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PLC-13-0261s �• Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ` L INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Tye: PLUMBING JOB ADDRESS: 9050 Ai S FBC 2PLC,! ) Permit No. 1 Master Permit No. r ° I City. Miami Shores County. Miami Dade Zip: Folio/Pa=W. Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Robil it 5*g02fr marks* +17,e• Phone#-. QW • 18f -Il91f Address: l,® QdX *407 City: Ifr ke /asbd State: r L Zip: 3 3 2 Tenanul essee Name: Phone# Email: slue of Work for this Permit: v 1 Type of Work: OAddress t on X tion of Work: Square/Linear Footage of Work: ONew l7Repair/Replace ODemolition Submittal Fee $ Permit Fee $ G CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ Technology Fee $ TOTAL FEE NOW DUE gm •ceyy) .r . ` ` 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 zip Application is hereby matte 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 CONUNAENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITII 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 rebispection fee will be charged Signature Owner or Agent The foregoing instrument was acknowledged before me this day o by R06i5cj who *;y known me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Si � Print: My Commission Expires a % 'P alv JODI L SLOM MY COMMISSION # EE 056818 EXPIRES: February 5, 2015 - l9j"F��w BmWThruBudgd"Services APPROVED BY SignaUue Contractor The fore oing instrument was acknowledged, �beffo�re me this day o 20 `3 by �,�l�l— +sJ!/°ii . who is Aerc2211v Imo wn to me or who has produced as identification and who did take an oath. —1 — t--, Plans Examiner * NIYCOMM1SS #EE 0121 EXPIRES: Nmmba 15, 2016 g�edilguBN�1"Sedras zoning Structural Review Clerk Revised 3/12/2012XRevised 07 110107)(Revised 06/10/2009XRevised 3/15/09) Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ,�, n COMPLETE CONTRACT R'S INFORMATION BUSINESS NAME: S' d �' (� r �XA-' P�ju' ° BUSINESS ADDRESS: 5qg Sa)xarosS , Pkwq,c v S"rjk- V STATE ZIP CODE 3yJ� BUSINESS PHONE: 96'e- ) WO FAX NUMBER 11 Mr-09rlll CELL PHONE (9 , qy-q01a14 QUALIFIER'S NAME: I 1)ic7 r J -Ohk)suy) QUALIFIER'S LIC NUMBER: E -MAIL ADDRESS (IF APPLI, Created on 3119109 BY MLDV 1 RV 3126109 MLDV Jeff Atwater Casia Sinco CHIEF FINANCIAL OFFICER BUREAU CHIEF Julius Halas DIVISION DIRECTOR . Keith McCarthy •� SAFETY PROGRAM MANAGER FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF STATE FIRE MARSHAL 200 East Gaines Street - Tallahassee, Florida 32399 -0342 TeL 850-413-3644 Fax. 850 -410 -2467 CERTIFICATE OF COMPETENCY OFFICIAL COPY THIS CERTFIES THAT: Victor H Johnson 599 Sawgrass Corporate Parkway Sunrise FL 33325 BUSINESS ORGANIZATION: Southern FIRE Control Inc. Contractor II is limited to the execution of contracts requiring the ability to layout, fabricate, install, inspect, alter, repair, and service water sprinkler systems, water spray systems, foam -water sprinkler systems, foam, -water spray systems, standpipes, combination standpipes and sprinkler risers, all piping that is an integral part of the-syst= beginning at the point of service, sprinkler tank heaters, air lines, thermal systems used in connection with sprinklas, and tanks and pumps connected thereto, excluding pre - engineered systems. Issue Date: 07/01/2012 Type: 07 Class: 12 County: License/Permit #: 997517- 0001 -1997 Expiration Date: 06/30/2014 Chief Financial Officer 0 1-42 r 51 FQWS CLASS U.S. PlQ6TAGE ' PA19 1470 M1, FL. PEAMIT NO.. W -THIS IS NOT A BILL ¢O NOT FAy Rr�EWAI 255.3 .• 267932'3 B 571TH � ttN` ROL .INCO CC D 'JI'?004 DOING DC�S %i DADE oWSO THERN'FIRE:CONTROL INC WORKER'' /.S CONTRACTOR 10 DO NOT FORWARD SOUTHERN FIRE CONTROL INC VICTOR JOHNSON PRES 599 SAWGRASS CORP PKWY SUNRISE FL 33325 I PA OW co 09/20/201.2 00007 0001 , tii�ttiit��Iltttlt ! =itittllt� ;iltlttti t,ttlttltitt,11146 DO NOT FORWARD SOUTHERN FIRE CONTROL INC VICTOR . JOHNSON PRES 599 SAWGRASS CORP PKWY SUNRISE FL 33325 .11#nt,.»llJh$111111111 11181sihils,lrit,1111 1111111 t��3,� AC40 o® CERTIFICATE OF LIABILITY INSURANCE ;/2/` oD 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 B_ ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ( :RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLIER. RTANT- 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 endorsemeft A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCERS Deborah Dingle Frank R. Furmaa, Inc. PHONE (954) 943 -5050 (FA Ax (954)942 -6310 C. 1314 East Atlantic Blvd. E4WL .deborahefurmaninsurance.com ADDRESS P. 0. Box 1927 INSURER(S) AFFORDING COVERAGE NAIC # Pompano Beach FL 33061 INSURER AAdmiral Insurance Co rl 4856 INSURED Southern Fire Control Inc 599 Sawgrass Corporate Pky Sunrise FL 33325 I INSURER F: WS OMWIM oc%naletu I II IM91L12 11 t;UVCKAWr -* %IGRIIFIVf,rG nv■ ■.r.■....-- - -• - - -- - - 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. ILTR TYPE OF INSURANCE UL BURK POLICY NUMBER POLICY EFF D POLICY EXP D LIMITS GENERAL LIABILITY x x Frank Furman, Jr/DEB EACH OCCURRENCE $ 11000.000 $ 100,000 B COMMERCIAL GENERAL LIABILITY MED EXP one $ EXCLUDED F0 CAODOO1673501 /30/2012 /30/2013 A CLAIMS-MADE OCCUR PERSONAL & ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: E SI UM $ POLICY x PRO 7 LOC UTOMOBILE LIABILITY 11000,000 BODILY INJURY (Per persm) S ANY AUTO B ALL OWNED SCHEDULED 2G97646 /3/2012 /3/2013 BODILY INJURY(Peracdderd) $ AUTOS AUTOS NON PER DAMAGE Per arrt $ X HIRED AUTOS x TOSWN� 'NEED $ X UMBRELLALUAB X OCCUR EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 C EXCESS LUAB CLAIMS -MADE I g I 0 $ 821006977 /30/2012 /30/2013 DED RETENTION$ x g WC STATUS OTH- D WORKERS COMPENSATION E L EACH ACCIDENT $ 11000,000 AND EMPLOYERS' LIABILITY ANY PROPRIETOR/P� ® E.L. DISEASE- EAEMPLO $ 1,000,000 OFMCERIMEMBEREXCLUDED? (Mandatory atory In NH) NIA C3319276 /3/2012 /3/2013 E.L. DISEASE - POLICY LIMB $ 1.000.000 DESCRIPTION OAF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Mach ACORD 101, Additional Remarks SchedWe, N mere space is required) CERTIFICATE HOLDER IS AN ADDITIONAL INSUREDS FOR GENERAL LIABILITY WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH THE NAMED INSURED. vc9a■■r1v4%1 r =rWI- -- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLE4 BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES VILLAGE LICENSING DEPARTMENT AUTHORIZED REPRESENTATIVE 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 Frank Furman, Jr/DEB ACORD 25 (2010105) Uv Te88 LU-1 U AVIJRY %Oumrur%^ 1 Ivn. rul rig"= reserveu. INS025 po1oos).o1 The ACORD name and logo are registered marks of ACORD BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954831 -4000 VALID OCTOBER 1, 2012 THROUGH SEPTEMBER 30, 2013 DBA: Receipt 'p1,LL OZ�R TYPES CON'? Business Name: SOUTHERN FIRE CONTROL INC Business T Type: y (FIRE sPRIIJKLER CON'?: Owner Name: VICTOR H JOHNSON Business Opened:12 /30/1991 Business Location: 599 SAWGRASS CORP PKWY State /County /CertfReg:99751700011997 SUNRISE Exemption Code: Business Phone: 305 st t,'A n S¢o� s aj CI � . k . Rooms yea, In Professionals Tax Amount Transfer Fed rE ' `' ' „( Fr , ' s �� "pia `. f. `a tyK�S " Collection Cost Total Pai9 135.00 0.6 a s .,,c ; ;@ 01�, we . m �p w _�± '' 1hY 0.00 135 -00 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 meet all County and/or Municipal ty planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred v tvn the business is sold, business name has changed or you here moved Ine business location. This receipt does not Indicate that the businessils NagaI ort:hat It is in compliance with State or local laws and regulations. Mailing Address: VICTOR H JOHNSON 599 SAWGRASS CORP PKWY SUNRISE, FL 33325 2012 -2013 Receipt #038 -11- 00010333 Paid 09/26/2012 135.00 y h