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EL-17-2209Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. EL -8-17-2209 Permit Type: Electrical - Residential Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 9/5/2017 Expiration: 03/04/2018 Parcel Number Applicant 500 NE 92 Street Miami Shores, FL 1132060141200 Block: Lot: PORTO CABRAL LLC Owner Information Address Phone Cell PORTO CABRAL LLC 500 NE 92 Street MIAMI SHORES FL 33138-3157 500 NE 92 Street MIAMI SHORES FL 33138-3157 Contractor(s) Phone EVOLUTION ELECTRICAL CONTRACT (786)351-5784 Cell Phone Valuation: Total Sq Feet: $ 1,400.00 0 Type of Work: REPLACEMENT OF 8 OUTLETS AND 2 GFIS Additional Info: Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $1.20 $2.25 $2.25 $0.40 $150.00 $3.00 $1.60 $160.70 Pay Date Pay Type Invoice # EL -8-17-65050 08/31/2017 Credit Card 09/05/2017 Credit Card Amt Paid Amt Due $ 50.00 $ 110.70 $ 110.70 $ 0.00 Available Inspections: Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical Underground W. W. 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. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constr - .n - .d zoning. Futhermore, I authorize the above-named contractor to do the work stated. 00. XWI Ark September 05, 2017 Authorized Signa icant / Contractor / Agent Building Department Copy Date September 05, 2017 1 t Miami Shores Village Budding Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION ❑ BUILDING dELECTRIC ❑ ROOFING ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS JOB ADDRESS: City: Miami Shores County: Folio/Parcel#: Occupancy Type: FBC 20M Master Permit No. I 1'- 22-0Z5 ELIC-- l2O Sub Permit No. ❑ REVISION ❑ EXTENSION RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS Miami Dade Zip: 33156 Is the Building Historically Designated: Yes NO Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 90(t Vii h1'1, (i Address: 4.5 7 (6 I - i ' � 8) F City: r-/-�')-�/L'1%},I� i ,�- — State: '' ti � Zip: S.7j Tenant/Lessee Name:` (_ Phone#: Email: s(`. -4.\K)4, --v q& (-)01-1471' j, c? - CONTRACTOR: Company Name: £✓.4 /..r -/p 4 GGE cA ! 0047 Phone#: .496 35 /SIBS% Address: /i63 / ivii ,SCS p 1 City: /11 a le a 4 / State: / `Z, ,c �i Qualifier Name: Ai e.%l 1,14 �. - Phone#: Zip: 330/ 2 - Phone#: - / S4 0(1 State Certification or Registration #: Certificate of Competency #: /0E000 6/ V DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $0 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Description of Work: ri eg.. sod / j///1 • ❑ Demolition Specify color of color thru tile: Submittal Fee $c54::) °Permit Fee $ /,�ePe90 Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ e CCF $ CO/CC $ (Revised02/24/2014) TOTAL FEE NOW DUE $ I ' O 0 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 OWNER or AGENT The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 3 day of , 20 17 , by Ls day of / t -A � , 20 1- , by 1_ T !'J(Q r I tilt (n cam-, � ,who is personally known to me or who has produced i�fCZi'V 4 U (.-- as me or who has produced as Signature ONTRACTOR 2� crIuho is personally known to identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: APPROVED BY (Revised02/24/2014) 6‘6, °?0 (s' :* .}2� •a3 :� ®• 'c3_ 'i `o°�� i'Bade6.��o0). ko,ary pot „,a, llllllEl�� identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: <;;;;';',„ " ,.;.,' f M'(. •`fir?% EXPIRES April 6, 2018 0 PAEZ MMIS ION MFF109688 (407) 398.0153 FlorldallotaryService,com Plans Examiner Zoning Structural Review Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. eilik Al? GCS Owner's Name (Fee Simple Title Holder): 'ice Owner's Address: 43-1 (ocL > City: •1-(1)\-(14),\A ( & Job Address (Of where work is being done): �� City: Miami Shores 41151 11 State : Phone#: ,%a1 '•-(-6% C& Zip Code: State: Florida Zip Code: - �<3� Contractor's Company Name:4/0 % (etEc L cod• ' Address: /,6 / AAP 5e p City: /a 601/4 G State: f-60/e-fia Zip Code: 33 a /.1 - Qualifier's ZQualifier's Name : /4/4011 /- cliN Lic. Number: / 0 e oo O 6"/ O Phone #: X86 ?/S `4' Architect) Engineer of Record Name: Address: City: State: Zip Code: Phone #: Describe Work: hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless of all legal involveIent.. Signature Owner or Agent The foregoing instrument was aknowledged before me this _ day of ,20 ,by Who is personally known to me or who has produced as indentification. Signature Notary Public: Sign: Seal: Contractor or Architect The foregoing instrument was aknowledged before me this 2,6 day of t -.L .$ , 2011by who is personally known to me or who has produced r•enr►� •..,5 indentification. ' MY . MIc'. ION #FF109688 S April 6, 2018 Jfl NotaglService,com Notary Sign: - Seal: 5•'.. Of F�.O:' 407;1'08 0' ISIS M PAEZ as CTQB Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY 10E000610 41 EVOLUTION ELECTRICAL CONTRACTORS INC ACOSTA ANTONIO Is certified under the provisions of Chapter 10 of Miami -Dade County QUALIFYI,JG TRADE(S) 0001 ELECTRICAL 0002 BUF3LAR ALARM 0004 FIRE ALARM SPECLT Mans H Sales P E ' Secratery o1lhe Bos'E J41� % www inamdada. pv hcoron+y Municipal Contractor's Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY CC NO: 10E000610 BUSINESS NAME/LOCATION EVOLUTION ELECTRICAL CONTRACTORS INC 11631NW58PL MIAMI, FL 33012 RECEIPT NO. 7493217 TYPE of BUSIPIES* 1EVOLUTION ELECTRICAL 1 ELECTRICAL CONTRACTOR. CONTRACTORSI t - r I TM: rsceIpt is sot vslld lee IM follewiM Msa elpeli Ms: Arsatta4 EWA RtaleakKey Mame,ks, J l Miami Gardens. Mtsai Iako, Pains.* Ba,. Pisscret, Swim Islas Bieck. Town anode! Bay. r / For .so lelsrstatlsa slsNmTWMIIIIIIMEIRMINIUMBMEN 1 f __ _ MC EXPIRES SEPTEMBER 30, 2017 , Pursuant to County Code Sec 10-24 PAYMENT RECEIVED BY TAX COLLECTOR 09/22/20,16 0229-16-009047 / 1123/1 • 010185_ Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 6738299 BUSINESS NAME/LOCATION EVOLUTION ELECTRICAL CONTRACTORS INC 11631 NW58PL MIAMI F1.33012 RECEIPT NO. RENEWAL 7011810 LBT EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 !/ �1EC. TYPE OF BUSINESS PAYMENT RECEIVED OLUTION ELECTRICAL CONTRACTORS 196 ELECTRICAL CONTRACTOR �PAYME COLLECTOR 10E000610 ( 1 y Worker() '$75.00 07/19/2016 I 1 CREDITCARD-16-042322' Legal Business Tu Receipt only confirms payment d the Local &siaess Tnx. The Receipt is no a license, i permit er a twtiRraliea d tlM holder's enddica8otn, to do business. Relda utast amply with any governmental, /or aoge amaeebl rgdaMry Iawa and regehemeote which apply to the beside= 1 J The RECEIPT NO. shave mast be displayed en NI commercial vehicles 1 Miami -Dade Cede Sec $a-Z7S. For mo�vr mre information. visit i�rvriamidade.Serfftexcellectot - oci(l ': - CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 08/31/17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). , PRODUCER Southern Star Insurance Agency, Inc 8338 SW 8th Street Miami, FL 33144 Phone (305) 262-2740 Fax (305) 503-7450 CONTACT NAME: PHONE Ertl: (305) 262-2740 FAX No): (305) 262-2647 E-MAIL southernstarinsurance l.com ADDRESS: @9mai INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : GRANADA INSURANCE CO N INSURED EVOLUTION ELECTRICAL CONTRACTOR, INC 11631 NW 58TH PL HIALEAH, FL 33012 305-978-8537 INSURER B : 07/30/2017 INSURER C : EACH OCCURRENCE INSURER D : PRTOcED PREMISES ((Eaa occurrence) INSURER E : MED EXP An one (Any person)$ INSURER F : PERSONAL & ADV INJURY 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 LTR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBERPOLICY EFF (MM/DD/YYYY) POLICY EXP (MMIDDIYYYI) LIMITS A GENERAL LIABILITY V COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE V OCCUR ❑ N N 0185FL00072497-2 07/30/2017 07/30/2018 EACH OCCURRENCE $ 1,000,000.00 PRTOcED PREMISES ((Eaa occurrence) $ 100,000.00 MED EXP An one (Any person)$ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: n POLICY PRO ❑ LOC JFCT PRODUCTS - COMP/OP AGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS ❑ HIRED AUTOS ❑ NNON-OWNED ❑ . COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILYINJURY(Per accident)$ PROPERTY DAMAGE (P_ er_accident) $ $ ❑ UMBRELLA UAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE N I A En WC STATU- TORY UM TS ❑ EOTH E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ELICTRICAL CONTRACTOR LIC.#10E000610 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2nd Avenue Miami Shores,FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ROBERTO OJEDA ACORD 25 (2010/05) QF © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD +•. CERTIFICATE OF LIABILITY INSURANCE GATE (MM/DD/YYYY) 09/05/17 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 teen ADDITIONAL INSURED, the policy(ies) 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;.. Southern Star Insurance Agency, Inc PHONE FAx (A/c,..110,.Extl: (305) 262-2740 (ac, No)c (305) 262-2647. 8338 SW 8th Street .-DpREss: southernstarinsurance@Jgmail.com Miami, FL 33144 Phone (305).262-2740 Fax(305)503-7450 I INSURER(S) I S) RANO AFFORDING COVERAGE INSURER A : GRANADA INSURANCE CO INSURED — - - - EVOLUTION ELECTRICAL CONTRACTOR, INC INSURER C : INSURER C 11631 NW 58TH PL . INSURER D : HIALEAH, FL 33012 305-978-8537 INSURER E : COVERAGES INSURER F : 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 _ _...._ .... ...._ LTRI. TYPE OF INSURANCE ADDLBUBR i N WVl) POLICY NUMBER POLICY EFF POLICY EXP (MM/OD/YYYY MM/DD/YYYY ' LIMITS GENERAL LIABILITY ) (_ ►I__ �/ COMMERCIAL GENERAL LIABILITY 1 • I , EACH OCCURRENCE i $ 1,000,000.00 DAMAGE TO RENTED CLAIMS -MADE VI OCCUR PREMISES (Ea occurrence) $ 100,000.00 N ' N 0185FL00072497-2 07/30/2017 07/30/2018 MED EXP (Any one person) I $ 5,000.00 PERSONAL 8 ADV INJURY $ 1,000,000.00 GENERAL AGGREGATEs 2,000,000.00 PRODUCTS COMP/OP AGG I $ 2,000,000.00 NAIC N GEML AGGREGATE LIMIT APPLIES PER: POLICY !,._I PRO- '.....I LOC j AUTOMOBILE LIABILITY I ANY AUTO • ALL OWNED :--1 SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB EXCESS LIAB r -1 OCCUR CLAIMS -MADE DED i RETENTION$ WORKERS COMPENSATION 1 AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE (Mandatory EXCLUDED? II NIA, NH) U yes, describe under iDESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) ELICTRICAL CONTRACTOR LIC.#10E000610 CERTIFICATE HOLDER Miami Shores Village Building Department 10050 NE 2nd Avenue Miami Shores,FL 33138 ACORD 25 (2010/05) QF CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. COMBINED SINGLE LIMIT (Ea accident) .....-. $ BODILY INJURY (Per person) . $ BODILY INJURY (Per accident $ PROPERTY DAMAGE (PPer accident) EACH OCCURRENCE AGGREGATE I ( I WC STATU- 1_._; OTH- —:,.TORYJ.IMITS. _.--,1__ER_ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE! $ E.L. DISEASE - POLICY LIMIT • $ 1 AUTHORIZED REPRESENTAT IROBERTO OJEDA ©1988-'010 ACORD CORPORATION. All rights reserved, The ACO D name and logo are registered marks of ACORD 1 ELLE Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address 500 NE 92 Street Miami Shores, FL Permit Permit NO. EL -6-15-1557 Permit Type: Electrical - Residential Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 4/29/2016 Expiration: 10/26/2016 Parcel Number ................................_.._...... . 1132060141200 Block: Lot: Applicant PORTO CABRAL LLC Owner Information Address 500 NE 92 Street MIAMI SHORES FL 33138-3157 500 NE 92 Street MIAMI SHORES FL 33138-3157 Phone Cell Contractor(s) Phone Cell Phone RICHARD ELECTRIC INC (954)854-7090 r,, �, Valuation: DAM Sq Feet: $ 1,400.00 0 Type of Work: REPLACEMENT OF 8 OUTLETS AND 2 GFIS Additional Info: Classification: Residential Scanning: 1 CANCELLED Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $1.20 $2.25 $2.25 $0.40 $150.00 $3.00 $1.60 $160.70 Pay Date Pay Type Invoice # EL -6-15-56079 06/23/2015 Check #: 1514 $ 50.00 $ 110.70 04/29/2016 Credit Card $ 110.70 $ 0.00 Amt Paid Amt Due Available Inspections: Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical Underground W. W. 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. OWNERS 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. Futhermore, I authorize the above-named contractor to do the work stated. April 29, 2016 • u Zt, e"ner / Contractor / Agent Building Department Copy Date April 29, 2016 1 BUILDING PERMIT APPLICATION ❑ BUILDING ❑PLUMBING JOB ADDRESS: City: Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20LCD Master Permit No. RQ_ I CJ q/n Sub Permit No. ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ MECHANICAL 0PUBLIC WORKS Miami Shores ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACT Q NCEILE,O DRAWINGS • County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: ConsttuctionT e: Flood Zone: BFE: FFE: CZOWNER: Name (Fee Simple Titleholder): t Q Phone#: Address: City: NAA ` t\ - State: Zip: Tenant/Lessee Name:. Phone#: Email: CONTRACTOR: Company Name: Address: City: !► • Sta Zip: OcIA diU3/Vk Phone#: Qualifier Name: State Certification or Registration #: C` O \ O &I—Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: cg C ' irPhone#:CiY !S Value of Work for this Permit: $ { fro.00 City: State: Zip: Square/Linear Footage of Work: Type of Work: ❑ Addition ►= (Alter ion 11 New Description of Work: 15 0 04 l n Repair/Replace ❑ Demolition Specify color of color thru tile: 6O . Co Submittal Fee $ Permit Fee $/J ' os9 CCF $ $ ' 2C3 CO/CC $ 0 Scanning Fee $ 3 - Radon Fee $ a-sx; DBPR $ a • Vi3 Notary $ P Technology Fee $ \ , C© Training/Education Fee $ G • `4'6 Double Fee $ 7;�� Structural Reviews $ P Bond $ 5a TOTAL FEE NOW DUE$ I ( 0 - 0 (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 tliatia11\t14 1'Orroing information is accurate and that all work will be done in compliance with all applicable laws regulatinc oonstrucction and 4zp' ini. "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 ch ; .sted notice, the inspection will not be approved and a reinspection fee will be charged. 7 Signatxrr OWNER or ENT Signature CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 02/I day off ~( , 20 , by A�y/,1 day of ��( jye , 20 6 , by r � �' `2 �t , who is personally known to 'vet' (I I 411' me or who has produced 7401— /2 30 7 ZI 7 21bds identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ���►RY '4. NOTARY PUBLIC �<<���� -ESTATE OF FLORIDA 0 �"'''` ? Comm# EE1381Sd8 sssssssssssssssss*'ss*#ass*s*"*15 ssss HARCID LOPEZ APPROVED BY (Revised02/24/2014) me or who has produced identificationd who did take an oath. NOTARY P `QJ, o is personally known to 0i2 f ixtC $411 ash 6`c-' Sign: Print: eZ / / /vr 2,' ELVIRA LOPEZ MY COMMISSION C FF 072394 EXPIRES: March 21, 2018 NJ°jFor noes Bonded Ara Buffet Notary Services Seal: s4,s4,ssssssssssssssssssssssssssssssssssssssss4,1, *sssssssssssssssss Plans Examiner Zoning Structural Review Clerk HOLLYWOOD, ft.. Uy+O1 4GO OM ftk M t'• ELECTRICAL CONTRACTORS LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 RICHARD, MAHINDRA RICHARD ELECTRIC INC 2131 NORTH 58TH AVENUE HOLLYWOOD FL 33021 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myioridalicense.corn. There you can find more information about our divisions and the regulations thatimpactyou, subscribe to department newsletters and team more about the Department's initiatives. Our mission at the Department is: License Efficiently. Regulate Fairly. We constant strive to serve you better so that you can serve your customers. Thank you for doing business in Florida. and congratulations on your new license! DETACH HERE RICK SCOTT, GOVERNOR (850) 487-1395 pSTATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION EC 13005087 ISSUED: 08/12/2014 CERTIFIED ELECTRICAL CONTRACTOR RICHARD, MAHINDRA RICHARD ELECTRIC INC IS CERTIFIED under the provisions o/ CA.489 FS. Exphtion date . AUG 31. 20113 L1403120002430 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD LICENSE NUMBER The ELECTRICAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 RICHARD, MAHINDRA RICHARD ELECTRIC INC 2131 NORTH 58TH AVENUE HOLLYWOOD FL 33021 ISSUED: 08/12/2014 DISPLAY AS REQUIRED BY LAW SEQ # L1408120002430 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VAUD OCTOBER 1, 2024 THROUGH SEPTEMBER 30, 2015 Receipt : EL cTRI CAL?AL.ARIIS/ CONTRACTOR Business Type: DBA. Business Name: RICHARD ELECTRIC INC Bis Opened:M10./12 /2013 Owner Name: put;ttruws t:ictwt<:.' usnestC.@rVR@ 'EC 13005087 Business Location: 2131 N 58 AVE State/Courty g. HOLLYWOOD Exemption Code: Business Phone: 954 322 7017 Rooms Seats llumDer of Machines: 1 Tax Amount Transfer Fee if NSF Fee Employees Machines Professionals 1 for Vending Business Only Penalty Vending Type: Prlor Years Codeclion Cost Total Pad THIS RECEIPT MUST BE THIS SECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: P.ICHARD ELECTRIC INC 2131 N 58 AVE HOLLYWOOD, P. 33021 0.00 0.00 0.00 0, CO 27. CO o.cc. POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning and zoning requirements. This Business Tax Receipt must be transferred moved the the business is sold, business name has changed or you have business location_ This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations 201.4 - 2015 Receipt 01CP-13-00014024 Paid 08/28/2014 27.00 ACORU® CERTIFICATE OF LIABILITY INSURANCE L.....--- DATEICID 06/18/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS POLICIES AUTHORIZED CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, E CTB1D OR ALTER THE COVERAGE AFFORDED BY THE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), 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 Finney Insurance Corporation 5601 Sheridan Street Hollywood, FL 33021 N Laura Murray PRONE (A �: 954-966-5533a c. No: 954-989-8208 A iOlUlf 011 + P -COD 061 AFFORDNGCOVERAGE - MAIC! INSURER A : Granada Insurance DEQ Richard Electric Inc 2131 N 58 Avenue Hollywood, FL 33021 INSURERS : 05117/2016 INSURER C : $ 1.000,000 ENSURER D : CLAIMS -MADE OCCUR NSUem E : - $ 100,0000 INSURER F: S 5,000 COVERAGES CERTIFICATE NUMBER: 000000000 REVISION NUMBER: 3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDfI1ONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOLSUBR POUCY NUMBER POLICY (IUJ YYYYYYI POLICY R OOIYYYY1 LIMITS A COMM6iC1ALGfERAL LABILITY 0185FL00045845 05/17/2015 05117/2016 EACH OCCURRENCE $ 1.000,000 CLAIMS -MADE OCCUR TO RENTED - $ 100,0000 PREMISES (Ea occurrence) MED EXP (Any one person) S 5,000 PERSONALE ADV INJURY S 1.000.000 GENT AGGREGATE POLICY 1 OTHER LENT APPLIES PER JECT 1 1 LOC GENERAL AGGREGATE S 2,000.000 PRODUCTS- COMP/OP AGG S 2,000,000 S AUTOMOBILE LAIHIJTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS - _ SCHEDULED AUTOS AUTOSNON-OWNED COMBINED SINGLE LIMIT (Ea acciden0 S BODILY INJURY (Per person) S BODILY INJURY (Per =deed) S rypraide M)) DAMAGE S $ UMBRELLA UAB MESS LAB OCCUR EACH OCCURRENCE S AGGREGATE S DED 1 RETENTIONS CLAIMS -MADE S WORKERS COMPENSATION AND EYPLOYERW LIABILITY Y/N ANY PROPRETORJPARTIaIE U E N/A 1 PSTATUTE EOR EL EACH ACCIDENT $ EXCLUDED? ED? (Mandatory in NH) 0 dasate under DESCRIPTION OF OPERATIONS below EL DISEASE- EA EMPLOYEE S EL DISEASE- POUCY UWT S DESCRIPTION OF OPERATIONS /LOCATIONS/YE7ECLES (ACORD 101. Additional Remarks Schedule, may be attached It more apace Is muted) License EC13005087 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department _ 10050 NE 2 Ave Miami Shore, Florida 33138 SHOULD M W OF THE ABOVE DEED POLICIES BE CANCELLED BEFORE THE EXPNIAT1ON DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WmH THE POLICY PROVISIONS. "7EPRESEt.,.....LALET %/ffy al -M) ACORD 25 (20141D1) ®1988-2014 ACORD CORPORATION. Ali rights reserved. The ACORD name and logo are registered marks of ACORD • • Printed by LLM on June 18, 2015 at 08:48AM port Viewer Page 1 of 2 1 !1 100% JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION • CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW • • CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual fisted below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 5282015 EXPIRATION DATE: 5/272017 PERSON: RICHARD MAHINDRA FEIN: 270341678 BUSINESS NAME AND ADDRESS: RICHARD ELECTRIC INC 2131N58AVE HOLLYWOOD FL 33021 SCOPES OF BUSINESS OR TRADE: UCENSED ELECTRICAL CONTRACTOR Fossa to Chapter 44005(14 RS, at 01t cer of a corporation who eteds exemption from tins chapter M Ming a oeftrrate 01 Ne0on under this secaon may not recover benefits or compensation under This chapter Pvwsnt to Pouter 440 0.5112). F.S . Csnfiales of elscbon to be ecempt apply only within the scope of the business or trade listed on the notice of electron to be exempt Pursuant to Chapter 440 05(13), F.S.. Notices of election to be exempt and cerbtce es of election lo be exempt shall be subject to rescca0on ff, at any time after the ding of the notice or stile issuance of Vie artRicate. the person named an the notoe or certificate no longer meets the requremeres el the sector for issuance of a ce t4*ate The department shat revoke a DFS -F2 -DW -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1E09 V tps://apps8.fldfs.com/crreportviewer/reportViewer.aspx?data=kdvpginc9D7Q3gH6TER6eP 1 KMZ%2fSz5bX... 6/4/2015 RICHARD ELETRICAL INC , 06/18/15 State Florida County of Dade Before me this day personally appeared Mahindra Richard , who ,being duly sworn , deposes and says: The Contractor has provided an affidavit stating that he will be the only person allowed to work on your project . That he will be he only person working on the project located at : 500 NE 92 street - Miami Shores , FL. Swor to (or affirme ,201 by indr and su ; cribedjefore me this 18day of June har Personally Know Or Produced identification F) 09 iAv1- cpi iti' L lc* Type of I ��QIq ) z Print , Type or Stamp N . me of Notary ELVIRA LOPEZ ISSION 1 FF 072394 EXPIRES: March 21, 2018 Bonded Thru Budget Notary Services Miami Shores Vinage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption _ Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signat State of Florida County of Miami -Dade The foregoing was acknoe before me this (u Ai Owner ,93 day of ,) un e ,20 )5. who is personally known to me or has produced as identification. * CO ISSION # FF 072394 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S Andrews Ave Rm. A-100. Ft. Lauderdale, FL 33301-1895 954-831-4000 VALID OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016 DBA: Business Name: RICHARD ELECTRIC INC Owner Name: MAHINDRA RICHARD Business Location:2131 N 58 AVE HOLLYWOOD Business Phone: 959 322 7017 Rooms Seats Employee* 1 Receipt:E ECT I7c6PLIALARA4SICONTRA Business Type: Business Opened:09/12/2013 Slat e/County/CertiReg: ' 13005087 Exemption Code Machlnos Prof.ssianals ?C - qD EL is -- t om THIS RECEIPT MUST BE THIS BECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: RICHARD ELECTRIC INC 2131 N 58 AVE HOLLYWOOD, FL 33021 POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS This tax is levied for the pnvilege of doing business within Broward County and is non -regulatory in nature You must meet all County andior Municipality planning and zoning requirements This Business Tax Receipt must be transferred when the business is sold. business name has changed or you have moved the business location This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations 2015 - 2016 Receipt i*NWW-15-00001339 Paid 10/2112015 29.70