that this Business Tax Receipt (BTR) may expire on September 30th of
the year that this INTERIM BTR has been issued. Ensuring renewal by October 1st
is the responsibility of the business entity.
For further information you may call: (305) 416-1570 or (305) 416-1918.
Favor de tomar nota que este Recibo de Impuesto para Negocio INTERINO puede
vencerse el 30 de Septiembre del alio emitido. Asegurar la renovation para el fro de
Octubre es la responsabilidad del negocio.
Para mas information puede Ilamar al: (305) 416-1570 0 (305) 416-1918.
Souple pran not ke Resi Enpo pou Biznis-sa ap exspire 30 Septanm ane ke yo kap
ba 'w lysans tampore-an. Se responsablite dirijan Biznis sa pou li renouvle-I Pwemie
Oktob kap vini. Si -w bezwen plis enfomasyon sou zafe sa , pa bliye rele nan
(305) 416-1570 ou byen (305) 416-1918.
Iitg crf L xtli
POST THIS DOCUMENT IN A CONSPICUOUS PLACE.. THIS IS NOT A BILL
NOT TRANSFERRABLE OR VALID AT ANOTHER ADDRESS
UNLESS APPROVED BY THE FINANCE DEPARTMENT. DO NOT PAY
CITY OF MIAMI 444 S,W.2 AVE 8'" FLOOR. MIAMI, FL 33138,
PHONE 1305)418-1818.
RECEIPT FOR ATLANTIC COAST CONSTRUCTION IN
ISSUED OG 21, 2016 TOTAL FEE PAID 13i :00
CUSTOMER NUMBER 136170
RECEIPT NUMBER 170644
NAME OF BUSINESS ATLANTIC COAST CONSTRUCTION IN
LOCATION 564 NW 23 ST
IS HEREBY IN COMPLIANCE
TO ENGAGE IN OR MANAGE
THE OPERATION OF: ADMINISTRATIVE OFFICE
Jose M. Fernandez
Finance Director
Thls hsuenca of a business lax receipt does not
permit the holder to ',rotate any zoning taws of the
Chy nor door it exempt the holder from any Noensu
or permits Met may be required by law.
Tlas document does not consliNte a ce4ldcahon
Thal the holder n qualified to engage In the
bualnea, profession or occupation spooled herein.
The doouMeol Indicates payment of the business
tax receipt only.
JEFF ATWATER
CHIEF FIRANCIAL OFFICER
STATE OF FLOM/A
DEPARTMENTOF FINANCIAL SERVICES
DIVISION OF WORKERSCOMPENSATION
• • 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-1mm Florida Workers' Compensation law.
Eti-e.CTIVE DATE: 9123/2016 EXPIRATION DATE: 9/23/2018
PERSON: SIERRA ALBERT
FEIN: 650891825
BUSINESS NAME AND ADDRESS:
ATLANTIC COAST CONSIRUC1X)N INC
564 NW 23 STREET
MIAMI ft 33127
SCOPES OF BUM E TRADE:
LICENSED GENERAL
CONTRACTOR
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onsy ott mocha' benefits a thropesseon wet ritchsciter.Purssert bawl" 411EL05(12).. F.S. C4Tbk otetedmiobs sersdtopt- apply trty
terintstssoto•tett/stress Ix Ira:attest twaroc teschon la tamely* Pummel', Doper 44=04 FS_ Nem tisitudrote, St be
trsethgt et:Meets d shactsm to WI Men* she th satteci httevocech K. hret Omen' th Irma ante ..'ear CWTdhe certf
iro portzsmothatl itst wow ts mares re fr meetsloragittlewsits d S benswastisitstecon.Thetispertnere ste ratio'
OFS-PIDINC-2S2 CERTIFICATE OF ELECTION TO RE EXEMPT REVISED 0843 QUESTIONS? (850013-1609
Oct 20 2016 02.53PM Athena Fax 954-368-2575
page 1
AR a' CERTIFICATE OF LIABILITY INSURANCE
DATE
1012DI20D/16
THIS CERTIFICATE I9 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 le en ADDITIONAL INSURED, the pollcy(lee) must be endorsed. If SUBROGATION IS WAIVED, eubJect 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
Athena Insurance/ Great Florida of Sunrise
4972 N Plne Island Rd
Sunrise FL 33351
NAME: Sabrina Vera
"i e, amu, (844) 670.1747 PA)C, Nal:
ADD(!eS; Ilorencla@greatflorldo.com
INSURERIS) AFFORDING COVERAGE
NAIC #
INSURER A: WESTERN WORLD INSURANCE INSURANCE CO
13108
INSURED
Atlantic Coast Construction
564 NW 23RD ST
MIAMI, FL 33127
INSURER B
MIEKH
INSURER C :
07/06/2017
INaURERD:
$ 1,000,000
INSURER E :
INSURER P :
X
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS 19 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWri-HSTANDING 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
INS
SUER
WVD
POLICY NUMBER
POLICY EFF
IMM(DD)YYYY)
POLICY EXP
IMNUDONTYY)
LtIRITe
A
X
COMMERCIAL GENERALUABILrrY
X
MIEKH
07/06/2016
07/06/2017
EACH OCCURRENCE
$ 1,000,000
CLAIMS -ADE
X
OCCUR
PREM SES rrO. enxl
$ 100,000
MED EXP (Any one Peron)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000,000
OEN'L
X
AGGREGATE Limn' APPLIES PER:
POLICY PRO-
JECT LOC
OTHER'
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS • COMPfOP AGG
$ 1,000,000
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
—
_
SCHEDULED
AUTOS
NON -OWNED
AUTOS
COMBINED SINGLE UMIT
(Ei *Olden()
$
BODILY INJURY (Pet person)
$
BODILY INJURYPer accident )
$
PROPERTYDAMA0E
(Perrcoldent
$
$
UMBRELLA LIAB
EXCESS UAE
_
OCCUR
CLAIMS -MACE
EACH OCCURRENCE
$
AGGREGATE
$
DED
RETENT ON $
$
WORKERS COMPENSATION
AND EMPLOYERS• LIABILITY y r N
ANY PROPRIETORIPARTNERJEXECUTIVE ❑
OFFICER/MEMBER EXCLUDED?
(Nendatory In NH)
I?ee deeerine unser
DESCRIPTION OF OPERATIONS below
N!A
PER OTH•
STATUTE ER
E.L. EACH ACCICENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS! LOCATIONS i VEHICLES (ACORD 101, Additional Remark, &thedule, rney be tittle Mod If mon apace is required)
License #CGC051904
CERTIFICATE HOLDER
CANCELLATION
Village of Miami Shores
10090 No 2 ave
Miami Shores FI 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DAT! THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTA11 VE
ACORD 28 (2014/01)
®1988.2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo ars registered marks of ACORD