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MC-16-1840Project Address Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795-2204 Pe mit Parcel Number Permit NO. MC -7-16-1840 Permit Type: Mechanical - Commercial Work Classification: Addition/Alteration Permit Status: APPROVED sue Date: 7/8/2016 Expiration: 01/04/2017 Applicant 9050 BISCAYNE Boulevard Miami Shores, FL 33138- 1132060100010 Block: Lot: PUBLIX SUPERMARKETS, INC Owner Information Address Phone Cell PUBLIX SUPERMARKETS, INC P 0 BOX 407 LAKELAND FL 33802-0407 (863)688-747_ J Contractor(s) MARKET REFRIGERATION INC Phone (321)676-0426 Cell Phone Valuation: Total Sq Feet: $ 82,000.00 0 Tons: Additional Info: INSTALLATION OF REFRIGERATION CASES Classification: Commercial Approved: In Review Comments: Date Denied: Scanning: 3 Date Approved: : In Review Type of Work: Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $49.20 $36.90 $36.90 $16.40 $2,460.00 $9.00 $65.60 $2,674.00 Pay Date Pay Type Invoice # MC -7-16-60423 07/01/2016 Credit Card 07/08/2016 Credit Card Amt Paid Amt Due $ 200.00 $ 2,474.00 $ 2,474.00 $ 0.00 Available Inspections: Inspection Type: Ventilation Final Rough Rough Duct Duct Detector Test Review Mechanical 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 authorize the above-named contr o the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy July 08, 2016 Date July 08, 2016 1 BUILDING Li 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 PERMIT APPLICATION El BUILDING ❑ ELECTRIC ❑ ROOFING LJ PLUMBING Q MECHANICAL fl PUBLIC WORKS JOB ADDRESS: 9050 Biscayne Blvd City: Miami Shores County: STM FBC 201 Master Permit No. CC -12-15-3052 U REVISION Sub Permit No. MO— (6 ( 9C) LJ CHANGE OF CONTRACTOR ❑ EXTENSION RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS Miami Dade Zip: Folio/Parceltt; 11-3206-010-0010 Occupancy Type: Load: Construction Type: Is the Building Historically Designated: Yes NO X Refrigeration Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): PubIIX Super Market Phonett: Address: 3300 Publix Corporate Parkway City: Lakeland State: FI zip, 3381-3311�l Tenant/Lessee Name: Phone#: 7� yr-r — yT1/-060/ Email: CONTRACTOR: Company Name: Market Refrigeration Phone#: 321-676-0426 Address: 341 Thor Ave City: Palm Bay State: Fla zip: 32909 Qualifier Name: William Morrison Phonett: 321-676-0426 State Certification or Registration #: CAC1814149 DESIGNER: Architect/Engineer: Address: City: Certificate of Competency #: Value of Work for this Permit: $ 82,000.00 Type of Work: ❑ Addition If Alteration Description of Work: Deli upgrade Phone#: State: Square/Linear Footage of Work: ❑ New U Repair/Replace Zip: [1 Demolition Specify color of colorrthru tile: � l�� Qs �20^Submittal Fee $ �O` Permit Fee $ L1• LJ q • avec $ Scanning Fee $ c ' 00 Radon Fee $ :RC wGt. 0 DBPR Notary $ I Technology Fee $ �S O Training/Education Fee $ ((d' -/ 0 Double Fee $ Structural Reviews $ (Revised02/2412014) Bond $ TOTAL FEE NOW DUE $ of 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: 1 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 0 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, o 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. Signature NER or AGENT The foregoing instrum t was acknowledged before me this 1 day of � Signature CONTRACTOR The foregoing instrument was acknowledged before me this , 201(e , by /45 -day ofJ (,.fyt.e 20 Lk? , by %Ji 1 t , rJ/t %lt %��ISL'i'� , who is personally known to me or who has produced as who is personalba kinow.n *o me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ).A.,•L y JODI L. SLOAN MY COMMISSION # FF 184644 EXPIRES: February 5, 2019 Nf�TFOF Fl�\OP Bonded Thru Budget Notary Services *****************************t#********* APPROVED BY (nevi . dT2/24/2014) 1 identification and who did take an oath. NOTARY PUBLIC: Sign: (/fLJi'ct_ /� L'y�%r1Gl r!t_161 Print: L .fir ht& ci Seal: ...roe, ••'eb,,•,t, CYNIMIA L. �1MIWAtO Nolary Public - Stele o1 Roads . My Comm. Expires Jun 2, 2017 .,'r...):/ • . : Commission M FF 019530 ***********'�`*:1'�'�11A•i+**li•oVelIArWnialN'at kW tit* Examiner Structural Review Zoning Clerk LIMITED POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, that PUBLIX SUPER MARKETS, INC., a Florida corporation ("Publix"), by and through it undersigned officer, having its mailing address at P. O. Box 407, Lakeland, Florida 33802-0407, pursuant to a proper Corporate Resolution, does hereby appoint ROBERT J. MCGARRITY, P.E., Director of Construction for Publix Super Markets, Inc., to do and execute all or any acts with respect to the permitting, notice of commencement, construction and occupancy of Publix stores under construction or to be constructed, or in connection with the remodeling of Publix stores, as fully as said corporation might or could do through its officers. IN WITNESS WHEREOF, the undersigned has caused the within to be duly executed by its proper officer and the seal of the corporation hereto affixed by proper authority of its Board of Directors. Two Witnesses: PUBLIX SUP ' ;le NC. By: - Aar/ John A. Att.f. J ., Senior Vice President, STATE OF FLORIDA COUNTY OF POLK The foregoing instrument was acknowledged before me this 15TH day of September, 2015, by JOHN A. ATTAWAY, JR., Senior Vice President, General Counsel, and Secretary of PUBLIX SUPER MARKETS, INC., a Florida corporation, on behalf of said corporation. He is personally known to me and did not take an oath. ode (IV1. Parrish, Not My Commission Expires June 8, 2018: e, n ` JOYCE M. PARRISH �/ MY COMMISSION 8 FF128022 1110 EXPIRES: Jute 08, 2018 Public STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CAC 1814149 ISSUED: 06/09/2016 CERTIFIED AIR COND CONTR MORRISON, WILLIAM ALAN MARKET REFRIGERATION -INC IS CERTIFIED under the provisions of Ch.489 FS. Expiration date : AUG 31, 2018 L1606090000769 BEIDW IS YOUR BUSINESS TAX RECEIPT PLEASE DETACH AND POST IN A CONSPICUOUS LOCATION MARKET REFRIGERATION INC 341 THOR AVE SE PALM BAY FL 32909 MaLavuz Rvnt.:1 .e Palm Pay. FL 1240? BUSINESS TAX RECEIPT Palm Bay Business Name . : MARKET REFRIGERATION INC :,ocation Addr . : 341 THOR AVE SE Lic Nbr Classification 16-00018840 REPAIR - AC/REF/Nip ISsued: September 14, 2015 Restriction: Comments: Ctl nbr . 0012494 Expireo: September 30, 2016 t•-7.*V, ACORL'7® �. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 6/16/2016 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(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 Sihle Insurance Group, Inc 1021 Douglas Ave. Altamonte Springs FL 32714 CONTACT Fawn Peacock PHONE 321-724-0022 FAX 321-724-2063 (A/C No, Fac) (NC Not not ss• FPEACOCK@sihle.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:FCCI Insurance Group 10178 INSURED MARKREO-01 Market Refrigeration, Inc. PO BOX 500868 Malabar FL 32950 INSURER B:SUmmlt COnSUlting Inc GL0012598-5 INSURER C : 1/1/2017 INSURER D $1,000,000 INSURER E : INSURER F : X COVERAGES CERTIFICATE NUMBER: 1138706175 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 INSRL TYPE OF INSURANCE ND DS WVD SUBIt POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY GL0012598-5 1/1/2016 1/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 X Employee Benifit MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GE 'L AGGREGATE POLICY OTHER: X LIMITAPPLIES PER: PRD -. LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ A AUTOMOBILE X X LIABILITY ANY AUTO AUTOWNED HIRED AUTOS X SCHEDULED NON -OWNED AUTOS CA0019655-5 1/1/2016 1/1/2017 COMBINED STNGLE LIMIT (Ea accdent) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE UMB0013368-5 1/1/2016 1/1/2017 EACH OCCURRENCE $3,000,000 AGGREGATE $ DED X RETENTION $ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below_ Y I N N / A 0830-55026 12/31/2015 12/31/2016PER X OTH- STATUTE ER E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 A Equipment Floater CM0006459-5 1/1/2016 1/1/2017 Rented Eq 25,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Contractor License # CAC1814149 * Per FL Statute a 10 day notice of cancellation applies for non -pay of premium. CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Dept. 10050 N.E. 2nd Avenue Miami Shores FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDAHOREPRESENTATIVE Li ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-256772 Permit Number: MC -4-16-983 Scheduled Inspection Date: October 03, 2016 Inspector: Perez, JanPierre Owner: INC, PUBLIX SUPERMARKETS, Job Address: 9050 BISCAYNE Boulevard Miami Shores, FL 33138 - Project: <NONE> Contractor: H LAMM INDUSTRIES INC Permit Type: Mechanical - Commercial Inspection Type: Rough Duct Work Classification: Addition/Alteration Phone Number (863)688-747_ Parcel Number 1132060100010 Phone: (954)491-8929 Building Department Comments HVAC MECHANICAL - DUCT WORK CHANGES. Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments W\1 S)Q)\,\- \1\00.D(i September 30, 2016 For Inspections please call: (305)762-4949 Page 4 of 31 0 z D 0 D c r m d co m m N_ d y rn a PROJECT NAME -Lb l I 7-9 L( PROJECT NO — T 9 ed j��p��,,�Q AIR DUCT LEAKAGE TEST SUMMARY AIR SYSTEM '"'"�£ad 'Q Et CidC-'F FAN CFM (Q) LEAKAGE CLASS (CO e;:)11 PAGE OF _ SPECIFIED TEST PRESSURE (P,) DUCT CONSTRUCTION PRESSURE CLASS (Pc) DESIGN DATA FIELD TEST DATA RECORD SUBJECT DUCT SURFACE AREA IN FT2 ALLOWABLE LEAKAGE DIAMETER PRESSURE "W.G. DATE PERFORMED BY WITNESSED BY ACTUAL CFM FACTOR CFM/100 FT2 CFM (TEST SECTION) ORIFICE TUBE DUCT ACROSS ORIFICE TOTAL SYSTEM I33 "" "` ^- •^>>- *•_ TEST SECTION(S) les4