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DS-14-869Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 211578 Permit Number: DS -4 -14 -869 Scheduled Inspection Date: May 12, 2014 Inspector: Rodriguez, Jorge Owner: , JIFFY LUBE Job Address: 8787 BISCAYNE Boulevard Miami Shores, FL 33150- Project: JIFFY LUBE Permit Type: Driveways /Sidewalks(Slabs Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1132060280450 Contractor: FELIX FERA PLUMBING Phone: 954 - 981 -3016 Isu comments REQUIRED CONCRETE ASPHALT WORK FOR SEWER CONNECTION. REOPEN PERMIT SO THAT A FINAL INSPECTION CAN BE MADE ON CONCRETE POUR BACK. FINAL CONCRETE POUR BACK WAS NEVER CALLED IN AND PERMIT EXPIRED #DS07 -406 INSPECTOR COMMENTS False May 09, 2014 For Inspections please call: (305)762 -4949 Page 12 of 22 Inspector Comments Passed. J v�/ Failed Correction Needed ❑ Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. May 09, 2014 For Inspections please call: (305)762 -4949 Page 12 of 22 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 APR 8 p 1014 FBC 20 t� BUILDING Permit No. q PERMIT APPLICATION Master Permit No. 1 H ® l Permit Type: BUILDING ROOFING JOB ADDRESS: __� 1 PE,4 L'O6V 5 U) b City: Miami Shores County: Miami Dade Zip: �a l Folio/Parcel #: it 320le 67--6 0 45 0 Is the Building Historically Designated: Yes NO "�A' Flood Zone: OWNER: Name (Fee Simple Titleholder): Phone#: Address: PC> 27, E Lo City: 005TZx'j State: Tenant/Lessee Name: Email: CONTRACTOR: Company Name: �l to m PrR-A SC-"i CE Phone#: q5_4-97151-727 Address: PAxAEoDA 801>, sot rc- E City: -,Do'J►e State: F�09_ 4 0 Pr Zip: 1�4 Qualifier Name: 64( L- FA 624 ni-s Phone#: State Certification or Registration #: (_ 6re.1'5 019 0 / !` Certificate of Competency #: Contact Phone#: q 51j - q 3 d - ® (Arj 'R Email Address: A 0 jrRot-I'l el & I G45 d MC . C-0 t=1 DESIGNER: ArchitectfEngineer: Value of Work for this Permit: $ SquareAAnear Footage of Work: -0 Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: SU 099 V0 PC-a+=1%-f- -c) 711A41- .A Ft_hAt- It.�SpE �°��N CAQ MOWe ®tom C01tAt44_-% 9,�, ,)e_ 6RrG,e-. SOL- r_QW _%C- - PW2-fl -CK- %)4c, NC-015e_ ® w Nwo Team t a is pa ajo 'q- DS 0.1- i 40 LO Color thru tile: Submittal Fee $ - Permit Fee $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ $ ooding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for 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 ENAPROVEMENTS 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 r Signature Signature er Agent Contractor The foregoing instrument was acknowledged before me this day of 201. , by K NrLv�S c, , who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: i The foreg ing instrument was acknowledged before me this day of WA , 20 L�, by _ who is ersonally know me or who has produced as identification and who did take an oath. Sign: � Lo—,(, Q( \ Q-� Print: ` , r0 r e� ommis5kvo ({ Notary Public, State of Texas +t +� My Commission Expires June 03, 2014 �n�x�n--�x APPROVED BY � 1: Plans Examiner Structural Review (Revised 3 /12f2012)(Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) NOTARY PUBLIC: Sign: _ Print: My Col Amon CATAPAW MYCOMOSS14N#Iffims EXPmm. -Jane 04,7016 m° Zoning Clerk *jiffylube- February 19, 2014 RE: Jiffy Lube Store #391— 8787 Biscayne Blvd., Miami Shores, FL To Whom It May Concern: Jiffy Lube Intematlonal, Inc. 910 Louisiana Houston, TX 77002 Per the Lease Agreement dated December 7, 1985 between Commerce Partnership #1124 and Jiffy Lube International, Inc. Article IV, Section 4.01 states, Lessee shall, throughout the term of this Lease and at its sole cost and expense, take reasonably good care of the demised premises, and keep them in good order, condition and repair and in compliance with all of the terms and provisions of all laws and ordinances and any recorded agreement, and promptly at Lessee's own cost and expense make all repairs necessary to maintain such good order, condition, repair and compliance... In his capacity as Construction /Facilities Development Manager, Marcus Duffel is authorized to sign contracts or other documents pertaining to the construction, remodel and maintenance of Jiffy Lube properties. If you have any questions, please feel free to contact me or Marcus directly. Sinc ly, Darrell A. Billies Construction Manager 713- 241 -6011 *jiffylube- Darrell A. Billips Construction Manager Jiffy Lube International, Inc. 910 Louisiana Street OSP12020B Houston, Texas 77002 T, +1713 2416011 F: +1713 217 3077 M: +1 281 546 2880 E: darrell.billips @shell.com *jiffylube- Marcus Duffel Construction / Facilities Development Manager Jiffy Lube Intennational, Inc. 910 Louisiana St. 12th Floor Houston, Texas TX 77002 T. 713.241.6583 E: marcus.duffel @shell.com 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 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: ye"-y.- yEa'4 seag l ex-5 BUSINESS ADDRESS: '6150 AAC*aDA 81JD . STV r CITY 1- I E STATE FL- ZIP CODE 353%4 BUSINESS PHONE: 9?-1- 14"7 3 FAX NUMBER qu l - 1S,K v CELL PHONE 3( *S QUALIFIER'S NAME: Eci G FMiz 1 n J S QUALIFIER'S LIC NUMBER: GCs C_ t 5-0 To 1,!57- E -MAIL ADDRESS (IF APPLICABLE):. Created on 3119109 BY MLDV I RV 3126109 MLDV •< ®����° :mow ¥. R k §!K� -�& :� © ° wa¥*�s \, - . \% 7 \3f� «. ? \� / ` FELIX -5 OP ID: J3 CERTIFICATE OF LIABILITY INSURANCE 04/28/2014 D04(IIAI/2014 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 pollcy, certain policies may require an endomement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endomemen s . PRODUCER CONTACT Brown & Brown of Florida, Inc. 1201 W Cypr Creek Rd 111130 P.O. Box 667727 Ft. Lauderdale, FL 33310 -5727 Joseph Florello Jr FAX Ai No E3d Ai No): ADDRESS: INSU AFFORDING COVERAGE NAIL # INSURER A: Colony Insurance Com n 39993 PREMISES oeanrem� INSURED Felix Fern Services, Inc INSURER B: Travelers Cas Ins Co of Amer+ 19046 Attn: Jay Schaffer 3760 Hacienda Blvd, Ste F INSURER C :Brad efield Employers Ins. Co+ 10701 GENERAL AGGREGATE Davie, FL 33314 INSURER 0: PRODUCTS - COMPIOP AGG INSURER E: Emp Ben. $ 1,000,00 INSURER F: AUTOMOBILE UABOJTY ANY AUTO 0O D SCHEDULED AUTOS HIRED AUTOS ANUTOS 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. LTR TYPE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village g POLICY NUMBER POLICY YYYy) D LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR GL851090 02/02/2013 05/0212014 EACH OCCURRENCE $ 1,000,00 PREMISES oeanrem� $ 100,00 MED EXP (Any are person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEML AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMPIOP AGG $ 2,000,00 Emp Ben. $ 1,000,00 B AUTOMOBILE UABOJTY ANY AUTO 0O D SCHEDULED AUTOS HIRED AUTOS ANUTOS BA3B69668314SEL 02/0212014 02/0212015 COMBIsINGLE uMrr 1,000,00 X BODILY INJURY (Per person) $ BODILY INJURY (Per acddeM) $ PROPERTY DENn $ $ A JMBREL! 9 UAB Excess LUW X OCCUR CLAIMS4AADE XLS162806 02/02/2013 06J0212014 EACH OCCURRENCE $ 4,000,00 X AGGREGATE $ 4,000,00 DED I X I RETENTION$ 0 $ C WORKERS COMPENSATION AND EMPLOYERS LUU30JTY A PR EEW� CUTiVE Y� OFFICERAMM'Wim (Mandatory In NH) K ee,'jFn Nunder DESCRIPTION OF OPERATIO below. NIA 083050981 06114/2013 06/14/2014 X WC STJA X OTH E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE - POLICY LIMR $ 1,000,00 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ANach ACORD 101, AdMomd Remaft Schedule, H nwre apace Is required) Re: General Contractor, Eric Fabritius CGC1508015. For concrete replacement CERTIFICATE HOLDER CANCELLATION MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village g THE EXPIRATION. DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10060 NE 2nd Avenue Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE —itek� ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD