ELC-14-1398 (2) iami Shores Village
110 ilding Department
.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20
BUILDING Master Permit No. / 7
PERMIT APPLICATION Sub Permit No.
BUILDING ELECTRIC ROOFING REVISION EXTENSION RENEWAL
❑ ❑ ❑ ❑
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: •l o D gi.S e4 7.nL �D Q o
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: //'3-206 -0®/ -0/&o Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: G
OWNER: Name(Fee Simple Titleholder): `,�D k o g 1 lf6�-6.1nL& Phone#: 30 �o
Address: no ` �L 5 C� Io4 6LSk to
City: S(ADre State: Zip: 3 313y
l�
Tenant/Lessee Name: t Z Phone#:
Email: M I I ca. l V 0-0 C
CONTRACTOR:Company Name: ��� tc �r'�Gt�G LL L Phone#:
Address: 712.0 '
City: �!q'�'� ^^ State: �� Zip:
Qualifier Name: L'ZG/La - dJ. i`-��� !-a- Phone#: 3��^' 97-)_-/8"/ 2
State Certification or Registration#: �C /30 0 3 b y�— Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition 0 Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: /Jeal �•2 e.• '�t f�j1 0ecJ �r%et.
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ J Z4�, -mO CCF$
Scanning Fee$ Radon Fee$ DBPR$ A_400aw'- t
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ [ __)q . G O
(Revised02/24/2014)
Bonding Company's Name(if applicable)
1
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS,TANKS,AIR CONDITIONERS, ETC.....
OWNER'S AFFIDAVIT: 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 no ' e f commencement an onstruction lien law brochure will be delivered to the person
whose property is subject to attachme . Also, certified copy of recorded notice of commencement must be posted at the job site
for the first inspection which occ seven ) days after th uilding permit is issued. in the absence of such posted notice, the
inspection will not be approved nd a reins ction fee will charged.
Signature Signature
LO Wor AGENT CONTRACTOR
The foregoing instru nt was acknowledged before me this The foregoing instrument was acknowledged before me this
—i�day of 20/ g
� by lq day of -S� \IL! 12011 by
T LI i who is personally known to �ykcc� who is personally known to
me or who has produced as me or who has produced ��`� as
identification and did take an oath.Z identification and who did take an oath.
NOTARY PUB C: NOTARY PUBLIC: \\����'\P��enis /1i�--
Sign: 1. Sign:
_ _ v,: Cl/ _
Print: ' (c S Print: 0m/SQ, �-
Se I• Seal: ' F �'"••� ..... °•' �•
RUTH A.BYDASH -- U OP
*4,
: Notary Public-State o1 florfda FL r'J R�\\\����
• �� Comm.Expires Mu 27,2018
�%•°�„p`` 9=M 11yao NstiorW Notary
lans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Mar 16 15 02:19p David Landy Construction 786-513-3100 p.1
OP 10: RF
CERTIFICATE OF LIABILITY INSURANCE O,LTF_v?.1r.9,D(!.'YYYYI
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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 PQLICtES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 1NSURERI,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, sLJb)ect to
the [ermS and zonditions of the policy.certain policies may req'.lire an endorsement. A statement on this certificate does not confer rights to the
certificate holder in GeL of such endorsement(si. —�
—' CO1'i TACT ;
PRCUL CL-1 N 1ME
Abacoa nsurance Group-MIA P14011F_.__ _
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8000 NW 7th Street,Suite 202 N Na.BxI). ac ru)
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Miami,t=L 33126 nDnREs�.:
;Kathleen, Betancourt PRO DUCr_R TRIAN-�
CUSTOMER ID Q: .. -
IrJSURER(S)AFFDRDING COVERAGE t.AIC x
suritD Triangle Electric 8, Fire LLC INSURERA:Everest indemnity Ins CID 10851
Ractuel Cano INSURERB:Granite State Insurance .23809
7720 NW 53 St NSUR,:R c Philadelphia Insurance Co 18058
Miami, FL 33166
NSURER D
INSURER
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
IIIIS IS TO CERTIFY THAT 1-11F F'i1LF':ES OF INSURANCE LIS-EC BELOW HAVE P.FEN ISSUED TO THE INSURED NAMED ADOVE FOR THE POLICY PERIO,)
;1111;;ATED NeiwiTHSIANDING ANY REQUIREMENT, TERM OR CONDITION 'JF ANY CONTRACT OR OTHER DOCUytErIT WITH RESPECT TO 1l4H:CH THIS
IIFiCA"I'- MAY F317, IS:i 11EU OF', A tY PERTAIN. Till_ WSLIRANCE AFFORDED BY THE POLICIES ^.ESCRISED HEREIN !S SUF.J"C'T TO :ALL TH- 1'CRIVIS.
EXCI_USIC4S AND COND TIONS011" SUCH POLICIES L,V -S SHOWN htAY I,WiE BEEN REDUCED BY P.41D Cl_AIL(S
t INSR TYPE OF INSURANCE ADDL.SUBR POLICY NUMBER Kt"01)YYYY MM DDIYYYY WAITS
I POLICY EFF PCLIC?FXP
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GENERAL LIABILJTY - 1,C00,000
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AUTOMOB.LELIABILITY
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(:E',,CRIPTION OF OPERATIONS,I_O/1,1 TtOk5 P,d;:LES IMI-h ACORD 101•Atklltio—I RwIla IkS SQhwu.,:,it munr sPdce IS rOCuiruan
CERTIFICATE HOLDER CANCELLATION �—
S-iOULD ANY OF THE ABOVE DESCRIBED nOLICIES BE CANCELLED BEFORE
Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL B: DELIVERED IN i
g0 ACCORDANCE WITH THE POLICY PROV:SIC)NS.
10050 NE 2nd Ave.
Miami Shores, FL 33t33 urrloR::,r_nR_P=.EscN:Anva -
Kathleen Betancourt
1988.2009 ACO RD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD