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REV-17-346 i1 Miami Shores Village °�� Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 BUILDING Master Permit No. P 'O'P_ PERMIT APPLICATION Sub Permit No. 9�11t_11 ❑BUILDING LECTRIC ❑ ROOFINGAd EP REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP ONTRACTOR DRAWINGS JOB ADDRESS: 7 City: Miami Shores County: Miami Dade Zip: i Folio/Parcel* Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): ` � Phone#: Address: City: State: Zip: Tenant/Lessee Name: Phone#: Email: 1 CONTRACTOR:Company Name: 1r094�� f�, 7>j:r2!!?7Phone#: 17R6 Q—;5 /vy 700 Address: A(:x,-� ' —72WX03;f 45 ' 1 C—cJ City: / State: Zip F Qualifier Names-'�DgN jj Phone#: State Certification or Registration#>riZ<V<D `?"�JQ —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 ❑ Alteration ❑ New _ ❑ Repair/Replace ❑ Demolition Description of Work: ' /ter sa7�.� �'c!la G' Specify color of color thru tile: - Submittal Fee$ -- Permit Fee$ t��i®a CCF$ GO 0 CO/CC$ Scanning Fee$ ` Radon Fee$ 2-. DBPR$ Notary$ Technology Fee$ Training/Education Fee$ 20 Double Fee$ `�— Structural Reviews$ Bond$ t TOTAL FEE NOW DUE$ (Revised02/24/2014) v � 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 perdo the work and installations as indicated. I�certifyvno 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature ��'� � �� Signature OWNER or AGENT ONTRACTOR The foregoing instrument s a nowledged before me this The foregoi instrument was dknowledged before me this day of 20 �� by d..of 20 �- by who is.per$Qna_Llkknown to � �a 1�� . is personally known to me or who has produced as me who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: \ NOTARY PUBVC: Sign: �"_ Sign: � Print: �Z• A—a/� C C7�ii��1' — Print: ota:. , MARIA C.f�RIGUEZ a '..•. o MY COMMISSION#EE 86D383 Seal. • ° Seal: # M1'; •'4"ION#EE 860393 EXPIRES:Apr026,2017 a* EXPli?,` 'i ii 26,2017 met°p�O� BandeiThruBudgetNo�yServloes krdW Thru Nfty 9 APPROVED BY A P"� 3lk Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) uc 1 ri cc RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD - ®� i EC13007099 x The ELECTRICAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. K Expiration date: AUG 31, 2018 FERGUSON, DENHAM GEQRGE�r VALDEN SERVICE SYSTI M ', LLC 2301 NW 191ST ST ;.Y MIAMI FL 33056 S,l Ms; P K 'N ISSUED: 08/14/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1608140004549 i Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT ABILL—DO NOT PAY LBT./ 6422497 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES VALDEN SERVICE SYSTEMS RENEWAL SEPTEMBER 30, 2017 LLC 6690672 650 NW 100 TERR Must be displayed at place of business MIAMI, FL 33150 Pursuant to County Code Chapter SA—Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED VALDEN SERVICE SYSTEMS LLC 196 ELECTRICAL BY TAX COLLECTOR CONTRACTOR 75.00 09/13/2016 Worker(s) 1 EC13007099 0223-16-005879 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holders qualifications,to do business.Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec Ba-276. ®1 D For more information,visit wwwmiamidade.novhaxcollector A�O® CERTIFICATE OF LIABILITY INSURANCE FDATE(MMI/DDnYYY) 02/13/2017 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(ies)must have ADDITIONAL INSURED provisions or 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: Daniel Ronbinson Simplified Mortgage and Insurance Services,Inc. (PHONE 954-583-1500 Ext): 954583-1500 ac No): 954-583-6987 665 SW 27 Avenue Suite#5 E-MAIL ADDRESS: Ft Lauderdale,FI 33312 INSURERS AFFORDING COVERAGE NAIC tl: INSURERA: Wilshire Insurance Company INSURED INSURER B: Valden Service Systems,LLC INSURER C: R.O.Box 693513 INSURER D: Miami,FII 33259 INSURER E: INSURER 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. 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 ADDL SU R POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED CLAIMS MADE X OCCUR PREMISES Ea occurrence) $ 100,000.00 MED EXP(Any one person) $ 5,000.00 A CLOO182534 01/15/2017 01/15/2018 PERSONAL&ADV INJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000.00 POLICY❑JET LOC PRODUCTS-COMP/OPAGG $ 2,000,000.00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LI IT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA UAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STA UTE ER ANYPROPRIETORIPARTNERIEXECUTIVE I N f A E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more apace Is required) Electrical Services CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E.2 Avenue Miami Shores,Florida 33138 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 8/12/2015 Report Viewer t1 l00% s C JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW" CONSTRUCTION INDUSTRY EXEMPTION EThis certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 8/5/2015 EXPIRATION DATE: 8/4/2017 PERSON: FERGUSON DENHAM FEIN: 141921254 BUSINESS NAME AND ADDRESS: VALDEN SERVICE SYSTEMS LLC 2301 NW 191 ST 9 MWMI GARDENS FL 33056 s SCOPES OF BUSINESS OR TRADE: 1 LICENSED ELECTRICAL I CONTRACTOR Pursuamto Chapter 440.05(14),F.&,an oi8ca of a eapaadon who elect&aXemPNon from thla Chapter I SGng a certificate cf elactim�under this section may not recover bens�tt&a compertagen under this chapter.Purausmto Chapter 440.05(12).F.&,Cart�9cet®d election to be memPL.aPPIY�Y R w111*m the scope ofthebminess a trade listed onft notice ofelection tobe exempt Pursuamto Chapter 440.05(13),F.S.,Notices of eledonto be 5gg .a n1 endcertlEcates of elaaan to be exempt shall be sub)ectto rav*,don if.at anytime after thetiling oftre notice a the Issuance of the certificate, the Wean named en the notice a certiteate ne longer meets the r gWremeda of ins section fa isauanca of a cer flerae.The depatrnem eha0 revoke e DFS-F2-DWG252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413.1609 r I s ) E I ) Valden Service Systems LLC Contact: Denham Ferguson ELECTRICAL CONTRACTOR Phone: 786 253 7700 P.O. BOX 69-3513 E-Mail:denny@valdenllc.com MIAMI, FL,33269 State License#:13007099 Date 02 13 2017 State Of Florida County Of: Miami Dade Before me this day personally appeared Denham Ferguson who,been duly sworn.disposes and say. That he or she will be the only person working on the project located at 9350 NE 9 Place.Miami Shores FL 33138. SW to a rmed) and subscribed before me this Z day of 2017 by .�'Q Personally known OR Produced Identifica Ty ,¢e of identiftcatkqn Prqduced t Print,type or Stamp Name of Notary MYC c* EXPIRES: r1 p2B,2017 �'o�mo�`a 9ondedllaueudgw�yBeNbe�