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DS-18-1583Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit NO. DS-6-18.1583 Permit Type. Driveways/Sidewalks/Slabs 1 Work classification: AdditionlAlterabon Permit Status: APPROVED tssue Da 6125/2018 Expiration: 12/22/2018 Parcel Number Applicant 1151 NE 99 Street Miami Shores, FL 33138- 1132050180070 Block: Lot: ADAM CARRICO TRS Owner Information Address Phone Cell ADAM CARRICO TRS 1151 NE 99 Street miami shores FL 33138- (415)533-8653 Contractor(s) EMPOWER GENERATORS INC Phone (954)922-3800 Cell Phone Valuation: Total Sq Feet: $ 470.00 0 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Work: INSTALL GENERATOR ON NEW PREFAB Bond Return : Scanning: 1 Additional Info: Classification: Residential Fees Due CCF DBPR Fee DCA Fee Education Surcharge P&Z Review Fee Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $2.00 $2.00 $0.20 $35.00 $100.00 $3.00 $0.80 $143.60 Pay Date Pay Type Amt Paid Amt Due Invoice # DS-6-18-67870 06/25/2018 Credit Card $ 143.60 $ 0.00 Available Inspections: Inspection Type: Final Foundation Review Planning Review Building MU 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 -named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent June 25, 2018 Date Building Department Copy June 25, 2018 1 BUILDING PERMIT APPLICATION 'BUILDING ❑ ELECTRIC ❑PLUMBING ❑ MECHANICAL 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 Master Permit No. Sub Permit No. ❑ REVISION ❑ EXTENSI ❑PUBLIC WORKS ❑ CHANGE OF CONTRACTOR JOB ADDRESS: % / 5/ JV t. q / 6-frect City: Miami Shores County: Miami Dade .�.JVEQ JUN082018 FBC 20n �44• ELA e-1583 ON ❑RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS Zip:3313? Folio/Parcel#: % 1-32Q5-017-O 70 Is the Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: OWNER: Name (Fee Simple Titleholder):. dam Carrico Address: l 15 1 NE 99 61: City: %rilarni5horeS State: Ft. NO BFE: FFE: Phone#: ) /5 - S33-31o53 Zip: 33133 Tenant/Lessee Name: N1 / A Phone#: Email: CONTRACTOR: Company Name: 4E,n,9o&Cr V'G/1Grat trS ThC Phone#:C/5-/-9A2-38o0 Address: 3/0') . it) £4-. City: t t n i Q Beach State: FL Zip: 3 3 0011 Qualifier Name': RD br:r+ 5 I oW i nor! i State Certification or Registration #: C & C / 5 P 0 0 1 r1 Certificate of Competency #: Phone#: 95 - 9,. 3 700 DESIGNER: Architect/Engineer: /l1 / A Phone#: Address: City: State: Value of Work for this Permit: $ Type of Work: ❑ Addition ❑ Alteration Square/Linear Footage of Work: Zip: E New ❑ Repair/Replace ❑ Demolition Description of Work: j im,54Q I tar?Ld b/ 6-ennra1ot ILjPTc k - L n'S +4 1 l g® CO�j' +and6y Cr>✓ncrator on nprc-Pab Pad Specify color of color thru tile: !'-� W Submittal Fee $ Permit Fee $ 0 ' Q CCF $ CO/CC $ Scanning Fee $ Radon Fee $ 2 • cc, DBPR $ Z . GL7 Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ (3 ' e O (Revised02/24/2014) Bonding Company's Name (if applicable) jJ I R Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) N aI P 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 approved and a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this d(a� of *Sib, , 20 (g , by c'•1Y1 ` Lk,liecc0 pp is per onally known to IGY% me or who has producedt\e11,--• 'Fe. - &.. as identification andCw6o did ?aU anla Gay NOTARY PUBLIC: Sign: Print: a � 15 (� l ,-r,,,,,�,, S �� r'ino,�. ma . Seal: ,s.s�a�� moo APPROVED BY ,,,,‘et114111171f/iii, ^e',OWN TSl' Z osis ioN • '% -- yCP ••• Signature CONTRACTOR The foregoing instrument was acknowledged before me this S day of 3u nG , 20 IV , by RO }5)0‘JIn6)6 , who is personally known to me or who has produced Kim as identification and who did take an oath. NOTARY PUBLIC: Sign: DiAtoiclibigaaalL Print: D t✓ b ixah od c Seal: Plans Examiner F:DEBO 4,,S. HODGE _�MY COMMISSION N FF176428 =F � EXPIRES: Novcmber 16, 2018' ****************** Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY e.9 ISSUED: 07/17/2016 DISPLAY AS REQUIRED BY LAW SEQ # L1607170001741 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2017 THROUGH SEPTEMBER 30, 2018 DBA: EMPOWER GENERATORS Receipt #:GENERALSCONTRACTOR Business Name: Business Type: Owner Name: ROBERT GLENN SLOWINSKI Business Location: 364 SW 4 CT DANIA BEACH Business Phone:954 922-3800 Rooms Seats (QUALIFIER) Business Opened:12/12/2011 State/County/Cert/Reg:cGc1 52 0 012 Exemption Code: Employees Machines Professionals 5 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 0.00 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: EMPOWER GENERATORS 364 SW 4 CT DANIA BEACH, FL 33004 Receipt #1CP-16-00021166 Paid 08/28/2017 27.00 2017 - 2018 ACORO® CERTIFICATE OF LIABILITY INSURANCE L.....-----' DATE(MMIDD/YYYY) 04/25/2018 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 po icy, 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 Corporate Insurance Advisors 1401 E Broward Blvd Suite 103 Ft. Lauderdale FL 33301 CONTACT Elliot Shtekher NAME: PHONE (954) 315-5000 FAX (954) 315-5050 (A/C, No, Ext): (A/C, No): E-MAIL eshtekher@ciafl.net ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Nationwide Insurance Company 25453 INSURED Empower Generators Inc 364 SW 4th Court Dania FL 33004 INSURER B : MAPFRE Insurance Company of Florida 34932 INSURER C : Commerce and Industry Insuranc 19410 INSURER D : Technology Insurance Co. 42376 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 2018 -2019 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 ADDLSUBR INSD WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY GLZ03036643607 04/22/2018 04/22/2019 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- JECTLOC PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 $ B AUTOMOBILE X LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY 5204070002725 04/22/2018 04/22/2019 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ Medical payments $ 5,000 C X UMBRELLA LIAR EXCESSLIAB OCCUR CLAIMS -MADE 8E086488233 04/22/2018 04/22/2019 EACH OCCURRENCE 5,000,000 $ AGGREGATE $ 5,000,000 DED RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N/A TWC3711352 04/22/2018 04/22/2019 X PEATUTE EOTH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1, 000, 000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: General Contractor - License # CGC1520012 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Dept. 10050 NE 2 Ave. Miami Shores 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 FL 33138 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD