ELC-12-1631 (2) x
Miami_ Shores Villnye - \'
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Bq ldi De . art ent �
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10050 N.E.2nd,Avenue,Miami Shores,Florida 33138 � 291i
Tel:(305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
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BUILDING Permit No. e1rr��?-=16a l
PERMIT APPLICATION Master Permit No.
r FBC 20 1 C5
Permit Type: Electrical C)Aun
OWNER:Name Fee Simple Titleholder): P7 A/1 1�1d115 1'.2�' 13•�(1 ErLU�►•1 Phoon#:
( p ) �i� � S �
Address: d Z A e 3(-p Sr `
City: )A)A'&11 'S11o _GS State: , Zip:—13S)38
Tenant/Ussee Name: Phone#:
Email: ��INC-NG/`'� MS`j�� • ��
JOB ADDRESS: (OC7 . E .LO STlk tot
City: Miami ShoresMiami Dade Zip: 33
Folio/Parcel#: ZZ-3206 .0/4" filpll�-
Is the Building Historically Designated:Yes NO Flood Zone:
CONTRACTOR:Company Name: VIria 4 r Phone#: qSq ( '�
Addre s: p
City: State: t� Zip:
Qualifier Name: Q Y Phone#:
State Certification or Registration#: f' Certificate of Competency#:
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ I � Square/Linear Footage of Work:
Type of Work: ❑Address OAlteration ❑New LlRepair/Replace ODemolition
Description of Work: V�//� //�� //� �y/��//��
1 1 K 0 �l�� 1 V 1
***************************************dFees********************************************
Submittal Fee$ ,O ermit Fee$ ! �� CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$ LD
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip i
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
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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the ab ce of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature ja Signature
Owner or Agent ontractor I
The foregoing instrument was acknowledged before me this X701 The fo 'nst ontwa C,030arn
knledged before me ss3— `'dayof� f 20LL,by PAY/d Knc�en day of YIO
who is personally known to me or who has produced who is erson known t
oo has produced
P Y P P Y
As identification and who did take an oath. and who did take an oath.
NOTARY PUBLIC: NOT LR.KILCREASE
.Qi�•I PyB'
MY COMMISSION#EE 007393
' E IBES:Ju1 17 2014
?1 ? Q E /Y BfWfitBfS
Sign: �J LYQ Sign: °`
Print: Sdv/6- 140— e-& Print:
My Commission Expires: NOTARY PUBLIC-STATE OF FLORIDA My Commission Expires: 4-
Sylvia Halter I 1
i, E m�ssion#EE098053
� � �� �**a****** *** **:***$***** *m*a**x****** x* *xa* xss***
C BONDING CO.,INC.
APPROVED BY L�2m Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/102009)(Revised 3/15/09)
♦SHORES Git
l... .....� Miami hores Village
Building Department
�0RNA 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION FORM
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS
SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A$30.00 FEE PER YEAR.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. V COPY OF QUALIFIER'S STATE LIC CARD
B. `� COPY OF LOCAL BUSINESS TAX RECEIPT
C. v COPY OF LIABILITY INSURANCE(CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT)
D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER
B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT
C. COPY OF LIABILITY INSURACE(CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT)
D. COPY OF WORKER COMP INSURANCE(EITHER CERTIFICATE OR EXEMPTION)
YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES,FL 33138 i
COMPLETE CONTRACTOR'S INFORMATION
BUSINESS NAME: Otlubb Ela Q+
is-e&- Uyl 1 , I-LC
BUSINESS ADDRESS:3�O� I W q1 Ne,
CITY
STATE r(_ZIP CODE
BUSINESS PHONE: (% I J FAX NUMBER(q
[)j Q
CELL PHONE QUALIFIER'S NAME:
QUALIFIER'S LIC NUMBER:
E-MAIL ADDRESS (IF APPLICABLE): kPn6l ; 1E:fl(s (S? 1' S
Created on 3119109 BY MLDV 1 RV 3126109 MLDV
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-- -- - - - _ - - - -Lr"-"B"USINESS-TAX-RECEIPT--
11
L BUSINESS-TAX-RECEIPT--
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000
VALID OCTOBER 1,2011 THROUGH SEPTEMBER 30,2012
DBA: Receipt#:181-2632
Business Name:CHUBB FIRE & SECURITY LLC Business Type:ELECTRICAL/ALARMS/CONT
ype:ELECTRICAL/ALARMS/CONT OR
(ALARM SYSTEM CONTR 1)
Owner Name:SZACHOR JOSEPH J Business Opened:05/31/1991
Business Location: 3921 SW 47 AVE #1004 State/County/Cert/Reg:EF0001151
DAVIE Exemption Code:NONEXEMPT
Business Phone:
` K
Rooms Seats Employees Machines Professionals
7
For Vending Business Only
Number of Machines: Vending Type:
Tax Amount Transfer Fee NSF Fee F Penalty Prior Years Collection Cost Total Paid
27.00 0.00 0.,00 0.90 0.00 0.00 27.00
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:
I
CHUBB FIRE & SECURITY LLC Receipt #032-10-00004815
3921 SW 47 AVE #1004 Paid 07/14/2011 27.00
DAVIE, FL 33314
1
__20-11-- 20.12 _
I
I
I
AC E® DATE(MM/DDNYYY)
CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 09/04/2012
THIS CERTIFICATE IS ISSUED ASA 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.4T-
HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
I
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 CONTACT
NAME
Willis of New York, Inc. PHONEFAX
c/o 26 Century Blvd. 877-945-7378 888-467-2378
P. O. Box 305191 -MAIL certificates@willis.com
Nashville, TN 37230-5191 AnnRFqq-
INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: First Specialty Insurance Corporation 34916-001
INSURED
Red Hawk Fire & Security, LLC INSURERB: Zurich American Insurance Company 16535-003
3921 SW 47 AVE., SUITE. 1004 INSURERC:
DAVIE, FL 33314
INSURER D: �
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:18430028 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 TYPE OF INSURANCE D' SUB POLICY NUMBER POLICY EFF POLICY EXPI TR LIMITS
A GENERAL LIABILITY IRG15285 /10/2012 4/10/2013 EDACHOCCURRENCE $ 2,000,000
X COMMERCIAL GENERAL LIABILITY PREMISETO aocccurence $ 50,000
CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5 000
PERSONAL BADVINJURY $ 2,000,000
GENERAL AGGREGATE $ 2.000.000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000
POLICY PRO X LOC $
B AUTOMOBILE LIABILITY BAP509588400 /10/2012 4/10/2013 EaerBlddeDSINGLELIMIT $ 2,000,000
X ANYAUTO BODILY INJURY(Perperson) $
ALLOWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Peraccident) $
HIRED AUTOS NON-OWNED PROPER DAMAGE
AUTOS Perarxident) $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I RETENTION$ I $
B WORKERS COMPENSATION WC509588300 /10/2012 4/10/20131%
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000 x
OFFICERIMEMBER EXCLUDED?
fMandatory inNH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
ff yes,describe under
DESCRIPTION OF OPERATIONS belowE.L.DISEASE-POLICYLIMIT $ 1,000,000
I
t
1
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach Acord 101,Additonal Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
i
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHO DR ESENT
Miami Shores Village
10050 NB 2nd Ave
Miami Shores, FL 33138
Coll:3847276 Tpl:1435360 Cert:18430028 @,1§88-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered markif of ACORD
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000
VALID OCTOBER 1,2012 THROUGH SEPTEMBER 30,2013
DBA:RED HAWK FIRE & SECURITY LLC Receipt#:181-2632
R
Business Name: Business Type: (ALARM SYSTEM CONTR 1)
Owner Name:SZACHOR JOSEPH J Business Opened:05/31/1991
Business Location: 3921 SW 47 AVE #1004 State/County/Cert/Reg:EF0001151
DAVIE Exemption Code:
Business Phone:
Rooms Seats Employees Machines Professionals
7
For Vending Business Only
Number of Machines: Vending Type:
Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid
27.00 3.00 0.00 0.00 0.00 0.00 30.00
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:
RED HAWK FIRE & SECURITY LLC Receipt #03A-11-00006648
3921 SW 47 AVE #1004 Paid 09/06/2012 30.00
DAVIE, FL 33314
2012 - 2013
— — — — — 0E2e%1AIA Mr% t%P%l 16ITv/ 1 /1A A I MI jd%11LIrA0% -IF-A v .-..-...-■.+� — — —
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. C-F_1-1 21-112 F_"C1 6 15 1.2-7
��FE8WKE0�T OR 8k 28250 Py 4233; (1n9)
ARECORDED COPY MUST osPOSTED omTHE VmSITE xrTIME upFIRST INSPECTION RECORDED 08/30/2012 12:24:49
HARVEY RUVIN, CLERK OF COURT
/ ' MIAMI D
PERMIT FOLIO 4 /4/C} - *»E CuuwT'' FLORIDA
LAEST PAGE
STATE OF FLORIDA: '-StATE OF FL)IRIDA,COUNTY OF LADE 80
' oOuwnroFMww|�cwDs '�=�cu,
original filed in th 05re on 's &
gay of
THE UNDERSIGNED hereby gives notice that improvements will 10 ^
<
propert)4 and in accordance with Chapter 713,Florida Statutes,the following Kfd_fttEtf1&UVIr
inprovided inthis Notice mCommencement.
1. Legal desbription of property and street/address: \�»�� ��Y£���
2. Description of improvement:.
3. Ovvnor(s) name and address:
'
Name and address cvfee simple titleholder: ,
4. Contractor's name and address:FLORIDA STATE FIRE AND SECURITY, FL 33314
5. Surety: (Payment bond required by owner from contractor, if any)
Name and address:
Amount ofbond
0. Lender's name and address:
/ ,
7. Pamonuwithin the state ofFlorida designated byOwner upon whom notices orother documents may boserved uo
provided byS i Statutes
.
Name and address:
8. |naddition tuhimself, Owners designates the following pomonV$ooreceive ocopy ufthe Uenor'sNotice aaprovided
in Section 713.13(1)(b), Florida Statutes.
Name and address: `
9. Expiration date ofthis Notice ofCommencement: (the expiration date is 1 year from the date cfrecording unless
,__Qfferent date is specifii ed)
Sl�n�ature_of Owner
Print Owner's Name. Prepared by
Sworn toand subscribed before methis o01111f
day of .20//'
`
Address:
Notary Public
Print Notary's Name Psvtv,�A_
My commission expires: lione- 9; 010L�
123m-52 PAGE 4u/02
NOTARY PUBLIC-STATE OF FLORMA
S via Halter0 TnU ATLANTIC BONDING
CO,IN—