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EL-16-2062Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit NO: EL-7-16- 062 Permit Type: Electrical - Residential Work Classification: Alteration Perrnit Status: APPROVED'. ISsue Date: 811912016 Expiration: 02/15/2017 Parcel Number Applicant 42 NW 101 Street Miami Shores, FL 33150- 1131010180250 Block: Lot: Owner Information Address Phone DARYL AND MONICA BRANTON Cell DARYL AND MONICA BRANTON 42 NW 101 Street MIAMI SHORES FL 33150-1267 Contractor(s) Phone NEC ELECTRICAL CONTRACTOR INC (786)389-8116 Cell Phone Valuation: Total Sq Feet: $ 4,000.00 0 Type of Work: PANEL REPLACEMENT AND UPGRADE GFI 0 Additional Info: Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Amount $2.40 $3.38 $3.38 $0.80 $225.00 $3.00 $3.20 Total: $241.16 Pay Date Pay Type Amt Paid Amt Due Invoice # EL-7-16-60705 08/19/2016 Check #: 1324 $ 241.16 $ 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. 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-nam con : ctor to do the work stated. August 19, 2016 Authorized Signature: Owner / Applicant / on -ctor / Agent Date Building Department Copy August 19, 2016 1 CONTRACTOR: Company Name: �/ r% L \ t CP l Cvh U1-6.c,_,1 U` Phone#: C, S $ `1 11 1 S- Address1 a- Lc 5v- ` S 4, ` (Vitt b FL `3i 1� City: `k\ A wti State: FL < t� AA nn Zip: `2,`3 L �' Qualifier Name:1ai I<d- ‘61L ,,vvrPhone#: rc `� 4 4 T ( (`° State Certification or Registration #: (= G \ 3 !mod 0 'Q Certificate�of Competency #: Phone#: City: State: Zip: Value of Work for this Permit: $ O0 D Square/Unear Footage of Work: Type of Work: El Addition ❑ Alteration n New ❑ Repair/Replace ❑Demolition C-L-- - Description of Work: L--/G Specify color of color thru tile: Submittal Fee $ Permit Fee $ 31�SCCF $ v . 0 CO/CC $ 9' Radon Fee $ 3 - 3 G) DBPR $ 3 Notary $ L 5 Technology Fee $ 3 • 2-0 Training/Education Fee $ 0 ' Double Fee $ Scanning Fee $ 3 Miami Shores Village RR Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION UNE PHONE NUMBER: (305) 762-4949 S4,y FBC 201'4 BUILDING Master Permit No. 12GI (P" PERMIT APPLICATION Sub Permit No. EL-ICO -a-0 2- ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL '❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores Occupancy Type: Load: County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes Construction Type: Flood Zone: BFE: OWNER: Name (Fee Simple Titleholder): p4 Address: ei-Jij / J �i-'% City: M(-t'( State: L NO FFE: Phone#: _ 7(6 1 bc..2 LL Tenant/Lessee Name: • Phone#: Email: Zip: DESIGNER: Architect/Engineer: Address: JUL 21 2016 BY: Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ 2 ft day of TAB- 62Arric- � , who is personally / known to N+1na" as The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 20 f/ day of J4 % , 20 / Y , by 4"'"° ` is personally known to c 0011 4 lll/ii,/ ,,* ..... �ed1' Sign: Myc••.*9'. Sign: Print: - • , N';'' Print : i 0o'S ti Seal: me� Seal: 9a' aJ \a,,d'V. ��. -. -************************************s***ass*si****`*****************************************s******s***s****s** by me or who has produced r L identification and who did take an oath. as Bonding Company's Name (if applicable) Bonding Company's Address Oty 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. 1 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 lawsregulating 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 • tic: 'of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachme . Also a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which/r - - en ' •ays after the building permit is issued. In the absence • such posted notice, the inspection will not be appro ' and`a reins coon e will be charged. Signature WNER or AGENT Signature NTRACTOR me or who has produced identification and who did take an oath. NOTARY PUBUC: NOTARY PUB APPROVED BY Plans Examiner 0 !S S L/rz z :rroa 8 tiE Vit.. 0 Zoning (Revised02/24/2014) Structural Review Clerk workers' compensa BY SIGNING B CONTENTS. Signature: State of Florida day labor, part-time employees or be the only person allowed to w n in County of Miami -Dade Miami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Com • ensation 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 h t,.. ntr your prof rage from KNO ors for your project. The contractor has provided an affidavit stating that he or wi not use she will ct. In these circumstances, Miami Shores Village does not require verification of he contractor's company for day labor, part-time employees or subcontractors. GE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS The pforegoing was acknowledge before me this day of By)()YLjL P)fGnr-on Dr►v- i, ("1 C Q yl s `e-- as identification. 01-r1- - Notary. SEAL YANADY PrilETCi MY COMMISSIOty g PP 2 i463 1 EXPIRES; March t ; 2 19 Bonded Thru Notary Pub:,1;ru site s 1 US ' ,20j . who is personally known to me or has produced DATE: CACC GENERAL CONTRACTORS rAiI/Yvza silEtolrrvirffrild1 CONWELL & ASSOCIATES CONSULTING COMPANY Before me this clay personally appeared Kenneth F. Conwell who, being duly authorzied and says: That he or she will be the only person working on the project located at: 4 A1kt) /0 / � ,c-t ( I p,� Sworn to (or affirmed) and subscribed before me this (�i 1J VGA% 42/� (Signature) (Date) 1C,PlA �' 6„,..e ( __....f ,. Mp,. (Print name) ,,.,���tes Cons'.,,. ' •O fit'!(% I SEE L ;b 201 :- ' (Corporate sealrt O.'• . ' . STATE OF FLORIDA COUNTY OF MIAMI-DADE The foregoing instrument was ackn /%rhAfl�� ' &t et personally known to me or Notary Signature: Type or Print Name: wledged before me this / 4R. dv of ArLtZ U/�S1T20 16 by on behalf of COA'(f fitSSOC i ciw3 [ 1 who is oduced as identification. opt,, Zettie Jones 1:44• `�= COMMISSION 1 FF209081 =-'�- EXPIRES: March 14, 2019 44. ,oso` WWW.AMONNOTARY.COM 11771 SW 137 PLACE Miami, FL 33186 Tel: 305-926-5673 Fax: 305-385-7827 Email: info@caconsultingc.com ACORa►® �� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 08/11/2016 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 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 J&A Insurance Services, Inc 12918 SW 133 CT Miami, FL 33186 CONTACT Alina Jimenez NAME: (A/Co"ri . Ext): 786-518-2989 FNc, No): 305-233-4289 E-MAIL ainsuranceservices mail.com ADDRESS: I @9 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURERA: Granada Insurance Company 16870 INSURED Nec Electrical Contractor Inc 11720 SW 185 CT Miami FL 33177 INSURER B : INSURERC: INSURER D : INSURER E : INSURERF: COVERAGES 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 0185FL00061036 07/22/201607/22/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100 000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1 ,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES PRO JECT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY 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' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below �, / N N / A PER STATUTE OTH- ER 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 Work Within Building License # EC13007087 CERTIFICATE HOLDER CANCELLATION Miami Shores 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 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD