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EL-16-1009Yr I5-55� Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-260612 Permit Number: EL -4-16-1009 Scheduled Inspection Date: June 09, 2016 Inspector: Devaney, Michael Owner: STAVILE, ESTEBAN MATIAS Job Address: 5 NW 106 Street Miami Shores, FL 33150 - Project: <NONE> Contractor: CJ ELECTRICAL SERVICES INC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Service Change Phone Number Parcel Number 1121360060240 Phone: (954)292-5711 Building Department Comments RELOCATE MAIN PANEL AND CONVERT OVERHEAD TO UNDERGROUND Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments June 08, 2016 For Inspections please call: (305)762-4949 Page 43 of 45 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 5 NW 106 Street Miami Shores, FL 33150- Owner Information Permit Pennit NO. EL -4-16-1009 Permit Type: Electrical - Residential Work Classification: Service Change Permit Status: APPROVED Issue Date: 4118/2016 Expiration: 10/15/2016 Address Parcel Number 1121360060240 Block: Lot: 2723 NE 6 Lane WILTON MANORS FL 33334- Applicant ESTEBAN MATIAS STAVILE Phone Cell Contractor(s) Phone CJ ELECTRICAL SERVICES INC (954)292-5711 CeII Phone Valuation: Total Sq Feet: $ 3,800.00 0 Type of Work: RELOCATE MAIN PANEL AND CONVERT OVE Additional Info: Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee'''-', Additions/Alterations Scanning Fee TechnologyFee Total: $163.90 Amount $2.40 $2.25 $2.25 $0.80 $150.00 $3.00 $3.20 Pay Date Pay Type Invoice # EL -4-16-59417 04/14/2016 Check #: 527 04/18/2016 Credit Card Amt Paid Amt Due $ 50.00 $ 113.90 $ 113.90 $ 0.00 Available Inspections: Inspection Type: Review Electrical 1 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 acceptinglthis 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 aid-zertin�g. Futhermore, I authorize the above-named contractor to do the work stated. April 18, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date April 18, 2016 1 BUILDING PERMIT APPLICATION ❑BUILDING 161 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 ELECTRIC ❑ ROOFING E] PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS JOB ADDRESS: IZtA) 1 O S 4-Ic �X8 9IOZ V I bd7 Clatirdpaa Master Permit No. Sub Permit No. ❑ REVISION D CHANGE OF CONTRACTOR N3 FBC20-1s� F -c— is --S55 EL -t (to --kW ci ❑ EXTENSION El RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Miami Dade zip:3�\c G Folio/Parcel#: , 1 - 3 6— 6Uc Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): (.2--\--ACC-In 1"AQTl(S S\ou (Q Phone#:1 tel: LO1 81)— Address: S %moi (CO" c. --k City: kthri11 C‘INC1IeS State: Zip: 33 (SO Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: QT YAcca\ Set L CPS ( %KC_ Phone#: Address: 3-75T C j Ts(ee C.r (a City: Co C canc tk C(State: FL. Zip: 33x-1 Qualifier Name: 5 c.Oh u (41+2, Viv.)V'� Phone#:Q5`t ?151 11 State Certification or Registration #: 1 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ a� Type of Work: ❑ Addition ❑ Alteration Description of Work: Q (v c O (Y10 I N uv\c er5r can 3 Square/Linear Footage of Work: ❑ ++New ❑ Repair/Replace ❑ Demolition pang 1 3 cek1uecuter`14?U() -c3 Specify color of color thru tile: Submittal Fee $ ` Permit Fee $ /-4-0 ° irb Scanning Fee $ Radon Fee $ Technology Fee $ Structural Reviews $ (Revised02/24/2014) Training/Education Fee $ CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE$ 1 13 910 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 approveand a reinspectioi - - ill be charged. Signature OWNER or AGENT Signaturiat- CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 1.34 17 day of Apr, 1 , 20 /b , by VI 411‘ day of Qpf. \ , 20 \ 6 , by F kOurl 40110 51au.le , who is personally known to j co v% r ci\A , who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: = +tl`" t..... KYLE C HAMBRICK • MY COMMISSION # EE867056 EXPIRES January 22, 2017 Sign: Print: Seal: Ce ttormbl rc eC FloridallotaryService com identification and who did take an oath. KYLE C HAMBRICK =•• *:. ,, ;i • ; MY COMMISSION # EE867056 EXPIRES January 22, 2017 153 FiondallotaryService com NOTARY PUBLIC: Sign: 1/ r Print: Com ? 1-Iu+i10r:cc t' Seal: *****************************************************************ski************ski *************************** APPROVED BY G ;2� /4/ di/i-// Plans Examiner (Revised02/24/2014) Zoning Structural Review Clerk AR© ® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 12/21/2015 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 BB Insurance Marketing Inc 10167 W Sunrise Blvd, 3rd FloorE-M Plantation FL 33322 CT NAMEACT Andrea Lopez Ext 314 PHONE Fxt)• 954.452-4900 FAX 9541152-0450 (A/C. No): ADDRIESS*Andrea@bbimi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Travelers Property & Casualty 25674 INSURED CJELE-1 CJ Electrical Services, Inc. 3753 Coral Tree Circle Coconut Creek FL 33073 INSURER 8 : 660-9A501783 INSURER C: 12/20/2016 INSURER D : $1,000,000 INSURER E : $100,000 INSURER F : CERTIFICATE NUMBER: 1633722367 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 ADDL INSD SUBR WVD POLICY NUMBER POUCY EFF (MMIDDIYYYY) POUCY EXP (MMIDDIYYYY) LIMITS A x COMMERCIALGENERAL UABIUTY 660-9A501783 12/20/2015 12/20/2016 EACH OCCURRENCE $1,000,000 DAMAGE PREMSESO(EaENTED occurrence) $100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) 55,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GE X 'L AGGREGATE POLICY OTHER: LIMIT APPLIES JET PER: LOC PRODUCTS - COMP/OP AGG $2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED HIRED AUTOS — SCHEDULED NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' UABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVENIA OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N STATUTE EERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Electrical Contractor located at 3753 Coral Tree Circle, Coconut Creek, FL 33073. CJ Electrical Services, Inc. EC13005617 TE HOLDER CANCELLATION 1 Miami Shores Village Building Department 10050 NE 2nd Ave. 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 R RESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CJ ELECTRICAL 3753 Coral Tree Circle Coconut Creek, FL 33073 oy �3 /acck� Before me appeare-/Ruar tt S /AI @/ who, being duly sowrn, deposes and says: That he or she will be the only person working on the project located at: 5 NW 106th Street Sworn to (or affirmed) and subscribed before me this Ilk day of %pY , 2016 by —SZ,v,car,ne S" ; ° KYLE C HAMBRICK MY COMMISSION # EE867056 s-. �'` EXPIRES January 22, 2017 (a07) 398-0153 FloOdallotaryService com Personally known OR Produced Identification Type of Identification /f1/0141. Print, Type or Stamp Name of Notary Miami Shores Village 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 ACKNO .EDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami -Dade -�J The foregoing was acknowledge before me this l day of , te---1 (__ , 20)C'' . By Lu(C Notary: SEAL: who is personally known to me or has produced _ _ ... _ .._ dC`%i+i^ac4.7x.:7.-4=vm-c=i-ssvw.:":. =a:wxsu:""n!a:;= a'{�".._�"��a'..�.t=..rkY.- 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:C J ELECTRICAL SERVICES INC Business Name: Owner Name: JAINARINE SINGH Business Location: 3753 CORAL TREE CIR COCONUT CREEK Business Phone: Rooms Seats Employees 1 Receipt #:ELECTRICAL/ALARMS/CONTRACTOR; Business Type: (MASTER ELECTRICIAN) Business Opened:10/30/2007 StatelCou ntylCert/Reg:EC 13 00 5 617 Exemption Code: Machines Professionals For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 2.70 0.00 0.00 29.70 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT 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 WHEN VALIDATED 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. Mailing Address: C J ELECTRICAL SERVICES INC 3753 CORAL TREE CIR COCONUT CREEK, FL 33073 ARO Receipt #13B-15-00000175 Paid 10/07/2015 29.70 2015 - 2016 n"iecii" • 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 listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 10/26/2015 EXPIRATION DATE: 10/25/2017 PERSON: SINGH JAINARINE FEIN: 261185314 BUSINESS NAME AND ADDRESS: CJ ELECTRICAL SERVICES INC 3753 CORAL TREE CIRCLE COCONUT CREEK FL 33073 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by titghg a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt.. apply only within the scope of the business or trade fisted on the notice of election to be exempt Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election b be exempt shell be subject to revocation if, et any time after the Hing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a DFS-F2-0WC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609