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EL-17-12 Permit No. EL-1-17-12 9V.— o,� Miami Shores Village o Permit Type:Electrical-Residential �r 10050 . .2nd Avenue NE � NE ' ' Work Classification:Addition/Alteration Miami Shores,FL 33138-0000 Permit Status:APPROVE Phone: (305)795-2204 �OR1Dp Issue Date: 1/512017 Expiration: 07/04/2017 Project Address Parcel Number Applicant 1130 NE 91 Terrace 1132050010410 Miami Shores, FL Block: Lot: BARBARA TER HORST Owner Information Address Phone Cell BARBARA TER HORST 1130 NE 91 Terrace (305)432-1775 MIAMI SHORES FL 33138- 1130 NE 91 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 700.00 F JIMENEZ ELECTRICAL CONTRACT( 305/556-5759 - eTotal Sq Feet: 0 Type of Work:POOL ELECTRIC TO BRING TO ELECTRICA Available Inspections: Additional Info:POOL ELECTRIC TO BRING TO ELECTRICA Inspection Type: Classification:Residential Final Scanning: 1 Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical Underground W.W. Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee InvOiCe# EL-1-17-62515 $4.50 01/03/2017 Check#: 1151 $50.00 $263.60 DCA Fee $4.50 Education Surcharge $0.20 01/05/2017 Credit Card $263.60 $0.00 Permit Fee-Additions/Alterations $300.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $313.60 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNE AFFIDAVIT: I certi hat all th regoing information is accurate and that all work will be done in comp' iance with all applicable laws regulating co ion an zoning. uth more,I horize the above-named contractor to do the work stated. January 05, 2017 Authorize Sig a:Owner / Applicant / Contractor / Agent Date Building Department Copy January 05,2017 1 Miami Shores Village SAN 0 3 2017 Building Department BY: - 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 , Tel:(305)795-2204 Fax:(305)756-8972 t� INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201H BUILDING Master Permit No. aa PERMIT APPLICATION Sub Permit No. ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: I/3 0 N 4 Terr, City: Miami Shores County: Miami Dade zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: {Z-Load: Construction Type:�� Flood Zone: BFE: FIFE: OWNER: Name(Fee Simple Titleholder): 8G Y l3C[1-Ci 7f,jo K f Phone#: 35r- V3 2- 77r Address: City: AA t-&nn ' State:�'Ad reJ, zip: 33 ) 39 Tenant/Lessee Name: �/��,�- Phone#: Email: Te - ho)-SJ- B l__J (-Orn CONTRACTOR:Company Name: r 7iYYwr)e-z- (.o" YrcC}d✓ Phone#: Address: rp�� qg I 5sl- pie i ' Le��► �,�Y� � �' �L 3 4 71 City: Aja k6{t &iUK�Y ,r State: 1�L zip: Qualifier Name: 95j ane dfo , 7i r,-, ne L Phone#: State Certification or Registration#: EC /,300 9-7 79 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ O _ 00 Square/Linear Footage of Work: Kd 10if n Type of Work: ❑ Addition ❑ Alteration ❑ New E9 Repair/Replace ❑ Demolition Description of Work: Pofl -'tj b r' J ►^;G(.� �O C[��p Specify color of color thru tile: Submittal Fee$ i Permit Fee$ ��®d CCF$ �0 CO/CC$ � c Scanning Fee$ �— Radon Fee$ . E70 DBPR$ Notary$ Technology Fee$ Training/Education Fee$ © • ZO Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 2/ . �O (Revised02/24/2014) 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 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 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 AGE 61 CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of L ,20 f'�, by day of b¢L 20 1 (o by 3c.r bc,y 1 em-�-\o who is personally known to who is personally known to me or who has produced r L Q-- as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: �. e' kw- " " MARIA THERESA PINO ?O `� Notary Public State of Florida Commission#FF 15368 Sign: -_ Sign: %;� ctid:�', M Comm.Expires May 7,2017 Print: b.. _ Print: Seal: ;ter�"...... ;o, ` MARIA THERESA PING Seal: - %(oar,��1 r>✓v :°= Notary Public-State of Florida ` Commission#FF 15368 �N,,OF��P My Comm.Expires May 7,2017 s**ers**•r** ****** *******sr********* ***s****ss**ss***r*s************************s****ss*s**sa***r • y APPROVED BPlans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ,acoRO® CERTIFICATE OF LIABILITY INSURANCE DA 1 1/4/2017 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 endorsement(s). PRODUCER CONTACT NAME: Alexander Dopazo Dopazo & Associates Inc PHONE 305 470-8500 FAX UVC No-ExU- ( ) AIC, C No):(866)647-9673 8725 NW 18th Terr Ste 300 ADDRESS:alex@dopazo.com INSURERS AFFORDING COVERAGE NAIC# Miami FL 33172 INSURERAMa fre Ins Co of Florida 34932 INSURED INSURER B-Bridge field Employers Ins Co 10701 F Jimenez Electrical Contractor Inc INSURER C: 4910 5th West INSURER D: INSURER E: Lehigh Acres FL 33971 INSURER F: COVERAGES CERTIFICATE NUMBER:CL171415636 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. INSR I TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER M DD MM DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ 4250160024227 9/10/2016 9/10/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y I N/A B (Mandatory in NH) 083026529 1/2/2017 1/2/2016 E.L.DISEASE-EA EMPLOYE $ 1,000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) Electrician. Loc #001: 4910 5th West, Lehigh Acres, FL, 33971 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE M Dopazo CPIA/MAD ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSO25 0014nll