RC-19-833 (3)BUILDING
PERMIT APPLICATION
❑ BUIL ING
LUMBING
JOB ADDRESS:
❑ ELECTRIC
4�1'
Miami Shores Village
Building Department �6'l0,
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2C
Master Permit No. TL _(::�o _e --1 `11S
Sub Permit No.Vc-CH —6 — �3`�
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Cr r«j Vie,
the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type:
Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Title older):
61
Phone#: car
Address: �z D
City: ;�i 'al ! i yl fl 6es
State:
Zip:
Tenant/Lessee Name:
Phone#:
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Email:
3pS- —1-7
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CONTRACTOR: Company Na e:
Phone#:
J ✓
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r.
Address: t
City: ` _State: Zip:
Qualifier Name: C �� (Lf2-�7C Phone#:
State Certification or Registration #: (� �C 7� / ) Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $Tad Square/Linear Footage of Work:
Type of Work: ❑ Additi n Alteration ❑ N ❑ Repair/Replace ❑ Demolition
Description of Work: 1,
Specify color of color thru tile:
Submittal Fee $ <�: Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $
Structural Reviews $ _
Double Fee $
Bond $
(Revised02/24/2014)
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
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 issued. In the absence of such posted notice, the
inspection will not be proved and a reinspection fee will be charged.
Signature Si na ure
OWNER or AGENT CONTRACTOR
The fore ing instru ent was acknowledged before me this The foregoing instrument was acknowledged before me this
ay of 20 �� by day of , 20� by
IYKArL ri1 who is personally known to W Ater Gutierrez who is personally known to
me or who has produced (-Jt:VQ(574AN , 1Xr4as` me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
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Print: = e > Print:
�.t�a�P�•%� NIRIA M. PEREZ
e
Seal: :?ors ���ap rtl _ Seal: - * Notary Public -State of Florida
��> s/[�-py�, , �; - * • ; Commission # FF 925483 1
� �'/,�a; My Comm. Expires Jan 31, 202C
Z `i I Ci s � `. . ii,� OF FLO I
' IIIIIBondedthrou h ai
APPROVED BY -� d- //G Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
•. RICK SCOTT, GOVERNOR = ` ` Y - _ -JONATHAN ZACHEM, SECRETARY
Florida
lor
STATE OP•FLORIDA
DEPARTMENTfOF BUSIN FESSIONAL•REGULATION " 4
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CONSTRUC O1 i; G BOARD
THE PLUM'BI ,,TO rl`5 CERA - UNDERTHE , +
PROVI rt O _'� 4 T UTES
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EXPIRATI 31, 2620
Always verify licenses online at MyFloridal_icensexom ,
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l i f s v f f a
f Do notfalter,this document in any form.
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❑_ i This -is -your license, It is unlawful -for anyone -other than the -licensee to use this document. - - -
■
r a ♦ ; k c a. R 4 i -
Local Business Tax Heceipt
Miami —Dade County, State of Florida
-THIS IS NOT ABILL - DO NOT PAY
6121131
k-LBT-
BUSINESS NAMFULOCATION" RECEIPT NO. EXPIRES
WALTER PLUMBING CORPORATION RENEWAL SEPTEMBER 30, 2019
4054 SW 1 13TH AVE 6384093 Must be displayed at place of business
MIAMI FL 33165 Pursuant to County Code
Chapter 8A - Art. 9 & 10
OWNER SEC. TYPE OF BUSINESS
WALTER PLUMBING CORPORATION 196 SPEEIALTY PLUMBING CONTRACTOR PAYMENT RECEIVED
'C€C1427MO. BY TAX COLLECTOR
- 475.0.007,/23/20;1.8_.,
--Worker(s) 1 CREDITCARD=48056432"
This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license,
permit, or a certification of the holders qualifications, to do business. Holder must comply with any governmental
or nongovernmental regulatory laws and requirements which apply to the business.
The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276.
For more information, visit www.miamidade.gov/taxcollector
ACORO® CERTIFICATE OF LIABILITY INSURANCE
��
FDATE(MMrDD/YYYY)
06/25/2019
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 have ADDITIONAL INSURED provisions or 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
CONTACT
_NAME, Adriana L Clavi o Mauri
PHONE (305) 220.7447 FAX
N,l; (305) 220.4821
Excellence Insurance, LLC. DBA A&A Underwriters.
3801 SW 107th Ave
MAIL DRESS: certificates@aaunderwriters.com
AD
INSURERS AFFORDING COVERAGE
NAIC 1
INSURER A: SECURITY NATIONAL INSURANCE COMPANY
19879
Miami FL 33165
INSURED
INSURERB: BRIDGE FIE LD EMPLOYERS INSURANCE CO_
12158
INSURER C
_
WALTER PLUMBING CORPORATION
INSURER 0 :
4054 SW 113th Ave
INSURER E
INSURER F :
Miami FL 33165
COVERAGES CERTIFICATE NUMBER: 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.
ILSRR
TYPE OF INSURANCE
ADOL§T1
n
POLICY NUMBER
POLIIWDCYYYF
POLIDNEYP
I LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE XOCCUR
Blanket Additional Insured
SES1662478 00
10/25/2018
10/25/2019
EACH OCCURRENCE
$ 1,000,000
DAMAGE TRENTED,
_PgEM1�ES_(Eo occurre�g)
MED EXP (Any ono Person)
E 100,000
X
E 5,000
X
Blanket Waiver of Subrogation
1 PERSONAL a ADV INJURY
E 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO. l l LOC
X POLICYI JECT
X OTHER: Primary and Non Contrib
I GENERAL AGGREGATE
E 2,000,000
PRODUCTS • COMP/OP AGG
s 2,000,000 _
Deductible
E 1,000�
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
COMBINED SINGLE LIMIT
Ea accident
E
BODILY INJURY (Per person)
$
—
BODILY INJURY (Per accident)
E
j
I PROPERTY DAMAGE
f Per accident
—�
$
E
UMBRELLA LIABI
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
AGGREGATE
E
E_
DED RETENTIONS
(
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y! N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑N
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
830-38516
10/26/20,18
10/26/2019
PER OTH-
�X STATUTE ER
( E.L. EACH ACCIDENT
E 1,000,000
E.L. DISEASE - EA EMPLOYEE
—
E 1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
Plumbing Contractor License #CFC142751
105 d 111 IA07111113• M-1-1Ail
Miami Shores Village
Building Department
10050 NE 2nd Ave
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.
AUTHORIZED REPRESENTATIVE
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
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