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EL-18-1761Miami Shores Village • 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Pe mit 1asus Date: 71 Permit No. EL-6-184761 Permit Type: Electrical - Residential Work Classification: Alteration Permit Status: APPROVED 12018 Expiration: 01/02/2019 Parcel Number Applicant 1400 NE 104 Street Miami Shores, FL 33138-2664 1122320320270 Block: Lot: ROBERT & HELEN SHIPPEE Owner Information Address Phone CeII ROBERT & HELEN SHIPPEE 1400 NE 104 Street MIAMI SHORES FL 33138-2664 1400 NE 104 Street MIAMI SHORES FL 33138-2664 Contractor(s) LS CURTIS INC Phone CeII Phone (305)933-0683 Valuation: Total Sq Feet: $ 1,000.00 35 • Type of Work: CHANGE/ UPGRADE LIGH FIXTURES EXHAU Additional Info: CHANGE/ UPGRADE LIGH FIXTURES EXHAU Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $0.60 $2.25 $2.00 $0.20 $150.00 $3.00 $0.80 $158.85 Pay Date Pay Type Invoice # EL-6-18-68063 07/06/2018 Credit Card 06/27/2018 Credit Card Amt Paid Amt Due $ 108.85 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Review Electrical I 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. ERS AFFIDAVIT: I certi :t onstruction Rnd zoning. Futher e fo _•.ing information is accurate and that all work will be done in compliance with all applicable laws regulating tt�ari - abve-named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent July 06, 2018 Date Building Department Copy July 06, 2018 1 BUILDING PERMIT APPLICATION ❑ BUILDING ELECTRIC PLUMBING ❑ MECHANICAL JOB ADDRESS: 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 ❑ ROOFING RECEIVED JUN272018 Cp h FBC 20/1� rr/n� Master Permit No. Q.0 i `- W 0 Sub Permit No. it IS" MP ❑ REVISION EXTENSION ❑ RENEWAL ❑PUBLIC WORKS ❑ CHANGE OF CONTRACTOR City: Miami Shores County: Miami Dade ❑ CANCELLATION ❑ SHOP DRAWINGS Zip: Folio/Parcel#: 1 1-2 2 3 2"D .3 02 to Is the Building Historically Designated: Yes. NO I/ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):/Q03E/2>' A/VD I/XLBA/ ,CH/PREP Phone#: ( 1 6'_? /2if Address: /I /t' /V E leg .- City: H/i_3r1/ ,'Lhd/LCfj r State: 11_ Zip: 3 -/ s 1i Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: / S 4 /Z1� Phone#:7 Kp/ C/ -26 7 ./e 3 0 /94 i� City: %7(//J///� / State: /— Qualifier Name: ,CC.Gtid' ( /� 6///77,5" Phone#: State Certification or Registration #: COCQ(?/7c--- Certificate of Competency#: DESIGNER: Architect/Engineer: Phone#: Address: /�City: State:____Zip: Value of Work for this Permit; $ 1000 - Square/Linear Footage of Work: 3.5 Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: C= `, kv. . Gi/LS . lc L* L. XTt9 CL'S ,cSLa V' S ;, 6`tl%' Address: Zip: 2--Y/d7CJ ?7( V7 7/ • Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 1, O & - 8� Permit Fee $ /46-23, OU Radon Fee $ Z- - C7z, CCF $ CO/CC $ DBPR $ 2 ' 2-5 Notary $ (Revised02/24/2014) • Bonding Company's Narne (if applicable) Bonding Company's Address City . - ! . State Zip Mortgage Lender's Name (if applicable) f Mortgage Lender's Address »✓- " i" r 1• City , State Zip ti n. ) ( / ,t I ,' t 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. 1 "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 ro ert is sub'ect�to attachment.- Also, a certified copyofthe'recoided notice ofcommencement must be o`sted at •the job site P P Y I f� P 1 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 _ r^,, day of ( LuS fi , 20 (7 , by y /a /// _ _/0V /ti e., who who is personally known to me or who has producedf i- c570. 7)9tP•/d.5"• L2 identification and who did take an oath. NOTARY PUBLIC: �`,�111111w ifze ' voles Seal: ▪ : "is. \ .; .} 5. v 333 • •**•.. PU9''/ 4 0# ibty r#*1`********************************************************************************************* ,et as Signature CONTRACTOR The foregoing instrument was acknowledged before me this 7 day of Z)'?( ,20/d ,by f (c.,Lpl , who is personally known to me or who has produced identification and whodid,take an oath. NOTARY PUBLI \ tom.►, . .` 0,01"°•'',• ,, CASSANDRA ':= Notary Publl - NEBBIA as ommission # FF 979238 My Co Sign: Print: APPROVED BY# _L .2 )2/ -t / e Plans Examiner Bonded through National NotaryAssn, Assn, Zoning (Revised02/24/2014) Structural Review Clerk pa s� MJONATHAN ZACHEM, SECRETARY ,i -r p4 f �� • 0 1 �`u �� fi��(rf t e%" � 'iY �. '� iy Y' JyLk1 V � _S �, `ice • �r j' �;�•tl_ i RI DA !RQ,FESSIONALREGU_ LAtz_ EXPIRATION ATE A J601 $T.31, 2020= t;.�.,VF44 " Always verify licenses online atMyFloridaLicens. e co, mk - a 'Y : r t o:not alterthis document in any}form � x.ryr3�*`eP'� la�g,�wful. fort{}lanyone, other -than the,Iic�e� gnsee to use this �•sr. 1Z"k' ;:��C."v.�l+.�.1`"�.t+t�.k �^�t�'c d`;iC.:�.�•�`r�.�. ,.. S�kE �i''r,a�:'. 001804 Luca '.Bjiness'Tax Receipt Miami-Dade'County, State oLFiorida -THIS IS NOT A BILL - DO NOT PAY �5108006. BUSINESS NAME/LOCATION URTI L S CS'INC *'2034_1. NE30 AVE.:i 08 AVENTURA',FL 33180 RECEIPT NO. RENEWAL 2427060" 'EXPIRES SEPTEMBER.34, 2018 Mustlbo display d at place tit business Pursuantto County Code Ctaptor BA— Art. 9 & 10„., OWNER SEC. TYPE OF BUSINESS L S CURTIS INC s. ;196 ELECTRICAL CONTRACTOR- EC00031751. 3: >` WOrker(s) PAYMENT RECEIVED BY TAX COLLECTOR' $$45.00 07/01 /2017 'CREDITCARD-17-041201 This Local 9usinoss Tax Receipt only confirms payment of'ihe Local Business Tax. The Receipt is not a license, permit; or a eortificatian'of the holder's quahtications, to da business. Holder must comply with any governntontai or nonyovornmontai reyulutory laws andrenalromonts which apply to tfiebusiness „r ' Thu RECEIPT NO. above mustbesdisployod on all co 1imercidi uahtclos. Miami Dude Code Sec 8a-276. raw, ;APPE`7•ti For more information, visit y, t?y rnfinplrldtgovilaxcollooLor CERTIFICATE OF LIABILITY INSURANCE 4/3 OD18 THIS CERTIFICATEIS 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 AUTOMATIC DATA PROCESSING INS AGCY 250717 P: F: PO BOX 33015 SAN ANTONIO TX 78265 CONTACT NAME: PHONE FAX (NC, No, EA): FAX No): E-MAILDRSS: INSURER(S) AFFORDING COVERAGE NNC$ INSURER A: Twin City Fire Ins Co INSURED L. S. CURTIS INC. 20341 NE 30TH AVE APT 108 AVENTURA FL 33180 INSURER B : INSURER C: INSURERD: INSURERE: INSURER F: • V V Y GMV LV —..... .-... - ..-.____. __ 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 ADDL INSR SUBR WVD POLICY NUMBER POLICYEFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS LTR COMMERCIAL GENERAL LIABILITY OCCUR EACH OCCURRENCE S DAMAGE TO RENTED PREMISES (Ea occurrence) $ CLAIMS -MADE MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GEN'L GENERAL AGGREGATE $ AGGREGATE LIMIT PRO- JECT APPLIES PER: LOC PRODUCTS - COMP/OP AGG $ POLICY $ OTHER: AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED LIMIT (Ea accident) S BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) S _ S UMBRELLA UAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE S $ DED RETENTION 8 A WORKERS AND AND ANY OFFICER/MEMBER (Mandatory If yes, DESCRIPTION COMPENSATION D EMPLOYERS' LL4BLLY PROPRIETOR/PARTNER/EXECUTIVE YIN EXCLUDED? in NH) describe under OF OPERATIONS below N/A 76 WEG TR4954 05/01/2018 05/01/2019 X STATUTE PER OTH- ER E.L. EACH ACCIDENT $1, 0 0 0 , 0 0 0 E.L. DISEASE -EA EMPLOYEE 1, 000, 000 E.L. DISEASE - POLICY LIMIT S 1 , 000,000 DESCR/PT/ONOF Those OPERATIONS / LOCATIONS /VEHICLES ACORD 101, Additional Remarks Schedule, may be attached if more space is required) usual to the Insured's Operations. License #EC0003175 CERTIFIUA I t HULUtrc 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 REPRESENTATIVE, Vic• Cad2 .) r. Anoe "AAC Arnon lsACDADATIAKI All rinhfo ractsrvcsti ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD '°' i CERTIFICATE OF LIABILITY INSURANCE DATE 2/12/1/YYYY) 12/12/17 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 Insurance Industries 953 N.E. 125th St. N. Miami, FL 33161 Phone (305) 891-2808 Fax (305) 891-6367 CONTACT STACY PARKS NAME: PHONE FAX 891-6367 (A/C. No. ExU: (305 )891-2808 (A/C, No): (305 ) E-MAIL s: stacy@insuranceindustriesinc.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: ARCH SPECIALTY INSURANCE COMPANY INSURED L S CURTIS INC. 20341 NE 30 Ave #108-6 AVENTURA, FL 33180- (305) 892-0115 INSURER B : INSURER C : UNITED STATES LIABILITY INSURANCE COMPANY INSURER D : INSURER E : INSURER F 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 NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL LIABILITY Y Y AGL0043614-00 1778310 12/09/2017 12/09/2018 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000.00 '1 COMMERCIAL GENERAL LIABILITY MED EXP (Any one person $ 5,000.00 In II CLAIMS -MADE d OCCUR ❑ PERSONAL s ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000.00 $ ❑ POLICY 0 JF = LOC AUTOMOBILE LIABILITY ❑ ANY AUTO n CO aBINEDtSINGLE LIMIT(E $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ ALL W■ NED SCHEDULED AUTOS PROPERTY DAMAGE (Per accident) $ NON -OWNED ❑ HIRED AUTOS AUTOS $ IIIV C Y Y 10/26/2017 10/26/2018 EACH OCCURRENCE $ 2,000,000.00 v' UMBRELLA LIAB OCCUR AGGREGATE $ 2,000,000.00 EXCESS LIARXL1574975 ❑ CLAIMS-MADE❑ ❑ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE N / A ❑ WC STATU- TORY LIMITS ❑ ERH_ E.L. EACH ACCDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION ELECTRICIAN CERTIFICATE OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space Is required) HOLDER IS ALSO LISTED AS ADDITIONAL INSURED lrcrs 1 Ir mas 1 c r1 V LYcrs MIAMI SHORES VILLAGE 10050 NE 2 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 REPRESENTATIVE ''11a ACORD 25 (2010/05) QF ei-17700-LV IV MaiVRv vvrsr..,r ,,..n . . The ACORD name and logo are registered marks of ACORD