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CC-12-1928Certificate of Completion Miami Shores Village' 10050 NE 2 Ave, Miami Shores Fl, 33138 Tel: 305 =795 -2204 Fax: 305 -758 -8972 -" Building Inspection Department =' This certificate issued pursuant to the requirements of the Florida Building Code 106.1.2 certifying that at the time of issuance this structure was in .Y« compliance with the various ordinances of the jurisdiction regulating building construction or use. For the following: are IN AR .` Permit Type Commercial Construction Bldg. Permit No. CC -10 -12 -1928 r �R Owner PUBLIX SUPERMARKETS INC Contractor OAK CONSTRUCTION CO Subdivision/Project <NONE> Date Issued 03/19/2014 4 j Construction Type INTERIOR COMMERCIAL REMODEL Occupancy r' fg �Y: .7pA}rh Ry r 'k Cod ®cable 2010 FLORIDA BUILDING �� • 9050 BISCAYNE BLVD - w Miami Shores FL 33138 :k Locoon 3 //9 . Building OffldalS Approval Not Transferable POST IN A CONSPICUOUS PLACE P,. ca4.C• as Y+.,�x �, rt„vs`,�- Miami Shores Village Building Department 10150 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795,2204 Fax: (305) 756.8972 INSPECTION'S PRONE NUMBER: (305)5 762.4949 PMCED DEC 0 2 2013 FBC 20 (C BUILDING Permit No F— t° C-) 3 ")- PERMIT APPLICAT Master Permit No.� Permit Type: Electrical JOB ADDRESS: P City: Miami Shms County: Miami bade Tap: Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Aeikha- .year AwAs& Phone#: Addrem• 1V-4? X 1/07 City: State: Tenant/txa-ee Name: Phone#: Email: CONTRACTOR: Company Nam: /W l % e -E c 6 a. —phone#-. Address: 12,333 5 1-J /3/ A4 f- City: M / /+*I / State: E Zap: 3 3 / EZ, Qualifier Nanw. _e-1 t, A • M AGOAOC I Phone#. 30S"'?��r' State Certification or Registration#: if C- 0 3o'o/36o Certificate of Competency #: Contact Phone#: & 'c> / - �3 Cy Email Address::( GK. ig Sim M o "T 6/_.f$ flJE-% DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 0O, 6'00 Square/Linear Footage of Work: Type of Work: OAddrms j4Alterution ONew ORepair/Replwx ODemolition Description of Work: f 4jTe lent c A drf .l .�eQr�`r��i "' �l Submittal Fee Scanning Fee $ Permit Fee $ I/ 4 a �,r-' CCF $ CO /CC $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE S r ' Bohding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address Zip City State Zip Application is hereby made to obtain a permit to do the work and installation~ as indicated. 1 certify that no work or installation has commenced prior to the issuance of a i permrl t 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, HL3Al um,'I'ANKS and AIR CONL)1'1'IONERS, E'l'C..... OWNER'S AFFIDAVIT: l certify that all the foregoing information is atx:urate and that all work will be done in c)mplianc:e 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 $25(7A, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law b ochure will be defivered to the person whose property is subject to attachment. Also, a ceiWfaed copy of the recorded notice of c must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is is n the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The fojr. g 76t ent was acknowledged before me this day of , 20 _, by day of , 20 _L!, by R, c as: A R® M g t osJF-1 who is personally known to me or who has produced who is y known 'tom r who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: sign: Print Print: 'T ® c%2 NOTARY PUBLIC OA My Commission Expires: My Commission Expires: Comm 88 # EE67 * w Expires 21188017 APPROVED BY,�� Plans Examiner Zoning Structural Review Clerk (Revised 3 /12t2012XRev1sed 07110=XRevised 06110PAftRevised 3/15M) DATE - LICENSE NBR 105/25/20121110401057 EC13001360 The ELECTRICAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 48.9 FS. Expiration date: AUG 31, 2014 MALONEY, RICHARD W SUMMIT ELECTRIC CORPORATION 14531 HICKORY CT. DAVIE FL 33325 RICK SCOTT KEN LAWSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW SUMMELE -01 MQUINTERO CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 10129/2013 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 3ELOW. 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 endorsemen s). PRODUCER Collinsworth, Alter, Fowler &French, LLC 8000 Governors Square Blvd Suite 301 Miami Lakes, FL 33016 CONTACT NAME: NAME: PHO N ; {305) 822 -7800 Arc No): (305) 362 -2443 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC ri INSURER A: FCCI Insurance Group 11/112013 11/1/2014 INSURED INSURERB:FCCI Insurance Company 10178 INSURER C: MED EXP (Any one person) Summit Electric Corp. PERSONAL& ADV INJURY $ 1,000,00 12333 S.W. 131 st Avenue INSURER D: GENERAL AGGREGATE INSURER E: GEML AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC JEC Miami, FL 33186 INSURER F: $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY TdIAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RFOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PF.PTA; ; ,' F' ^: !rlcp ncSCn ;I.p FIFREIN IS SUBJFCT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER MMtDD EFF M Y EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FK OCCUR GLOOD93995 11/112013 11/1/2014 EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTEff_ PREMISES Ea occurrence $ 500,00 MED EXP (Any one person) S 10,00 PERSONAL& ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEML AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC JEC PRODUCTS - COMP/OP AGG $ 2,000,00 $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS NON -OWNED X HIRED AUTOS X AUTOS CA00081118 11/1/2013 11/1/2014 Ea accidenntSINGLE LIMIT $ 1,000,0 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PR E TY DAMAGE Per accident)- $ A X UMBRELLA UAB EXCESS LIAB X OCCUR CLAIMS-MADE UMBG00184311 11/1/2013 1111/2014 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,0 DED I X I RETENTION $ 10,000 S B WORKERS COMPENSATION AND EMPLOYERS' LIABILrfY. ANY PROPRIETORIPARTNERrEXECUTIVEYrN OFFICERIMEMBER EXCLUDED? FN (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 001WC14A21483 1/1/2014 1/112015 X TORY LIMITS T E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYE $ 500,00 E.L. DISEASE - POLICY OMIT $ 500,00 DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) Operations: Electrical Contractor It Miami Shores, City of Building & Zoning 10050 NE 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. AUTHORIZED REPRESENTATIVE HO 'mow -`C� 411/2 .rA v t VOID- &v I P%%. w ......V... - -- ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SUMMELE -01 MQUINTERO Ai ° -RO CERTIFICATE OF LIABILITY INSURANCE 10/29120 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 Collinsworth, Alter, Fowler & French, LLC 8000 Governors Square Blvd Suite 301 Miami Lakes, FL 33016 CONTACT NAME: PHONE 305} 822 -7800 � No : (305) 362 -2443 -MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC q INSURER A:FCCI Insurance Group AUTHORIZED REPRESENTATIVE INSURED Summit Electric Corp. 12333 S.W. 131st Avenue Miami, FL 33186 INSURER B:FCCI Insurance Company 10178 INSURER C: EACH OCCURRENCE INSURER D: DAMAGE TO RENTED PREMISES Ea occurrence INSURER E: MED EXP (Any one Person) INSURER F: PERSONAL & ADV INJURY nwmnw n_t-c /`CDTICtf ATC All RAIMCD. REVISION Numt:sttt: 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 I LTR TYPE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE POLICY NUMBER M LIGY E MWO P LIMITS A A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE _ OCCUR AUTHORIZED REPRESENTATIVE GL00093995 CA00081118 11!112013 1111!2013 1111!2014 11/112014 EACH OCCURRENCE $ 1 +000,00 DAMAGE TO RENTED PREMISES Ea occurrence $ 300,00 MED EXP (Any one Person) $ 10,00 PERSONAL & ADV INJURY $ 1,000,0 GENERAL AGGREGATE $ 2,000,00 GEML AGGREGATE LIMIT APPLIES PER. POLICY rx-1 PRO- LOC AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS X HIRED AUTOS X AUTOS "WNEO AUTOS PRODUCTS - COMP/OPAGG $ 2,000,00 Ea M&accidentSINGLE LfM1T $ $ 1,000,00 BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) S PR R AMA E er ecddant $ A B X UMBRELLA LIAS EXCBRS LIA® X OCCUR CLAIMS -MADE N 1 A UMB000184311 001 WC14A21483 11!112013 11112014 11/1/2014 11112015 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 DEC) I X I RETENTION $ 10,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNERIEXECUTIVE Y f N 10, cX^,LL'CE.^? (y (Mandatory In NH) If es, describe undue DESCRIPTION OF OPERATIONS below X WC SLIM JR LIMIS R $ EL EACH ACCIDENT $ 500,0 E.L. DISEASE - FA EMPLOYE $ OU- E.L. DISEASE - POLICY LIMB $ 500,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, B more space is required) Operations: Electrical Contractor %.cm I lrir.,A 1 C nVLair-m SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores, City of Building & Zoning ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE --- ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD a kv * 1% 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 Is the Building Historically Designated: Yes ETD DEC 0 Z 13 BY: FBC 20 l � Permit No. Master Permit No. CC- l -L®� �I NO Flood Zone: OWNER: Name e(�(Fee "" Simple Titleholder): �i, �� $r�� ♦�.Goi!�I' B Phone #: ��,� Address: +pT' 4(617? City: La lrel wcl State: Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Ten/w!A ele 2. J. 1N C- Phone #: - -� Qualifier Name: State Certification or Registration #: C.W'C Contact Phone#: Email Address: of Competency #: DESIGNER: Architect/Engineer: Phone#: Zii��p:: Value of Work for this Permit: C Square/Linear Footage of Work: Type of Work: ❑Address SAIteration ONew ORepair/Replace ❑Demolition Description of Work: go.-71 vP? 0 4�_ �x�x�x�. x�. xa�a��x�.. x. x. x• x• �a. ��x�n�. �. ��x�� •�a.x��x�+��xa�.x��Fees.x��x�x �x�x��xa�. x. x�x� .a�.x�x�x�.xa��x�•a��x�•�•.x �•�•�•�xa��•a�a�.x�•��.n� Submittal Fee $ Permit Fee $ ! CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 1 a 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 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 not be approved and a reinspection fee will be charged. Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before m��e //this day of , 20 _, by day of , 20!J /V 4- , by &" 4 &L- S0- who is personally known to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: {VDER STRASSE Sign: S in24 EE 42567 Print: Paint: @ ;ary, o �; Y Commission Expires N vemhat 16 2014 My Commission Expires: My Commission xpues: APPROVED BY '13 Plans Examiner Zoning Structural Review (Revised3 /12/2012)(Revised (Y7 /10 /07)(Revised 06110 /2009)(Revised 3/15/09) Clerk t V PINNA -1 OP ID: HG AC`ORD" �- CERTIFICATE OF LIABILITY INSURANCE °ATE (MMmorerrr) 1 01/29/14 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 endorsemengs . PRODUCER Phone: 561 - 683 -8363 SLATON INSURANCE Fax: 561 - 664 -5985 P.O. Box 220537 West Palm Beach, FL 33422 Richard Neyman, Jr. NAM"TE" Heidi McGuire PH°N 561- 721 -1305 AIC No: 561 -684 -5995 aoss: hmcgui latonriskservices.com INSURERS) AFFORDING COVERAGE NAIC # INSURER A: Philadelphia Indemnity 18058 02!01/15 INSURED Pinnacle Plumbing, Inc. & Pinnacle Mgmt Group, Inc, 1056 SW 1st Way Deerfield Beach, FL 33441 INSURER S :First Mercury Insurance Co. 10657 Nsup m c: North River Insurance Co 21105 INSURER D: Bridgefield Employers Ins.Co. 10701 INSURER E: Federal Insurance Company 20281 INSURER F: GENERAL AGGREGATE $ 2,000,0 r n�renw r_ma ^=0'n0If -A r= U"RRGCO. REvimiuN immumurm: 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. TYPE OF INSURANCE POLICY NUMBER LIMITS rB GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR X No Residential Ex MICGL000002364402 02101/94 ! 02!01/15 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrerx� $ 300'00 MED EXP (Any ane person) $ PERSONAL & ADV INJURY $ 1 +000,0 X No Sub Excl/XCU GENERAL AGGREGATE $ 2,000,0 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC PRODUCTS - COMPIOP AGG $ 2,000,00 $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS X H RED AUTOS X NN -OWNED AUTOS PHPK1126828 02/01/14 02/01/15 E amklEer SINGLE LIMIT $ 1,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per acc idert) $ --PROPERTY DAMAGE Per accident $ C D E X UMBRELLA LUIB EXCESSLIAe X OCCUR CLAIMS -MADE NIA 582- 101059 -6 0830 -25168 0 02101/14 07/01/13 02/01/14 il 02/01/15 07/01114 02!01115 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 DED I X I RETENTION $ 10,0( f0 WORKERS COMPENSATION COMPEMSA710N AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? ® (Mandatory in NH) If yea describe under DESCRIPTION OF OPERATIONS below Equip Floater V� R X T RY LIMITS R - $ E.L. EACH ACCIDENT $ 1,000,0 E.L. DISEASE - EA EMPLOYE $ 1,000,00 E.L. DISEASE - POLICY LIMIT $ 1,000,00 Leased 100,00 Deductibi 1 +00 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Sctredwe, n more space is requhed) MIASHOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores Village 10050 NE 2nd Ave Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE ©198&2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Miami Shores Village RECEIVED Building Department DEC O 2 013 90050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ; INSPECTION'S PHONE NUMBER: (305) 762.4949 FUJ5'up-W-1* FBC 20 l2� BUILDING Permit No. M c i 3 430 S PERMIT APPLICATION Master Permit No. cc -10 -12 -1X28 Permit Type: 1VI1N U JOB ADDRESS: 19006P City: Miami Shores Folio/Parcel #: 11 "�ZO(o010 -0010 Is the Building Historically Designated: Yes NO X Flood Zone: MO OWNER: Name (Fee Simple p Titleholder): NoRTHMN TRUST RAMC ETAL TRO % MZLI c OLM MA OT No G Phone#: Address: P 0 130X 32025 City: "� State: �- zip: 33802 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: ExaeN Re+rtger8t10n Phone#: 5(01 "585 "0342 Address: 605 Whitney Ave City: Lantana State: Pal- ZA p: 334(0Z Qualifier Name: Raymond Taylor Phone#: State Certification or Registration #: GAGoZZ413 : , Certificate of Competency #: Contact Phone#: 9(01 "585 -0342 Email Address: r.rooney cexcellrefrtgera+Aon.aom DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ a0e'e Square/Linear Footage of Work: Type of Work: ❑Address Alteration QNew ❑Repair/Replace Description of Wor$: Revision *(p , . . ❑Demolition Submittal Fee $ Permit Fee Scanning Fee $ Radon Fee $ CCF $ CO /CC $ DBPR $ Bond Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $_ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) N/A Bonding Company's Address City State Mortgage Lender's Name (if applicable) N/A Mortgage Lender's Address Zip City State zip ! 7 0 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 brochbre will be deliyered 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 approved and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 _, by , who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: Signature —contractor The foregoing instrument was acknowledged before me this l day of K104 , 2013-by 1.1 j ,G1YL, who+ known to me or who has produced as identification and whom an oath. NOTARY PUBLIC: �( '`°°°'�' APPROVED BY Plans Examiner Structural Review Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/04) Sign: Print: "�%► Sw �� My Commission Expires:""+ DOMMXSWABY Mr COMMISSION # EE858372 ca EXPIM: Dembe 13, 2016 Zoning Clerk EXCELLR OP ID: JT m `...- ° CERTIFICATE OF LIABILITY INSURANCE DA ;(2131113 ' 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 poilcy(les) 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). Phone: 561 -683 -8383 P.O. Box 220637 Fax: 561 - 684 -5995 West Palm Beach FL 33422 Casey CunnW, COCU CONTACT PHONE F Al A>C No E-MAIL ADDRESS: INSURERIS AFFORDINO COVERAGE NAIC 0 INSURERA :Brad efield Employers Ins. Co. 10701 INSURED Excell Refrigeration, Inc. 605 Whitney Avenue Lantana, FL 33462 INSURER 8: Hanover American Ins. Co. 36064 INSURER C: Federal Insurance Company 20281 INSURER D: Hanover American 36064 INSURER E: Hanover Ins. Co. 12M92 INSURER F PERSONAL & ADV INJURY COVERAGES CERTIFICATE NIIMRFR- RFVISIAN N1IMRFR- 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 IN& wV0 POLICY NUMBER POLICY IMMIDOPY EFF POLICY EXP 1MMMDFYYYY1 LIMITS B GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE FX OCCUR X Broad Form Miami Shores, FL 33138 586297004 PRIMARY AND NON CONTRIBUTORY 07101113 07101114 EACH OCCURRENCE_ $ 1,000,00 DAIEOMAGE ISE Ea ocaurence $ 100,00 MED EXP (Any are person) $ 10,0 PERSONAL & ADV INJURY $ 1,000,00 X Contractual Llab GENERAL AGGREGATE $ 2,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS - COMP /OPAGG $ 2,000,00 Emp Ben. $ 1,000, D AUTOMOBILE LIABILflY ANY AUTO AAILL� ED AUTOS HIREDAUTOS X ANUTOS ED 589075704 07/01/13 07101114 MBI ED SINGLE LIMIT $ 1,000,00 X X BODILY INJURY (Per perm) $ BODILY BODILYINJURY(Peracddent) $ Peracdderrt $ PIP -BASIC $ 10,0 E X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE UHJ877691103 07101/13 07/01/14 EACH OCCURRENCE $ 4,000, AGGREGATE $ 4,000,00 DED I X I RETENTION $ O $ A WORKERS COMPENSATION AND EMPLOYERS' LIAMIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICERNEMBER EXCLUDED? (Mandatory In NH) under DSCRaOie N OF OPERATIONS be NIA 30 -40614 EMLOYERS' LIABILITY INCL- 01/01/14 01/01/15 X O STAMTTU- X OTH- EL EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 EL DISEASE - POLICY LIMIT $ 600,00 C Equipment Floater 06641632 07/01/13 07/01/14 Rent/Leas 100,00 DESCRIPTION OF OPERATIONS/ LOCATIONS t VEHICLES (Attach ACORD 101, AddMonal Remarks Schedule, K fwm space B required) Re: Publix #794 9050 Biscayne Blvd. Miami Shores, FL 33138 CERTIFICATE HOLDER CANCELLATION MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E. 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores, FL 33138 ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/06) The ACORD name and logo are registered marks of ACORD 4{ i ' 4 ?-94'7 STATE OF FLORIDA.; D &PARTNENT t3 $llS NESS AN) PROF gg5 *6k: .9GULATiON ON TRUIrTI N NDII8 Lz 3NSING BOARD • SEQ #L12052900739 DATE BATCH NUMBER LICENS NBR T9 _ a5 ,:,29 2.012..1 - X8193'5 Named bei caw I5 CERT FTR�' Under the grovi>s rims o l ap Expiration date: AUG. 1, 2:014 ;A w cgtrl Yg #y3 iUa `Rvsv+''ii ti . b TAYLORr RAS� LFS1iI$ ' 4 •qa :EXCEL �.:;REFAT 7A.1 10 n 605 WHITNEY Ai R LANTANA FL X3462 1I Cif ,fi QOT RiEN LAW34N G.OV$OR SECRETARY DISPLAY AS REQUIRED BY LAW ANNE M . G A N N O N P.O. Box 3353, West Palm Beach, FL 33402 -3353 `"LOCATED AT** CONSTITUTLONALTAX COLLECTOR www.pbctax.com Tel: (561) 355 -2264 605 WHITNEY AVENUE Serving Palm Beach County LANTANA, FL 33462 Serving you. TYPE OF BUSINESS OWNER I CERTIFICATION # I RECEIPT #/DATE PAID AMT PAID BILL # 23-0148 AIR CONDITIONING CONTR TAYLOR RAYMOND LESLIE I CACO22413 I U13.704215 - 08/20/13 ' $59.50 I 840122121 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2013/2014 LOCAL BUSINESS TAX RECEIPT B2 -150 EXCELL REFRIGERATION INC LBTR Number: 199902713 EXCELL REFRIGERATION INC EXPIRES: SEPTEMBER 30, 2014 605 WHITNEY AVE LANTANA, FL 33462 -1641 This receipt grants the privilege of engaging in or managing any,business profession or occupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. AUG 2 A N N E M. G A N N O N P.O. Box 3353, West Palm Beach, FL 33402 -3353 *"LOCATED AT** CONSTITUTIONAL TAX COLLECTOR www•pbctax•Com Tel: (561) 355 -2264 605 WHITNEY AVENUE Se ea Serving Palm Bch County Serving you. LANTANA, FL 33462 TYPE OF BUSINESS OWNER CERTIFICATION # I RECEIPT #/DATE PAID AMT PAID BILL # 23-01 CW AIR CONDITIONING CONTRACTOR TAYLOR RAYMOND LESLIE CACO22413 I U13.704215.06/20/13 $185.85 840122122 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2013/2014 LOCAL BUSINESS TAX RECEIPT EXCELL REFRIGERATION INC B1 -150 LBTR Number: 199902712 EXCELL REFRIGERATION INC EXPIRES: SEPTEMBER 30, 2014 605 WHITNEY AVE LANTANA, FL 33462 -1641 This receipt grants the privilege of engaging in or managing any business profession or occupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. Of w Miami Shares Village Building Department 10WO N.B.2nd Averme, Miami Shares, Fonds 33138 Tel: (305) 795.2204 Faro (305) 756,8972 INSPECTIONI PHONE NUMBER; (30M 76U949 BUILDING PERMIT APPLICATION Permit Type: JOB ADDRESS: BUILDING is ®ty: Miami Shores county: Folio/Pe=Jt Is the Building Historiolly Designated: Yes NO Permit No. E, C IVED DEC 0 2 2013 0y: __0 J �-- FBC 20 l O Master Permit No. 12 —19 8 OWNER: Nance (Fee Simple Titleholder): F4614 A?4& -k r phone#; Address: & A>Y 0107F City: _LjAylaa state: Pl. Ziv. Temad i.,esree Name: pho ; Email: 33/m' CONTRACTOR: company Name- -ah 6 'W -rwe Phone#: Address: vopei 5W 'ago* A,.e City: i `Q&A(Ar /r state L Zip: 33312 Qualifier Name: State Certification or Reeshition #: .f' Certificate of Oompetancy #: Contact Phone#: Email Address: DESIGNER: ArchitecdEhghw: • ` pho; Value of Work for this Permit: $ siOC —'-' SguardUnw Footage of Work: Type of Work: DAddhion ®Alteration ONew l]Repait:IRepl a ODaRIDlltion Description or Work. __ln&W.Prs Wt Color 1kru We: .►asarsa�., aye. Emma.. aeeewROx��a :reabr,wa�+�,.�owe* SubmdtW Fee $ Permit Fee $ CCF $ CUJCC $ Sing Fee $ _ Radon Fee $ _.. DBPR $ $ Notary $. TrainingfEducaflon Fee $ Technology Fee $ Double Fee $ Structural Review $ 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 Zip State �p Application is hereby made to obtain a permit to do the work and install ations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work sill be performed to meet the standards of all laves 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 Com ENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500 the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged SignatureYU� e Oymer or Agent The foregoing instrument was acknowledged before me day of 20 LI, by -ReborA 3.00f r4 who is naIIy kno to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: a °`P�° p, °8�.� JODI L SLOAN MY COMMISSION # EE 056818 ��AwEXP IRES: February 5, 2015 0-01Oe Bonded Thor Budget ttotazy Services Prin )"L' LS I CYin My Commission Expir%?,,5 -15 ti APPROVED BY Signature Contractor The foregoing instrument was acknowledged before me i o�r'o day of Ve,- , 20 L3- by CL O who is personally known to me or who has produced as ident 6cation and who did take an oath. Plans Examiner NOTARY PUBLIC: Sign: _(' Print: P Stata of Florid My Commission Ex • My t0 8 298599 of * �e�* s* ee�aa arsMSSSV�eeeae�e� ►s�rea�v� *se�+�.eu Zoning Structural Review Clerk (Revised 3 /12I2012)(Rexised 97 1101WXRevised 06/IO/2 )(Revised 3/15109) 0210612014 1132 f'AX) P.0021002 OAKCO -2 OP ID; TM A�ORO° CERTIFICATE OF LIABILITY INSURANCE DAT 120/20/201 03/293 13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND'THE CERTIFICATE HOLDER. IMPORTANT: M the car0aate holder is an ADDITIONAL INSURED, the polley(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the teens and conditions of the policy, Certain Policies may require an endorsement. A statement on this eertltieate does not confer rights to the aerdficate holder in Ileu of such endorsemea e . PRODUCE Phone: 3016 -36A TI100 CONTACT KAMW 1 20000NNW8 BROWN 9 oUrtFSu 00 INC Fax. 305 71464401 PROM Miaml_Lakes, FL 33010-0809 L . INSURED Attn: Carlos Medrano 4000 $W 30th Avenue Fort Lauderdale, FL 33312 enVPDblr=e •" "' °a"• REVIBION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE US TED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINO 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 0 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS R 'IYMOFINSLEPANgU POLICYEPP PO BIIP umva oF.rnaRAL LU181LRY A X COMMERCIAL. OeNERAL UAMLW OLa9'Ei I04 04101120'13 04/01/2014 EACH OCCURRENCE s • 1,000,0 100,0 owme -MADE X OCCUR MID EXP WW one neon $ 6,00 PERSONAL&ADVINJURY $ 1,000,00 WITLAGGREOATEUMITAPPL190PER GENERALAGGREGATE 8 2,000,00 PoucY PRo- LOO PRDDUCTS.COAB+pDPAt�O S 2,000, AWiOMOD U LIAWUrV Frrl Ben. s 1 �0 ANYAUTO jh�CMWNID UI.BD aceJ eel BODILY INJURY (Perpmm) $ HIRED AUTOS NA�t� NED BODILY INJURY (Per aaddme S S LLA x OCCUR EXCES B °late�suAN OLNMSA=a 960828 04101/2095 04101/2014 BACH OCCURRENCE S Aa*RM-M S S,000,O 5,000,00 X 0 WORXERSCOMPENSATION Per AND MPLOYMW LUa1LIry A ANY PROPwEnoRrPARTNMw=umre Pi �� OFMIR 04(01!2093 049/214 X WO A ! Ll EWER M(CLUDED7 MIA EJL EACH ACCIDENT 500,80 in t" Mdeftry E.L 01$Z4W- PA C-b1i'1A t6 W0.00 E L DISEASE. POLICY LIAIIT IS 50,00 DUOrdPTION OP CPEMMONS I LOCATIONS I VEHICLES tAtt"kA00R010t. Addttlel>el Ram>drlm seivalue, Kmare apses to reslleuea) CER'T'IFICATE HOLDER _-- -__- - _ —_ -- Miami Shales Village Building Department 10080 N.E. 2nd Avenue Miami Shores, FL 33138 ACORD 23 (201010$) MIAMISH - - _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BORE THE 11IMMATION DAR' MUMCF, NOTICE WB.L B@ Dr=UVMW IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR!¢!! -D RSPRENTATM 019OB -2010 ACORD CORPORATION. All rights reverved. The ACORD name and logo are registered manta of ACORD J p ., Tax Tiafmbr Fee WFM wr Yew caved= Oom TOtal P'3 27.001 4.O�i 4.43 O.flb 4.Of 0.00 27.00 skis" . CHARLES J MEDRANO / QUAL 4000 SW 30 AVE HOLLYWOOD, FL 33318 Receipt tole -12- 00013818 Paid 09/23/201.3 27.00 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 RE- PERMIT #: %Z �� DATE: D. Owner o Architect Picked up 2 sets of plans and (other) Address: '9czs d From the building department on this date in order to have corrections done to plans And /or get County stamps. I understand that the plans need to be brought back to Miami Shores Village Building Department to continue permitting process. 7)__cknowledged by: PERMIT CLERK INITIAL: RESUBMITTED DATE: L PERMIT CLERK INITIAL: I ow mss. it l loll ��2- Lrt'ru�'I BUIELDING Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fag: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permi I,Rp P11 OCT 15 2012 1 tNo. 0 E" 1Q 0 PERMIT APPLICATION Master Permit No FBC 20 Permit Type: BUII.DING ROOFING OWNER: Name (Fee Simple Titleholder):_ %bisy SWr 0!'9arkd 17 Phone#: Address: '300_h4bio,4 rafkmax City: LakrlraaaPJ State: Zip: 33F11 Tenant/L.essee Name: -&Kl r Suer Agar)k1s Phone#: Email: JOB ADDRESS: gdSO 15444Ywe ON-/ City: Miami Shores County: Miami Dade Zip: 3313`d Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: HA; r-1- m ILc- ree- CONTRACTOR: Company Name: 02k tvNil rer-4,0" to Phone#: Address: 1041a> SW 30P Ave city: r4• P.gWdteAIt State: Fa.. Zip: 333)Z Qualifier Name: SAaol jr J'10d ra wa, Phone#: State Certification or Registration #: 2 G C 04'6V40 Certificate of Competency #: _ Contact Phone#: Email Address: DESIGNER: Architect/Engineer A 4 k o vs Phone#: 30.'l- 51'2- 72 X Value of Work for this Permit: $ /yet Square/Linear Footage of Work: 61/ SF Type of Work: OAddition RAllteration ONew ORepair/Replace ODemolition Description of Work: Tw ha ri ®r ( *,M A# Bra e 4 j Re -"®fr l Submittal Fee $ Permit Fee $ 4�m ©[1 CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ in on 41 f 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 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 not be approved and a reinspection fee will be charged (DA.,k Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me thi� day of 20 W;n 1�rj, who ' verso ly known me or who has produced "" As identification and who did take an oath. NOTARY PUBLIC: v vv— P a °'P M Y Commission Expires: x JODI L $LOAN * DIY COMMISSION # EE 056818 EXPIRES: February 5, 2015 Bath71n Bu* Nm"S.. The foregoing instrument was acknowl before me this I-+ day of 20 , by who is personally to me or who has produced as identification and who did take an oath. APPROVED BY /.AMI�P '/ S Plans Examiner (Revised 07 /10/07)(Revised 06 /10/2009)(Revised 3115109) NOTARY PUBLIC: Print: 0 JODIE FAYE &4y Comm. Expires May 28, 2013 :onvnisslon # DO 874022 onr, Through National Notary Assn. Zoning Structural Review Clerk A L1WrED POWER OF ATTORNEY KNOW ALL MIN BY THESE PRESENTS, that PUBLIX SUPER MARKETS, INC., a Florida corporation (" Publix" ), by and through it undersigned officer, having its mailing address at P. O. Box 407, Lakeland, Florida 33802 -0407, pursuant to a proper Corporate Resolution, does hereby appoint 44?P T_J. MCGARRITY7 P;E,, Dir"r of Construction for Publix Super Markets, Inc., to do and execute all or any acts with respect to the permitting, notice of commencement; construction and occupancy of Publix stores under construction or to be constructed, or in connection with the remodeling of Publix stores, as fully as said corporation might or could do through its officers. IN WITNESS WHEREOF, the undersigned has caused the within to be duly executed by its proper officer and the seal of the corporation hereto affixed by proper authority of its Board of Directors. Two Witnesses: STATE OF FLORIDA COUNTY OF POLK John At: "`Att9Wa3(5/-Tr ,k$enibr Vice President, General Counsel mitts— 27,1921 At • • - • fe �y'$a 4fv `• ;w.:•'.�!• • ' -rte The foregoing instrument was acknowledged before me this" day of - ^� 2012, by JOHN A. ATTAWAY, JR., Senior Vice President, General Counsel and Secretary o PUBLIX SUPER MARKETS, INC., a Florida corporation, on behalf of said corporation. He is personally known to me and did not take an oath. My Commission Expires: IMMMas j0ya K PARRISH tMY COIvALaSSION # DD996291 o E»RFS:1mm0S.2014 AMMMF t-0OF7�7fAttY FL NoMy MMM An= CM MNA'M J NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TW E OF FIRST INSPECTION PERMIT NO. TAX FOLIO NO. 11- 3206 - 010 -0010 OR 8k 28520 Ps s 1242 - 1243F (2p9s ) RECORDED 03/07/2013 11045 913 HARVEY RUVINP CLERK OF COURT MIAMI -DADE C.:OUNTYP FLORIDA STATE OF FLORIDA: C COUNTY OF MIAMI -DADE: ��1 CLEat THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information �J,� W GDO uu� nzusr is provided in this Notice of Commencement. 1. Legal description of property and street/address: 9050 Biscayne Blvd., Miami Shores, FL 33138 2. Description of improvement Interior Remodel at Publix #0794 Shores Center 3. Owner(s) name and address: Publix Super Markets, Inc. P.O. Box 407, Lakeland, FL 33802 -0407 (3300 Publix Corp. Parkway, Lakeland, FL 33811 -3311) Interest In property: Ground Lease Name and address of fee simple titleholder: Edward M Ellis & Susan 'M Wilder, as Trustees of The Willow Partners Trust, 711 Faulk , Ft 32±68 4. Contractor's name and address: Oak Construction Co., Inc, , 4000 SW 30th Ave, Ft Lauderdale, FE 33317- 5. Surety. (Payment bond required by owner from contractor, if any) Nameand address: N/A Amount of bond $ 6. Lender's name and address: N/A 7. Persons within the state of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7., Florida Statutes, Nameand address: Robert J. McGarrity, Director of Construction, See above - Owner 8. In addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes. Nameand address: N/A 9. Expiration date of this Notice of Commencement (the expiration date is 1 year from the date of recording unless a PrintOwner'sName Robert J. McGarrity, P. E. Sworn to and subscribed before me t ` • - I NotaryPublic_� PrintNotary's Ni Mycommission 20 a 123.01.52 PAGE 4 8102 W,OMY COMMISSIOWE 056818 * EXPIRES: February 5, 2015 t Thru Budget i y �rvt prepared by Paula Cameron tr a,', . •y, i 3A tH� aa, i I :s•,L pt .7 ��ir, �J. a h J]� �� , i i�r •r� • �1 1 t ss, dais �1• N,,j � � � i z t .•b...._ gib. r1f A. +J 4;l A'itiA • VA Al,��I,'yt�q�,`y + '��i•oT'�Lf1t111 ,� a a L •F � � 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301 -1895 — 954- 831 -4000 VALID OCTOBER 1, 2012 THROUGH SEPTEMBER 30,2013 DBA: OAK CONSTRUCTION CO INC Rerelpt #:G 8ffiJOl's AL7 CONT'RACT'OR Business Name: Business Type:CONTRACTOR) Owner Name: amRLSs i lmsDRANo / ouAL Business Opened:04 /25/2001 Business Lo"Wn- 4000 SW 30 AVE 8tate1C0UntWd0ft/RBg:CGC 056840 HOLLYWOOD Exemption Code: Business Phone: 954- 583 -9625 Rooms seats Employees Machines Professlonats 1'0 Far Yanding.BuslrtessOnty _- Number of Machines: Vandhia Tvoe: Tax Amount I Transfer Fes I NSF Fee _ I Penalty Prior Yeses I CoUecUon Cost I Total Paid 27.00 o.00 jr _0:00' 1 - 2.00 0.00 1 0.001 29.70, THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and Is non - regulatory In nature. You must most all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not Indicate that the business Is legal or that It is in compliance with State or local laws and regulations. Mailing Address: CHARLES J MEDRANO / QUAL 4000 SW 30 AVX HOLLYWOOD, FL 33312 2012 -2013 Receipt: #O1A -12- 00000285 Paid 10/03/2012 2'9.70 w f FEB 0g 2013 Q__tll MEMORANDUM Atkins North America, Inc. 2001 Northwest 107th Avenue Miami, Florida 33172 -2507 Telephone: +1.305.592.7275 www.atkinsglobal.com /northamerica To: City of Miami Shores, Florida -Plans Reviewer From: Elvys R. Diaz, R.A.- Project Manager - ATKINS Date: December 18th, 2012 Subject: Responses to Building Department Comments: Publix Store #0794 Permit: #12 -1928 Building Comment 1: Provide approval from Miami Dade County Fire Department. Response: General Contractor will comply. Comment 2: Approval from Miami Dade County DERM /PERA. Response: General Contractor will comply. Comment 3: This Structure is located in a high hazard flood zone. Provide all criteria. Response: This is a remodel "Alteration Level 2 ". There is no floor area increase. The scope of the work is basically interior d6cor, replacement and or relocation of equipment and expansion, within the building, of the exit pharmacy. Comment 4: Provide all permit applications prior to any further review. Response: General Contractor will comply. Comment 5: Remove all specifications that are not for this job. Correct the Summary of work. Response: Spec sections that are not for this job have been crossed out and Initialed. Comment 6: Details D -21A9 and D -1 /A9 are incorrect. Response: Detail D1 /A -9 is called out on A -1for New hand sink Chase in the Deli Department (Exterior wall). D -21A -9 is typical wall section Detail for new wall partition at "Deli Seating Area" and new wall partitions in "Deli Department" (similar). Vb Op Comment 7: Provide design wind loads for the new exterior doors. Response: Complied. See revised Sheet A -1. Comment 8: Provide product approvals that have been reviewed and signed approved by the designer of record for all new /altered exterior doors. Response: General Contractor will comply. Comment 9: The wrong code is identified in several areas. The correct code is the 2010 FBC. Correct all notes and details. Response: Complied. See revised sheets LS -1 and A-4. Comment 10: Provide separate permits per LS -1 for Fire Alarm, Fire Sprinklers and Fire Suppression systems. Response: General Contractor will comply. Comment 11: Provide manufacturers specification for walk in coolers. Response: See Specs note on Sheet EQ -1. Comment 12: Sheet S -1 references a special inspector for inspections where a special inspector is not required. The scope of work appears to require all inspections Response: The note for the special Inspections has been modified, as requested. See revised sheet S -1. Comment 13: The Accessible toilet stalls show the turning radius overlapping the water closet. The turning radius must not overlap fixtures without proper knee and toes clearance. FBC Acc. 304 Response: Complied. See Revised Sheet A -8. Comment 14: Provide dimensions for the bathroom vestibules. 48" clear between walls is required FBC Acc 404.2.6. Response: Complied. Dimensions Added to Sheet A -8. Comment 15: The detail for the water fountain must show a fountain for standing persons. FBC Acc 602. Response: No new water fountain is being installed under this Project. Detail has been removed. Comment 16: Provide details of the checkout isles showing compliance with the FBC Acc 904. Response: Checkouts are existing to remain. 'dimensions between them have been added to the drawings to show compliance. See Sheet EQ -1. Comment 17: Provide elevations of all interior service counters. Response: All interior Service Counters are existing to remain. Pharmacy which are shown in detail in Sheet A -11 Mechanical Comment 1: Need Shop Drawing for Hood Installation. Response: Sincerely, Elvys R. Va , R.A.- Project Manager ATKINS FBC Acc 904. kept new service counters at R Permit No: 12 -1928 Job Name: Publix Interior Alt October 26, 2012 Miami shores Village Building Department Building Critique Sheet 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Page 1 of 1 1) Provide approval from Miami Dade County Fire Dept. 2) Provide approval from Miami Dade County DERM /PERA. 3) This structure is located in a high hazard flood zone. Provide all Flood criteria. 4) Provide all permit applications prior to any further review. 5) Remove all specifications that are not for this job. Correct the summary of work. 6) Details D -2/A9 and D-1 /A9 are incorrect. 7) Provide design wind loads for the new exterior doors. 8) Provide product approvals that have been reviewed and signed approved by the designer of record for all new /altered exterior doors. 9) The wrong code is identified in several areas. The correct code is the 2010 FBC. Correct all notes and details. 10) Provide separate permits per LS-1 for fire alarm, fire sprinklers, and fire suppression systems. 11) Provide manufacturers specifications for walk in coolers. 12) Sheet S -1 references a special inspector for inspections where a special inspector is not required. The scope of work appears to require all inspection by the authority having jurisdiction. If a special inspector is to be utilized per the FBC provide a completed special inspector form to be reviewed and approved by this department. 13) The accessible toilet stalls show the turning radius (Nerlapping the water closet. The turning radius must not overlap fixtures without proper knee and toe clearance. FBC Acc. 304 14) Provide dimensions for the bathroom vestibules. 48° clear between walls is required. FBC Acc404.2.6 15) The detail for the water fountain must show a fountain for standing persons. FBC Acc 602 16) Provide details of the checkout isles showing compliance with the FBC Acc. 904 17) Provide elevations of all interior service counters.. FBC Acc 904 Plan review is not complete, when all items above are corrected, we will do acomplete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. Norman Bruhn CBO 305 - 762 -4859 Miami Shores Village Building Department 10050 N.E 2nd Avenu Miami Shores, Florida 3313 ' Tel: (305) 795 220 Fax: (305) 756897 Permit No. 0� I Job Name 9 ti. PLUMBING CRITIQUE SHE Permit No: 12 -1928 Job Name: October 15, 2012 Mechanical Critique - need shop drawing for hood installation. Page 1 of 1 Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. Jan Pierre Perez 305- 795 -2204 FES I : 1 Miami shores Building Department MIAMI SHORES VILLAGE 10050 N.E.2nd Avenue Miami Shares, Florida 331.38 Tel: (305) 795.2204 Fax: (395) 756.8972 OF EMPLOYMENT AS SPECIAL INSPECM11 111 HE FLORIDA BUILDING CODE I (We) have been retained by PUBUX fuP ro JAL", to perform special lnspoctor services under the Florida Building Code at the &AUX i 41,el project on the below Its ted structures as of (date). I am a registered architect or professional engineer licensed In the State of Florida. PROCESS NUMBERS: 1-1-1929 ❑ SPECIAL INSPECTOR FOR PILING FBC 1822.1.20 (114904.6,1.20) ❑ SPECIAL INSPECTOR FOR TRUSSES ?35' LONG OR e HIGH 2319.1724.2 (R44b9.e.1 ?24.2) tae SPECIAi INSPECTOR FOR REINFORCED AAASONRY, FBC 2122.4 (R4407.5.4) Q/ SPECIAL INSPECTOR FOR STEEL CONNECTIONS, FBC 221112 (R4406.5.4 0', SPECIAL INSPECTOR FOR SOIL COMPACTION, F8C 1820.3.1(R4404,4.9.1) ❑ SPECIAL INSPECTOR FOR PRECAST UNITS S ATTACHMENTS, FBC 1927.12 (84405.9.12) ffJ/ SPECIAL INSPECTOR FOR eo tj etzere 7Sri^./49 Mote. Only the marked boxes apply. The following lindividua l(s) employed by this firm or me are authorized representatives to perform inspection 1 R&IC 1e1 4. i ®Z�lsBi N 'Special Inspectors utilizing authorized representatives shall insure the authorized representative Is qualified by education or licensure to perform the duties assigned by the Special Inspector. The qualifications shall Include licensure as a professional engineer or architect; graduation from an engineering education program in civil or structural engineering; graduation from an architectural education progranr; successful completion of the NCEES Fundamental Exemination or registration as building inspector or general contractor. I, (we) will notify Miami Shores Village Balding Department of any changes regarding authorized personnel perforating Inspection services. I, (we) understand that a Special Inspector inspection log for each building must be displayed In a convenient location on the site for reference by the Miami Shores Vipage. Building Department Inspector. Ali mandatory Inspections, as required by the Florida Building Code, must be performed by rho County. The Wage building inspections must bra called for an 4 Mandato. "ry in;tmections: hired by the Owner are In addition to the mandatory inspbaIons perfumed by the irk under each Building Permit I will submit to the Building Inspector at the time of m end a seated statement indicating that, to the. best of my knowledge, belief and mlect outlined above meet the infant of the Florida Building Code and are in Created on 6/1012009 rigineerlArc�iitect Name , A 2ce"epe e: P6. MR Address /,f Z® AJU 11<5e Phone No. 30S' fyY 3 CK®1 440o s3i, ff/ i , FED 0 § 2013 Miarni Building Depart Ment 10050 N.E.2nd Avenue Miami Shores, Florida 331.38 Tel.: (305) 795.2204 Fax: (305) 756.8972 OF EMPLOYMENT AS SPECIAL INSPECTOR UNDER HE FLORIDA BUILDING CODE I (Vtte) have bean retained by kutxfu -efrl S ,TAG , to perform special inspector.services under the Florida Building Code at the e.ox q project on the below listed structures as of /-2 ° 19 - i-A (date). I am a registered architect or professional engineer licensed in the State of Florida. PROCESS NUMBERS: _ _ 12 - t rr 2 9 • SPECIAL INSPECTOR FOR PILING, PC 1822120 (114404.6.120) • SPEC I1AAL�. INSPECTOR FOR TRUSSES 4W LONG OR 0' HIGH 2319.1724.2. (84409.6.17.2.4.2) d SPEC:INSPECTOR FOR REINFORCED WONKY, FBC 21224 (84407.5.4) GK SPEC IAL INSPECTOR FOR STEEL. CONNECTIONS, FBC 2218.2 {R4408.5.2) SPECIAL INSPECTOR FOR SOIL COMPACTION, FBC 1820.3.1.(114404,4,3.1) 0 SPECIAL INSPECTOR MR PRECAST UNITS 9 ATiA CIHMENTS, FBC 1927.12 (84405.9.12) EK SPECIAL INSPECTOR FOR _ e-o N e2eTe 7FSTiNP7 Mote: Only the marked boxes apply. The follow)ng individu temployed by this firm or me are authorized representatives to perform inspection 2. 3, ._ ®i4 R ,Ica® 4• erz ®rd;��l 'Special Inspectors utilbing authorized representatives shall insure the authorized representative Is qualified by education or iicensure to perform the duties assigned by the Special Inspector. The qualifications shall include ficensure as a professional engineer or architect graduation from an engineering education program in civil or structural engineering; graduation from an architectural education pmpranm successful completion of the NCEES Fundamental Examinafion or registration As building inspector or general contractor. 1, (we) will notify Miami Shores Village Building Department of any changes regarding authorized personnel performing inspection services. I, (we) understand that a Special Inspector inspection log for each building must be displayed in a convenient location on the site for reference by the Miami Shores Village. Building Department Inspector. All mandatory inspections, as required by the Florida Building Code, must be performed by the County. The Village building Inspections mutt be called for on all mandatory inspections. Inspections performed by the Special Inspector hired by the Owner are In addition to the mandatory Inspections perfored by the Department Further, upon completion of the work Larder each Building Permit t will submit to the Building Inspector at the time of final inspection the t�mpleted inspection log form and a sealed statement indicating that, . to the best of my knowledge, belief and professional judgment those portions of the project outitned above reef the intent of the Florida Building Code and are in s�stantial accordance with the approved piano. Sigtt ®d Se d, .Eng ne.... ..... Nam /� e /�! �']' • S� 4(79 V ° � A Address 4? ?0 eJE rfc� Jz /� •�� /, v 3/�� o� Sao .• Phone No. 'err � ®Create��Q9 s s• � ®RID � ,. ��C�,, °� ®. F'. �� ®SAL ENG� NOTICE OF COMMENCEMENT A RECORDED COPY NNST BE POSTED ON THE JOB SITE AT TUNE OF FIRST INSPECTION PERMIT NO. STATE OF FLORIDA: COUNTY OF MIAMI -DADE: TAX,FOLIO NO. 11 -3206- 010 -0010 THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following Information is provided in this Notice of Commencement. OR pk 28520 Pgs 1242 - 12438 (2p9s ) RECORDED 03/0712013 11:45:13 HARVEY RUVINP CLERK OF COURT MIAMI -DADE COUNTYP FLORIDA glass` 1. Legal description of property and street/address: 9050 Biscayne Blvd., Miami Shores, FL 33138 2. Description of improvement: Interior Remodel at Publix #0794 Shores Center 3.Owner(s) name and address: Publix Super Markets, Inc. P.O. Box 407, Lakeland, FL 33802 -0407 (3300 Publix Corp. Parkway, Lakeland, FL 33811 -3311) Interest in property. Ground Lease Name and address of fee simple holder Edward M Ellis & Susan M Wilder, as Trustees of The Willow Partners Trust, 71 Faulk , New Smyrila Beach, Ft 32tf58 4. Contractor's name and address: Oak Construction Co., Inc, , 4000 SW 30th Ave, Ft Lauderdale, EE 33.512 5. Surety: (Payment bond required by owner from contractor, if any) Nameand address: N/A Amount of bond $ 6. Lender's name and address: N/A 7. Persons within the state of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7., Florida Statutes, Nameand address: Robert J. McGarrity, Director of Construction, See above - Owner 8. In addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida Statutes. Nameand address: N/A 9. Expiration date of this Notice of Commencement: (the expiration date is 1 year from the date of recording unless a PdntOwner's Name Robert J. McGarrity, P.E. Swom to and subscribed before me this a '§day of 20 NotaryPublic_� PrintNotary's N; Mycommission 123.01 -82 PAGE 4 8102 JODI L $LOAN W COMMMION # EE 056818 * EXPIRES: Februarys 5, 2015 {1dWIla Nod NotsffiySWAM Prepared by Paula Cameron Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 193507 Permit Number: CC -10 -12 -1928 Scheduled Inspection Date: June 14, 2013 Permit Type: Commercial Construction Inspector: Rodriguez, Jorge Inspection Type: Slab Owner: INC, PUBLIX SUPERMARKETS, Work Classification: Alteration Job Address: 9050 BISCAYNE Boulevard Miami Shores, FL 33138- Phone Number (863)688 -747_ Parcel Number 1132060100010 Project: <NONE> Contractor: OAK CONSTRUCTION CO Phone: (954)583 -9625 Building Department Comments INTERIOR COMMERCIAL REMODEL Infractlo Passed Comments INSPECTOR COMMENTS False Z` Inspector Comments Passed CREATED AS REINSPECTION FOR INSP- 179992. PRODUCE AND SEAFOOD. Failed Correction Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. June 13, 2013 For Inspections please call: (305)762 -4949 Page 19 of 25 Notice of Inspection end /or Treatment Data of Inspection /2- /3 Data of -11reatmerg p 12 cid — 1;2 Az:' Wood- Destroying Organism Treatment Pursuant to Chapter 482; Florida Statutes, 482.226 (8 ), this notice is required to be posted. Any licensee who performs control of any wood - destroying organism shall post notice of said treatment Immediately adjacent to the access to the attic or crawl area of other readily accessible area of the property treated. 3810 N.W. 5th Court • FT Lauderdale, FL 33311 Ph: 754 -235 -7126 Fax: 954- 306 -3710 N® 8140 3810 NW 5th Court - Ft Lauderdale, FL 33311 - Phone (754) 235 -7126 - Fax (954) 306 -3710 NOTICE OF TERMITE PROTECTION TREATMENT As Required By Florida Building Code (FBC) 104.2.6 Pro erty Information B er /Contractor Treatment Date 3 Name of Builder AJAX S. Treatment Time 9 Lot Shell Contractor Block // Subdivision Name L� Ll 5'M CONSTRUCTION TYPE: Street AddressTo tFj) / S%`� �W Monolithic �2 S/F L/F Stemwall Patio S/F l /F S/F OF City / State / Zip (A" l Additions S/F OF CHEMICALTYPE: per To Cypermethrin • Termidor Fipronil ❑ Dragnet Permethrin ray Only • Pro Build TC Cypermethrin ❑ Permise Pre - Construction ❑ Spray and Tamp ❑ Other Imidacloprid ❑ Residential ommercial TR ENTTYPE: ?' Chemical nderslab Date of Co pletion ❑ Footers Gallons �'i` ❑ Wood Treatment Applicator GUARANTEE RENEWAL ❑ None ❑ Yes ❑ 1 Year ❑ No ❑ 5 Years NO LIMIT TERMITE & PEST SERVICES, LLC. hereby confirms that this building has received a complete treatment for the prevention of subterranean termites. Treatment is in accordance with the rules and laws as established by Florida Depart- ment of Agriculture and Consumer Services. Exterior perimeter treatment was completed upon final grade. C OP ID: GBG CERTIFICATE OF LIABILITY INSURANCE °ATE(M""D'� 03/06/2013 THIS CERTIFICATE IS ISSUED AS A. MATTER OF INFORMATION ONLY AND CONFERS NO R�HT8 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 INSURERp3), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: U the cerelinl a holder Is an ADDITIONAL INSURED, the policyp") must be endorsed. B SUBROGATION IS WANED, aldh)eh:t to the temm and condillons of the 12080, certain Policies may require an endo» remelt A slatement on this certlftcate does not confer rights to the awki$eate holder In lieu of arch endnmomanNal YN & BROWN OF FLORIDA INC i NW 79th Cant Su1tdm0o FL 330164M E Lam ndlum Oak Construadon Co., Inc. Aft: Carlos Madmno 4000 SW 30th Avenue Fort Lauderdale, FL 33312 rrvurmAmr-im %- Phone: 306484.7800 Fax: 306- 714-4401 _ mavlolum rlur=rx: THIS IS TO CERTIFY INDICATED. NOTWITHSTANDING ANY REQU1 a ENt TERM OR DCONDITION OF ANY CONTRACT RE INSURED OTHER DOCUMENT' WITH FOR RESPECTT 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. NMI AWL SUM UR TYPEOFINSIRAL g SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village g GL20282B4090012 MGM 04MUM2 Awn Umm A GENERAL 1.11011MUTY X COMMERCIAL GENERAL UABRITY CLAIMS -MADE XI OCCUR 04M/2013 EACH oOCwRRENCE s 1.000, PREIaIRi ru o $ 300,0 MED EXP ate $ 10 PERSONAL & ADV INJURY $ 1,000.0 GENERAL At iEOATH $ 2,000. GENLAeGREGATE LIMIT APPLES PER: POLICY Ex-1 M M Loo PRODUCTS•COMPIOPAGO h: 2,000 a AUTOMOBILE LIABILITY ANYAUTO ALL OWNEDAUTOS SCIED UTOS TOS hIIR ®AUT08 NON4NVNEDAUTOS COMENEDSINGLELIMB Mae -mom $ BODILY INJURY (0er person) E BODILY NARY (Par sadden) S PROPERTY OAIMGB � 8 4 B X UMBRB LA LIAR MWESSLIAB X OCCUR CLAIMSMADE 30880828 0410IM2 04101=3 EACH OCCURRENCE S 641010 AGGREGATE ; 101000 4 'DEDLICTIBLE REneam s 0 X s A 1111OW03tBCOI TION AND EMPLOYEW LIABILITY ANY PROPRaTOWARTN CUMM Yr 1�-t (OFF7C L7(CLUDE04 L.J NNI (f desa,be w1dw N/A -IT 0202828808 04f011Z012 04�11PA13 X IT L ACCIDENT �, EL DISEASE- EAEMPLO $ �. E.L. DISEASE- m= L@AR I S . DEBCRWMN OF OPEBATIONB / LOCA=M i V[BpCLES (AKaeh ACORD 101, Addftlonal Re BalrodtAe Ifnma®spaa to rtquiraQ) MIAMISH SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village g THE �'A'� DA's THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS, 10060 N.E. 2nd Avenue AUTHORIZEDREPRESEKIATIVE Miami Shores, FL 38138 GB 788i -Y000 AGORD CORPORATION. All r19r18 r89011VOIL ACORD 26 (2009109) The ACORD name and logo are registered marks of ACORD LOO /LOO'd 908# L0:90 ELOZf90 /90 BbeSeegt96 ouI `Auudwo0 uoypnilsuo0 )IigO ;wo.a_A OP ID: GBG '4114. ® CERTIFICATE OF LIABILITY INSURANCE D0310 2013 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(les) 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 endomeme s . PRODUCER Phone: 305-364-7800 BROWN & BROWN OF FLORIDA INC Fax: 305 - 714 -4401 14900 NW 78th Court Suite0200 Miami Lakes, FL 33016 -5869 Colin E Lowe �MEACT PHONE FAX No: - AM 9 � PRODUCER CLwOmEgIp1kOAKCO,2 INSUREM AFFORDING COVERAGE. NAIC @ INSURED Oak Construction Co., Inc. Attn: Carlos Medrano 4000 SW 30th Avenue Fort Lauderdale, FL 33312 INSURERA :Amerlsure Insurance Company 18488 INSURERS :The North River Ins. Company 21105 INSURERC. $ 1,000,0 INSURER D: $ 388,00 INSURER E: $ 10,0 1 $ 110001 COVERAGES CERTIFICATE Nt1MRFR- RFVLSInN NLIMBFR- 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. ILA TYPEOFINSURANCE ADDL Miami Shores Village 9 POLICYNUMBER POLICYEFF LICYEXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR GL2028284090012 04/01/2012 0410112013 EACH OCCURRENCE $ 1,000,0 PREMISES Ea axiarerns $ 388,00 MED EXP (Any one person) $ 10,0 PERSONAL& ADV INJURY $ 110001 GENERAL AGGREGATE $ 2,000, GEWL AGGREGATE LIMIT APPLIES PER: POLICY Fx PRO- LOC PRODUCTS - COMP/OPAGO $ 2,000, $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ee accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Peracddem) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA A LWB EXCESSLLAB X OCCUR CLAIMS-MADE 5530850828 04/01/2012 04101/2013 EACH OCCURRENCE $ 6100010 AGGREGATE $ 10,000,0 DEDUCTIBLE RETENTION 0 $ X $ A wORIMRSCOMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/P,� YIN OFFICER/MEMBER EXCLUDED? El (Mandatory In NH) If yyee describe under DER RIPTION OF OPERATIONS below NIA 0202828506 04/01/2012 04/01/2013 X I WC STATU ER I t E.L EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 588000 E.L. DISEASE - POLICY LIMIT $, 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more "ace Is regWred) CERTIFICATE HOLDER CANCELLATION MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village 9 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 10050 N.E. 2nd Avenue Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 RECEIPT PERMIT #: 69 )qVi DATE: I J'� Contractor • Owner • Architect Pickup 2 sets of plans and (o er) Address: -- �)'K' b j., �ec-41M From the building department on this date in order to have corrections done to plans And /or get County stamps. I understand that the plans need to be brought back to Miami Shores Village Building Department to continue permitting process. Acknowledged by: PERMIT CLERK INITIAL: RESUBMITTED DATE: PERMIT CLERK INITIAL: Miami Shores Village Building Department RECEIPT 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 PERMIT #: �� ®1 '� DATE: l 2> Contractor • Owner • Architect Picked up 2 sets of plans and (other) r (Z.& Address: From the building department on this date in order to have corrections done to plans And /or get County stamps. I understand that the plans need to be brought back to Miami Shores Village Building Department to continue permitting process. Acknowledged by: PERMIT CLERK INITIAL: RESUBMITTED DATE: � 3 PERMIT CLERK INITIAL: 'e� Permit No: 12 -1928 Job Name: Publix Interior Alt October 26, 2012 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Page 1 of 1 Building Critique Sheet Provide approval from Miami Dade County Fire Dept. Provide approval from Miami Dade County DERM /PERA. This structure is located in a high hazard flood zone. Provide all Flood criteria. Provide all permit applications prior to any further review. emove all specifications that are not for this job. Correct the summary of work. Details D -2/A9 and D-1 /A9 are incorrect. Provide design wind loads for the new exterior doors. /000) Provide product approvals that have been reviewed and signed approved by the designer of record for all new /altered exterior doors. The wrong code is identified in several areas. The correct code is the 2010 FBC. Correct all notes and details. �0) Provide separate permits per LS-1 for fire alarm, fire sprinklers, and fire suppression systems. �- 1)?rovide manufacturers specifications for walk in coolers. Sheet S -1 references a special inspector for inspections where a special inspector is not required. The scope of work appears to require all inspection by the authority having jurisdiction. If a special inspector is to be utilized per the FBC provide a completed special inspector form to be reviewed and approved by this department. 3) The accessible toilet stalls show the turning radius overlapping the water closet. The turning radius must not overlap fixtures without proper knee and toe clearance. FBC Acc. 304 Provide dimensions for the bathroom vestibules. 48" clear between walls is required. t/BC Acc404.2.6 ) The detail for the water fountain must show a fountain for standing persons. FBC Acc 602 71provide rovide details of the checkout isles showing compliance with the FBC Acc. 904 elevations of all interior service counters.. FBC Acc 904 Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. Norman Bruhn CBO 305 - 762 -4859