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DOCK-16-1284 (2) Miami Shores Village Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 N JUN 0 7 2096 Tel:(305)795.2204 Fax: (305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 FBC 201y 54* BUILDING Permit No. EL--1 b -15 5-40 PERMIT APPLICATION Master Permit No. 0Ock — 3--1 — 1 as3 Permit Type: Electrical �/ L JOB ADDRESS: /3,47? /�` �s ST�� e City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: OWNER:NamepTitleholder): � /�f1 (Fee Simple Phone#: Address: /J� �d/S 7-- J —eeV4 City: A!/10w/ -S State: /'�L Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Lcm ol!b9/!/ l �� Phone#: Address: S City: i6l C1414 State: Zip: 1 �1 Qualifier Name: o `Phone#: 4? i� 5��`All State Certification or Registration#: G 3 Certificate of Competency#: Contact Phone#: Email Address: DESIGNER:Architect/Engineer. Phonek Value of Work for this Permit:$ r� Selma Square/Linear Footage of Work: Type of Work: OAddress DAlteration XNew 1 ORepaiirr/,Replace ODemolition Description of Work: Powe yi)- ac ll ct/— LL f C Submittal Fee$ Permit Fee$ ✓r®ice® CCF$ )ywo CO/CC$ Scanning Fee$ — Radon Fee$ ted' DBPR$ Bond$ 0 Notary$ 12r Training/Educatiou Fee$��Technology Fee$ 1�Q Q Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ O Bonding Company's Name(if applicable) 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 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 EMPROVEMENTS 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature ��"�� Owner or Agent Contractor The foregoing instrument was acknowledged befor me this The foregoing instrument was acknowledged before me this day of lja420 Ik by t2 n �, day of Tv n L 20 J—(,,by 1 c a e ) L o/ ,/h q� �oisersonally kno to me or who has produced w is personally known me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: a Sign: Print: Print: L%Q Notary Public Stateof FloridaMy Commission Expires: Michelle Perez My Commission Exp' spNotary PublicState of FloridaMy Commission FF 000321 Michelle Perez Expires 04!08!2®17 My Commission FF 000321 ovRo Expires 04/08/2017 �k�k�k�la$s�RA��kfi� �NH«skak8sak�Rak�k�k�k�kS��k�k�k�N4�k�k$�aksb�k�k#szkfl��ksk�kA��IsakA��kak�SBagaebsRnk�k�kaksh�ksk�k�k�k�k�ks�ak�ls �kffisR�BR�A�& sk sk �k APPROVED BY e. � Flans Examiner Zoning Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) CERTIFICATE OF LIABILITY INSURANCE 4 THIS CERTIFICATEIS 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),AUTIMIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 1 ffiPORTANT,B the cel holaw Is an ADMONAL INSURED,the pollcy(iss)nwst have ADDITIONAL INSURED Provisions or be endorsed. N SUBROGATION 0 WAIVED,subject to the tm and conditions of the Policy,min Policies may require an endorsement A statement on this certificate does not confer righils to the ceMcate holder in lieu of such erdorsemehh s FROWCER tAMACT PAYCHEX INSURANCE AGENCY INC , �'".I�r. (888) 443-6112 210705 P: F: (888) 443-6112 E PO BOX 33015 M1JRMS)AFF0RDWGCDVEMM SAN ANTONIO TX 78265 IOMMA: Twin City Fire Ins Co inBm® RJSURER hr: NWPJM C: LONGMAN ELECTRIC INC MURIRER D: 844 NE 98TH ST MOURM MIAMI FL 33138 INWFUER F: 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. NOTWITI-ISTANDING ANY REQUIREMENT, TERRA 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 TPPEOFINS(lIfANCE IDD SUB& POLKYNIZMBEB �� POLICPEW IdA9/TS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 CLAIMS-MADE❑OCCUR DAMAGE TO RENTED PREMISES(Ea oewrrelxe) 5 MID EXP(Any are parson) g PERSONAL&ADV INJURY GEWL AGGREGATE UMITAPPLIES PER: GENERALAGGREGATE PRO POLICY ,ECT F]Loc PRODUCTS-COAMOP AGG g OTHER.- AUTOMOBILE THER:AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea axkleM) ANY AUTO BODILY INJURY(Per parson) OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per a-mend) HIRED NON-OWNED PROPERTYDAMAGE AUTOS ONLY AUTOS ONLY (PeraeddeM) S S U�REUJ►LIAR OCCUR EACH OCCURRENCE g EXCESS LIAR CLAI<4S-MADE AGGREGATE g RETENIM S 5 IPOFXffitSctd1LGffiOXPER OTH- BtID�/.OfF.BS'll+�lldlP X STATUTE I ER ANY PROPRIETORIPARTNERIExEcunverm E.L.EACH ACCIDENT "1,000, 000 OFFICa~RER EXCLUDED? ❑ WA A O1y!nIYH) 76 AEG IX1296 05/01/2016 05/01/2017 E.LDISEASE-EAEMPLOYEE g1, 000, 000 B 1es•desarbs under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1,000, 000 DESCRIPTION OFOPERAnONSI LOCATIOM I Y&IC(MRD 101,AddWonal Remarks Schedv1%may be aMached if mors space Is rsquIred) Those usual to the Insured's Operations. LIC# EC13003713 CERTIFICATE HOLDER CANCELLATION 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 AUTt>OR¢EDREPRESEIUATIVE 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ©1988-2015/!CORD CORPORATION.All rights reserves ACORD 25(2016103) The ACORD name and logo ars registered marls of ACORD