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ELC-18-19Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Permit NO. ELC-1-18-19 Permit Type: Electrical - Commercial Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 1/4/2018 Expiration: 07/03/2018 Parcel Number Applicant 755 NE 91 Street Number: 2-F Miami Shores, FL 1132060440220 Block: Lot: BRUCE BENDER CURT DYER Owner Information Address Phone Cell BRUCE BENDER CURT DYER 5900 ALTON Road MIAMI BEACH FL 33140-2025 5900 ALTON Road MIAMI BEACH FL 33140-2025 Contractor(s) Phone Cell Phone QUINTANA ELECTRIC BROTHERS IN( (305)986-5893 (305)681-5317 Type of Work: REPLACE LIGHTS AND OUTLETS Additional Info: Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $3.38 $2.25 $0.40 $225.00 $3.00 $1.60 $236.83 Pay Date Pay Type Invoice # ELC-1-18-66037 01/04/2018 Credit Card 01/03/2018 Credit Card Amt Paid Amt Due $ 186.83 $ 50.00 $ 50.00 $ 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 construction and zoning. Fu hexmore7ratii iorize the above -named contractor to do the work stated. 4. ner / Applicant / Contractor / Agent Buil•l'rg Department Copy January 04, 2018 Date January 04, 2018 1 u 2-1 Ca; t ))0 BUILDING PERMIT APPLICATION BUILDING ELECTRIC 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 Master Permit No. ❑ ROOFING ❑ REVISION Sub Permit No. ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS n CHANGE OF [� -� CONTRACTOR JOB ADDRESS: •�5 J t \( 1\ S 1 t c -t a t' City: Miami Shores County: Folio/Parcel#: I I — 32-06 ! -! - 0 )? t7 Occupancy Type: d Load: Construction Type: Miami Dad& RECEIVED JAN 0 3 TOi/ e0- FBC 2011 ❑ EXTENSION 10 RENEWAL ❑ CANCELLATION 0 SHOP DRAWINGS Is the Building Historically Designated: Yes 3-3 17A NO 1/ Flood Zone: JJO BFE: FFE: OWNER: Name (Fee Simple Titleholder): 7(1)( Phone#: 05' 441 S ✓ 6 w Address: J cO� " ,,-``-(1 �., City: \ t a.M l \,LCJ(.b() Tenant/Lessee Name: 1�) /A- Phone#: Email: State: FL-- Zip: 33\4 CONTRACTOR: Company Name: L2( 4ViU fjl1 � 4rrt-V'S t L, Address: &f fo/ SW City: / r L i 6WY►� State: t" t Qualifier Name: _j(A6yi Phone#: zip: 3313c'( Phone#: State Certification or Registration #: — evo.2 9616 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ (,PO Type of Work: ❑ Addition ❑ Alteration ❑ New ® Repair/Replace Description of Work: 2g)-v 41/tic /D 0,7 v'//—/E sc.d;*-Ch Square/Linear Footage of Work: ❑ Demolition S rzipl4c_e wte�tfs Specify color of color thru tile: Submittal Fee $S 00 Permit Fee $ _ J ,57:-. CCF $I/�T CO/CC $ Scanning Fee $ 1 Radon Fee $ `— DBPR $ _ ./ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ _ Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ l €3C9 • 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 issue the absence s ch posted notice, the inspection will not be approved and a reinspection Signature be charged. OWNER or AGENT The foregoing instrument was acknowledged before me this \' - day of L .eY� , 20 19 , by -VC-e , who is personally known to me or who has produced ()-efS ci a--q tslikti1O. s-vt as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Ur'+ 1tf • -Q c Seal: — ilfrM a . „ _ _ '"'' CURT W. DYER Notary Public - State of Florida Commission I GG 118624 My Comm. Expires Jun 25, 2021 ********** 'r=*41,**** Ai'4e0 1PlialiA1a Y41911100Rs***************** i ...)* tiifye•*49*.*************************** Plans Examiner �c/C, 3fA��,``\ H��NIINNNI;. Signatur CONTRACTOR • The foregoing instrument was acknowledged before me this -51 day of 0nCA0or , 20 ) ( , by `Star. /uelYl4 Z. , who is ersonally know1Dto me or who has produced as identification and who did take an oath. NOTARY PUBLIC: APPROVED BY Sign: \\```��1y111111�` m Print:,����\0t QUINT, si I` Obe1 i �`r' v1-(��i,1o. Sew O° �q s�� 50••+. •••• Z • N(-0G137092 4; �? Structural Review Zoning Clerk (Revised02/24/2014) e�ava �laaa �eaaE , Iom atees, L%ad. TN N... e, mi. •T11l2T MOM aUOam. FLORIDA O Mfa Authorization For Installation, Alteration Or Replacement Of New and/or Existing Equipment, Remodeling, Structural Changes, Painting, etc. And Moving In and/or Out Owners Name(s): ,JCe- �el �h F art �y e ✓ Unit #: �F Date(s) Of Requested Actions: Type Of Work To Be Done (please be detailed and attach additional docu entation if necess ry): er ir,�•l `Al:w►t�s. nerl r o.1.^ct. reti .�,(..11- Permit(s) Required Prior To Start. If Yes, Provide Necessary Documentation Pre Inspection By: _ Date: Chosen Contractor and/or Vendor Name -Address -Telephone: �V t eNaC . Z lQ r.%1 Current Florida License Number and Insurance Information Of Selected Contractor aq6,1.0 and/or Vendor: SPECA\Templataa Original. & Blaolo\PolieierlRepair Remodel Mthethad Aloe 05/12104 Page 1 of I A I LI0I• raaiAo .. 30! tioPizIsolPW► moan xpdtrasnonoaymunti spluilpo salndunwpaas 3�- Fe uoii3edsui lsodµ sews :wwo w imam warns i3111/11i,N 7N i'N ups ACORD® CERTIFICATE OF LIABILITY INSURANCE "4, DATE (MM/OD/YYYV) 1 /3/2018 MIS 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 BB Insurance Marketing Inc 10167 W Sunrise Blvd 3rd Floor Plantation FL 33322 CONTACT Certificate Department PHONE FAX (A/C. No. Est): 888-728-0817 (A/c, No): 954-452-0450 E-MAIL certificates@bbimi.com INSURER(S) AFFORDING COVERAGE NAIC N INSURER A : Zenith Insurance Company 13269 INSURED QUINELE-01 Quintana Electric Brother's, Inc. 4801 SW 6th Street Miami FL 33134 INSURER B: INSURER C : INSURER D: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 1666487127 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 POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABIUTY SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS UAB O OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION$ A WORKERS COMPENSATION AND EMPLOYERS' UABIUTY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 2134694001 12/13/2017 12/13/2018 X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Electrical Contractor 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 ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD s y .f cri •4 II • 7 7 .! 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