EL-14-1302Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-231188 Permit Number: EL-6-14-1302
Scheduled Inspection Date: March 30, 2015
Inspector: Devaney, Michael
Owner: LUND, KENNETH AND ALEXANDRA
Job Address:1001 NE 96 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: POWER BY PURKIS, INC
timiaing uepartment comments
RELOCATE AND ADD ELECTRICAL OUTLETS &
SWITCHES & DATA PORTS AS PER PLANS
03-11-15
Construction project is active. see inspections related under
14-744
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Alteration
Phone Number (714)721-2270
Parcel Number 1132060143740
INSPECTOR COMMENTS False
Inspector Comments
Passed EJ
Failed
Correction ❑
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
March 27, 2015 For Inspections please call: (305)762-4949 Page 15 of 17
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
BUILDING
PERMIT APPLICATION
❑BUILDING )@ ELECTRIC ❑ ROOFING
Og4 8 2014
FBC 201L'�'
Master Permit No. R C .)`-4 -- 1` J UZ)
Sub Permit No. f �—) LA _13CDZ
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL Ej PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS:
City: Miami Shores
County:
Miami Dade
Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type:
Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
A PC
/ ` ��N[/�
Phone#:
Arirlracc• 16V % 'vtZ' /h��
V
City: II 1-1 State:
Zip:
Tenant/Lessee Name:
Phone#: & :�247C2
Email: �[_ ✓� (� P !dJ `l d�
CONTRACTOR: Company Name: a�C�� �` V
Phone#: �0 rw(� 0 (i0
Address: ����.2 S(N �3���i 4�c—
City: ��/1°� fi ( '6 State:
c /,
Zip: 37/Ub
Qualifier Name: r �l )�p� ((
Phone#:
C '--6'�t�cl ;E�O'!��DOY/�'Certificate
State Certification or Registration #:
of Competency #:
DESIGNER: Architect/Engineer: e (.C'c�C n-D
Phone#:
Address:
City:^4' At4"-7r ^ State: 'Y f Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New
9 Repair R ❑Demolition
Descri tion of Work:C> WC�t?
P
_p/lace
r �h'�f vi
S.
p�cr dolor Of color >thr=ti
Permit Fee $
CC C / C
Scanning Fee $ Radon Fee $
DBPR $ Notary $
Technology Fee $ Training/Education Fee $
Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
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 bsence such posted notice, the
inspection will not be appr d and a reinspecti fee will be charged. I 1
Signature Signature L
l
OWNER or AG NT CONTRACTOR
The foregoing instrument was acknowledged before me this
25"7G dd aay of � 11C -) S '� 20 % G by
�Kr-�e.`%K � J �who is personally known to
me or who has produced \ �-o as
identification acid who did take an oath.
NOTARY P
Sign:_
Print:
OSVAL'DO MARTINEZ
Seal: .`�' Notary Public - State of Florida
My Comm. Expires Feb 11. 2017
•,5....: r.g•• Commission #E EE 873545
The foregoing instrument was acknowledged before me this
4*f'� day of c , 20 % by
/1'"ir— - ILwr/uS , who is personally known to
me or who has produced 1r, %Q0-4,") ', C e J�,-SQ_ as
identification and who did take an oath.
NOTARY
Sign:
Print: R;��\
u),valOO MARTINEZ
Seal: `.�' N Notary Public - State of Florida
o; My Comm. Expires Feb 11, 2017
Commission #r EE 873545
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014) e-- "" `�
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation 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:
l . 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. In these circumstances, Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, You may be
personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Own/err %
Print Name:
Signature:
State of Florida )
County of Miami -Dade ) k.6,
Sworn to and subscribed before me this
day of , 20\U\
\/
By l&\'nA.N\1
County of Miami -Dade )
Sworn to and subscribed before me this
day of } AYA\AN , 20 �.
By
m. Exp My ires o�iresFab 11, 2017 oc My Comm. Expires Feb it, 2017
Commission #F EE 873545
Commission #F EE 873545
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
.-Permit N.l�C302
Niher's Name (Fee -Simple Title Holder): Phone #:_
Owner's Address: /0 6/' Aj
City:
Job Address (Of where work is being done): /`() u
City: Miami Shores
State: T r
Zip Code:
State: —Florida Zip Code:
Contractor's Company Name: 6�'' e2. �� R-4.5 Phone #:3! T c9-y/ ° S_`(�
Address: 7
City: '; �- % State: T- Zip Code: / G
Qualifier's Name: /fir iVe dr Lic. Number: CC -;0' sy Fccoo ySl
Architect/ Engineer of Record Name: 14'J"57' d Phone #:
Address: _
City:
Describe Work:
State: (
d ��S VIs ,'o Pt G
Zip Code:
1P�,s
I hereby certify that the work has been abandoned and/or the contractor/architect is
unable or unwilling to complete the contract. I hold the Build! i the
mi Shor armless for :ignature
ll leg invol a t.
Signatureg .r
ovine I qi Agent tractor or Architect
The foregoing instrument was aknbwledged before mel The foregoing inst ment was aknowledged befo me
this ! day of � 201�by V`�" this 11 day 2 js fi , 201 by
Who is personally known to me or who has produced who af%\)
personally known to me or who has produced
as indentiflcation. 4 (I�) `M 6 S— as indentification.
Notary
blic:
Notary
Sign:
�e
Sign:_
P
. .
'�
•'-
Seal:
Notary Public
f Florida
My Comm. Expires F 11, 2017
Commission N EE 873545
Seal:
Notary Public JState of Florida
My Comm. Expires Feb 11, 2017
Commission N EE 873545
Arlenis Silvera
From:
Sent:
To:
Subject:
Attachments:
To: Arlenis Silvera
From: Leacroft Bailey
ted@ltbelectricalservice.com
Tuesday, July 15, 2014 6:39 PM
Arlenis Silvera
Permit Info
20140714_110214jpg;scan0037.pdf
This letter is to inform you of a change of contactor at 1001 NE 96 Street, I am requesting that that there is no
call for inspection unless I come to the City of Miami Shores and schedule this inspection myself for permit #
EL-14-1302. Furthermore attached is a notarized the filled out change of contract form that is required by the
city. Both the owner and the contractor signature are on the form which is notarized. Which prove that owner
and contractor no longer has work relation. Also attached is a release of liability.
Thanks in regards, Leacroft Bailey
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
BUILDING
PERMIT APPLICATION
❑BUILDING)ELECTRIC ❑ ROOFING
-M y
JUN i 2014
BY:
FBC 20 �3
Master Permit No.ot�lq -1300
Sub Permit No. ELI -i — Ic5
cz-
[:] REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: %00 F
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):rkle"e-k Phone#: 74� 2Q 0e2,-L--z d
Address: to a / %jF 94,` S 7-
City:
Tenant/Lessee Name:
Email
C wr.--
CONTRACTOR:: Co pany Name: L7
Address: 3656 SW C
City: /to r-F 160 er
Qualifier Name:
State: f
rl-�' 2 d C 0 iv^
—,TP/✓
State: /
Phone#:
Zip: > 33I2
State Certification or Registration #:A eC / 300
� a� Certificate of Competency #:
DESIGNER: Architect/Engineer:
ri-Ilse, C
F(K(G,v(i Phone#:
3y� S o� 61611
Address: l 6' CI �� %(�
City: A'i-- State:
Tr Zip:
Value of Work for this Permit: $
01),2 '
0
U Square/Linear Footage of Work:
Type of Work: ❑ Addition
❑ Alteration
El NewRepair/Replace
❑/Demolition
Description of Work: ,-e lac,l
a , 'r een o✓2,
O20A2A �
SWi`%�f eS <� 41c'
Specify color of color thru tile:
Submittal Fees Permit Fee $ �1„3, 0� CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
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 issued. In the absence of such posted notice, the
inspection will not be approved and a reinspectiotj fke will be charged. n
Signature Ai1,�,.�-,i/X/ / r ;' Signature,
OWNER or AGENT \, / / / / CONTRACTOR
The foregoing instrument was acknowledged beforeme this
l�f r day of ^ - 20 1611 by
k� who is son ly wn to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
The foregoing irKtrument was acknowledged before me this
J L-3 . A�of 20 % by
1-3qci
t404ho is personallyknowppn to
me or who has produced >�— !4�-�) as
identification and who did take an
\\��111\llllllll i/
NOTARY PUBLIC:
:Sign:
Z//, ZPrint:
,J
40RIDP
,//IIIIII1 ,
Seal:
\�����111111111 rrriii
Cty
ca
111111111
d��
APPROVED BY ��i� .F�' ��i` r Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner - Workers' Compensation 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:
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;
The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
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. In these circumstances, Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be
personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner Yl
Print Name: N I�
Signature:
State of Florida )
County of Miami -Dade ) I
Sworn to and ubscribed before me this
day of , 20
By
(SEAL)
Tvve of Identification produced r �hsi
CDR
Contractor
Print Name: /rg CRO %F
;% t
Signatur . d14—
State of Florida )
County of Miami -Dade )
Sworn to 9d subscribed before me
this
day of
��` Ar/,
By
(SEAL)
Type of Identification produced
; .� •, o� o� ,� .
'fie
ra_•�,"----•
ID A
��iI/11111
n ►00
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. COPY OF QUALIFIER'S STATE LICENCES
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF LIABILITY INSURANCE*
D. COPY OF WORKERS COMPENSATION INSURANCE*
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER
B. COPY OF LOCAL BUSINESS TAX RECEIPT
B. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL
CONTRACTOR'S TAX RECEIPT.
C. COPY OF LIABILITY INSURACE*
D. COPY OF WORKERS COMPENSATION INSURANCE*
*YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW:
Certificate Holder:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
Certificate must specify the description of operations or contractor license number.
BUSINESS NAME: L T 6IPdf«c
BUSINESS ADDRESS: �� 3 h 56y c CITY 1�✓ /�'�� �r
STATE r-*" ZIP CODE 3 �3I2-
BUSINESS PHONE: ( G �j l �� FAX NUMBER( ) 6 �� 1
CELL PHONE () g QUALIFIER'S NAME:
QUALIFIER'S LIC NUMBER:
i
—Y\-�V ��/'"�-\V-VVvt-■-.' ry vier rvv..�rvv •. .ice .�r�r..
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1, 2013 THROUGH SEPTEMBER 30, 2014
DBA: Receipt #:EL CTR18CAL/ALARMS/CONTF
Business Name; LTB ELECTRICAL SERVICES INC Business Type: CONTRACTOR)
Owner Name: LEACROFT T BAILEY Business Opened:07/05/2004
Business Location: 3636 SW 21 CT State/County/Cert/Reg:EC13005352
FT LAUDERDALE Exemption Code:
Business Phone: 954-689-8811
Rooms Seats Employees Machines Professionals
1
r
For Vending Business Only
Malmhor of Unrhinac• VBndino Tvne:
Tax Amount
Transfer Fee
_NSF Fee
Penalty
Prior Years
I Collection Cost
I 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:
LEACROFT T BAILEY
i 3636 SW 21 CT
FORT LAUDERDALE, FL
33312
2013 - 2014
Receipt #OIA-12-00010443
Paid 07/23/2013 27.00
of STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
BAILEY, LEACROFT T
L.T.B. ELECTRICAL SERVICES, INC.
3636 SW 21 ST CT
FORT LAUDERDALE FL 33312
Congratulations! Wth this license you become one of the nearly
one million Floridians licensed by the Department of Business and
Professional Regulation. Our professionals and businesses range
from architects to yacht brokers, from boxers to barbeque restaurants
and they keep Florida's economy strong.
Every day we work to improve the way we do business in order to
serve you better. For information about our services, please log onto
www.myfloridalicense.com. There you can find more information
about our divisions and the regulations that impact you, subscribe
to department newsletters and learn more about the Department's
initiatives.
Our mission at the Department is: License Efficiently, Regulate Fairly
We constantly strive to serve you better so that you can serve your
customers. Thank you for doing business in Florida,
and congratulations on your new license!
(850) 487-1395
%•,_ STATE OF FLORIDA
DEPARTMENT OF
4 g PRO ESSONAL REGUILATION NESS AND'-
EC13005352 ISSUED_: 07/14/2013-
CERTIFIED ELECTRICAL -CONTRACTOR --
BAIL'EY,'LEACROFT T - -
- L.T.B: ELECTRICAL SERVICES, INC.
is CERTIFIED_unde7r the oGisions-of
t r h 489 FS-
Expiration date :,AUG:'/UG 31, 2014 --------- -'
The
DETACH HERE
t _ - -
q
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD.,
The ELECTRICAL CONTRACTOR
Named below IS CERTIFIED`
Under the provisions of,Chapter,489 FS.
' -Expiration date:- AUG' 31, 2014
io
BAILEY LEACROFT;r
L'T;B-.ELECTRICAL SERVICES; INC.
_ _'`
-3636,SW21ST'CTY --� _ _
FORTLAUDERDALE" �FL333.12 - ' +►; i
VIVA Fl0RI0A 500,
RICK SCOTT ISSUED: 07/14/2013 SEQ # L1307140000369 KEN LAWSON
Ad"- ft'��4
�� 08-01-2012
`'`��'aO NE f¢'4 '
JEFF ATVVATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 08/01/2012
PERSON: BAILEY
FE I N: 562465040
BUSINESS NAME AND ADDRESS:
LTB ELECTRICAL SERVICES INC
3636 SW 21 CT
FT LAUDERDALE FL 33312
SCOPES OF BUSINESS OR TRADE:
1- ELECTRICAL WIRING WITHIN BUILD
EXPIRATION DATE: 08/0112014
LEACROFT
IMPORTANT: Pursuant to Chapter 440 . 0504), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this
section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.0502), F.S., Certificates of election to be exempt... apply only within the
scope of the business or trade listed on the notice of election to be exempt Pursuant to Chapter 440.05(13). F.S.. Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation it, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or
certificate no longer meets the requirements of this section tar issuance of a certificate. The department shall revoke a certificate at any time for failure of the person
named on the certificate to meet the requirements of this section.
QUESTIONS? (850) 413—
OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW '..,
EFFECTIVE: 08/01/2012 EXPIRATION DATE: 08/01/2014
PERSON: LEACROFT BAILEY
FEIN- 562465040
BUSINESS NAME AND ADDRESS:
LTS ELECTRICAL SERVICES INC
3636 SW 21 CT
FT LAUDERDALE. FL 33312
SCOPE OF BUSINESS OR TRADE:
I- ELECTRICAL WIRING WITNIIe BUILD
IMPORTANT
OPursuant to Chapter 440.0504), F.S., an officer of a corporation who
elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chapter.
Pursuant to Chapter 440.0502), F.S., Certificates of election to be
H exempt.. apply only within the scope of the business or trade listed on
E the notice of election to be exempt
R
E Pursuant to Chapter 440.0503), F.S., Notices of election to be exempt
and certificates of election to be exempt shall be subject to revocation
if, at any time after the filing of the notice or the issuance of the
certificate, the person named on the notice or certificate no longer mee
the requirements of this section for issuance of a certificate. The
department shall revoke a certificate at any time for failure of the
person named on the certificate to meet the requirements of this
section.
CUT HERE
QUESTIONS? (850) 413-160E
* Carry bottom portion on the job, keep upper portion for your records.
OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
Jun 13 Z014 12:09:43 EDT FROM: F2M/17620076456 MSG# 615ZB104-007-1 PAGE 064 OF 006
'CERTIFICATE OF LIABILITY INSURANCE 8.05
16/1I(:3/2014)
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 be endorsed. If SUBROGATIONIS WANED, 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 endorsoment(s).
AC EN`IES IN!:HS
210204 P: (r8n66) 467--87.30 F: (888) 443-61.I.2
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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.
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CERTIFICATE HOLDER .....,... _,.__.
Miami. Shores Bl:l:L.1C1ing Dept.
10050' NE: :2ND AVTt,
M;1;AK ,`'itIC,7F [ C�, F1,, :3 3.1,38
ACORD 25 (2014/n11
ri.e Amon
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEPORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
..-..... ....... .—w— — ,-L, .Oi01 .. 111379 11S! Ur A%klu •CLI
Miami Shores Village
Building Department
BY:
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING ELECTRIC ❑ ROOFING
JUL 10 2014
FBC 20 10
Master Permit No.e
Sub Permit No. El d_ 1302_.
❑ REVISION EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
C� {7
JOB ADDRESS: 100 AJF C S,1—
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder)
Address: �w / luF. 4?G
City: r//l.,Ce7t
Tenant/Lessee Name:
Email
<.
State:
Phone#:/T 72f 2-2jF
hone#:
Zip:'3�>%S S--
CONTRACTOR: Company Name:
0efVelf
v
L)dt ��
Phone#: �ds s s% - OEt('�'
Address: C 9-2 22— w
13 % rr
'4 Le-
City: A. �4^ i
r--
State: �-' (
G
Zip: � O b
Qualifier Name: ��%�
`/ �U�� <S
Phone#: 3 �S'"gl "o�
State Certification or Registration #:
C 4t
n
.E�v Certificate of Competency #:
DESIGNER: Architect/Engineer:
C« v
Phone#:
Address: �f �l Gl N� 3 52 City: A- "(1�r State:.( Zip: /3l ,2-
Value of Work for this Permit: $ 'V Square/Linear Footage of Work:
Type of Work: ❑ Addition /❑ Alteration ❑ New ❑ epair/R place ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee $ h - .Permit.Fee•$Ld CCF $ W CO/CC $ K
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 7`C
(Revised02/24/2014)
k
Bonding Company's'Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State
Zip
Zi
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 tpg absen of such posted notice, the
inspection will not be appr ved and a reinspection fee will be charged.
i�
Signature Signature it
1 —
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of 20 �G� by
who is personally known to
me or who has produced 4:! �- ey6 =R22 FLZD as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
The foregoing instrument was acknowledged before me this
1!j7-- day of44� 20 / L/. by
l%U/lG/_S� who is personally known to
me or who has produced j? C� ,4.S'9 s
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
VRr ous Notary Public State or t lonuo
Seal: _�°: Joanna M Feliciano S I� w Notary Public State of Florida
My Commission FF 082753 Joanna M Feliciano
Expires 01/121201 B
My Commission FF 082753
of W Expims 01/12/2018
******************************************************** ********************
APPROVED BY 17ZiG,' ,2o/Otans Examiner
Zoning
Structural Review
(Revised02/24/2014)
Clerk
Miami shores
Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
Permit N. /`�3 °U
Owners Name (Fee simple Title Holden:_ .0 ���c/ U�UfPhone
Owners Address. 1120 / ivy q 6{F Vf'
City:
State: F< Zip Code:
Job Address (Of where work is being done): /6�
City: Miami Shores State:_Florida Zip Code:
Contractor's Company Name: �� wet b C ,���5,,� Phone
Address: aa�� S�v 1 Sr -
City:
Qualifier's Name:
Architect/ Engineer of Record Name:
State:_ r i Zip Code:_3,"
Lic. Number. -cc yK!p pO
Phone #:
Address:
City: State: Zip Code:
Describe Work: C,4 `c4chiP� ,p/ �S
1 hereby certify that the work has been abandoned and/or the contractor/architect is
unable or unwilling to complete the contract. I hold the Build! ff! . I nd the
!am' Shores h less for III al lnvoly n .
Signature Signature _
ownetorAgent ct
Contractor or
The foregoing instrument was aknowledged before me The foregoing ins ument was aknowledged before me
this day o,20/yby.k.:�!UP46 this day of 24/!�y �'
Who is personally known to me or who has produced who is personally known to me or who has produced
p( �--?' as indentification, j�bO2o?S�"DI�'3ys' d as indentification.
Notary Public:
Notary Public:
:%Mfl
Sign:
c State f Florida
.Seal: r�
NotaryFeliciano pubiic State o d
M Feliciano
sion FF 082753
212018
,
Joanna
mission FF 082753
My re
E.9
41 il. It.
L.T.B. Electrical Services, Inc.
3636 S.V. 21 CT. Fort Lauderdale, FL 33312
TEL:(951)689-S811 FA1:(954)636-1754
LIC 9: EC13005352 Emarl- ted@ltbelectricalservice.com
Release of Liability
Property Name: Lund's Resident
Property Location: 1001 NE 96 Street Miami Shores, FL 33138
Undersigned Customer: Kenneth Lund
Payment amount:
Upon receipt by the undersigned of a check from Kenneth Lund payable to L.T.B Electrical
Services, Inc and when the check has been properly endorsed and has been paid by the bank
which is drawn, this document shall become effective to release any intention to hold lien, to
stop notice or bond right the undersigned. All liabilities and responsibilities will also be release
against L.T.B Electric, including the one year service warranty.
L.T.B ELECTRICAL SERVICE INC
Submitted By: Ted Bailey, Service Manager Date: 7/14/2014
Release of Liability Accepted By:
Autho Print: Van:
Date: 7
Signing is the acce tance of the above
STATE OF FLORIDA
- DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
F -
ELECTRICAL CONTRACTORS LICENSING BOARD
1940 NORTH
TALLAHASSEEMONROE STREET
-9-9-0783
PURKIS, MICHAEL JOHN
POWER BY PURKIS, INC.
12222 SW 131ST AVE
MIAMI FL 33186-6402
ri
Congratulations! With this license you become one of the nearly one million
Floridians licensed by the Department of Business and Professional Regulation.
Our professionals and businesses range from architects to yacht brokers, from
boxers to barbeque restaurants, and they keep Florida's economy strong.
Every day we work to improve the way we do business in order to serve you better
For information about our services, please log onto www.myfloridalicense.conL
There you can find more information about our divisions and the regulations that
impact you, subscribe to department newsletters and learn more about the `
Department's initiatives. ,
Our mission at the Department is: License Efficiently, Regulate Fairly. We
constantly strive to serve you better so that you can serve your customers.
Thank you for doing business in Florida, and congratulations on your new licensel
AC# 6161-806
DETACH HERE
STATE OF FLORIDA
(850) 487-1395
WATF of FLORIDA AC# , sr L 6.5 8 0 6
DEPARTMENT'OF BUSINESS AND
PROFESSIOiNALi REGULATION
ER0014410 %06/13./12 118187781
'REG ELECTRICAL"<CONTRACTOR
PURKIS, MICHAEL--JOHN
POWER BY P.URKIS' 1INC.. ; `
(INDIVIDUAL",MUST MEET ALL LOCAL
LICENSING REQUIREMENTS PRIOR
TO CONTRACTINGUIN!ANY AREA)
iiAS REGISTERED under the provisions of ch.489
X piration data, AIIG 31, 2014 L12061301072
DEPARTMENT OF�BUSINESS.AND PROFESSIONAL REGULATION
ELECTRICAL. CONTRACTORS LICENSING BOARD. SEQ#L12061301072
06/13`/2012 118187781 ER00144101 t.
The ELECTRICAL CONTRACTOR 6,-
Named below HAS REGISTERED �'; ; _ }
Under the provisions of Chapter*'489--BPS,.
Expiration date: AUG 31, 2014
(INDIVIDUAL MUST MEET ALL LOCAL LICENSING}
REQUIREMENTS PRIOR TO CONTRACTING IN=Ai4Y.'-AREK)y. y
PURKIS, MICHAEL JOHN �:,.' j" ter'.
POWER BY PURKIS , - INC . -^ M
12222 SW 131ST AVE;'r 'r►t `�,`� ~
MIAMI FL 3 318 6- 6 4 b-21
RICK SCOTT
GOVERNOR
DISPLAY AS REQUIRED BY LAW
KEN LAWSON
SECRETARY
CTQB
Construction Trades Qualifying Board
mv,
BUSINESS CERTIFICATE OF COMPETENCY
94E000048
POWER BY PURKIS INC
D.B.A.:
PUR I�AEI_
Is certified under the provisions of Chapter 10 of Miami -Dade County
VALID FOR CONTRACTING UNTIL 09/3012015
Local Business' Tax Receipt
Miami -Dade: County, State of Florida
—THIS IS NOT A BILL — DO NOT PAY
3129723
131.16INESS NAME/LOCATION
POWER BY PURKIS INC
5901 SW 93 PL
MIAMI FL 33173
NER Y
VER BY PURKIS INC -f
-ker(s) 1
1
This Local Business Tax Receipt only,
permit, or a certification of the holder
nongovemmental regulatory laws and
Thte RECEIPT NO. above must be
1\ Iftom► .. For more ii
RECEIPT NO. EXPIRES I
RENEWAL SEPTEMBER 30, 2014�
3268638 Must be displayed at place of business
Pursuant to County Code
�— Chapter 8A — Art. 9 & 10
i
SEC. TYPE OF USINESS
196 ELECTRICAL CONTRACTORrPAMENT RECEIVED
94E000048 AX COLLECTOR
t $75.00 07/11/201a3
f I TXHS1�13-024489
�'"�� - ,1
nfirms payment of the Local Business Tax. The Receipt is not a license,
lualifications, to do business. Holder must comply with any governmental or
gturements which apply,to the business. e r
isplayed on all commercial vehicles — Miami —Bade Code Sec fla-276, r
irmation, visit www.miamidede aovRaxcollector ILJI
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation 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:
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;
The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
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. In these circumstances, Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be
personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner Cont c o
i
Print Name: Print Na
Signature: 614 Signature: 'U.
Oro u cu
c o
0
(Mcm
IL
State of Florida) 4�' . N State of Florida) ¢ M
County of Miami -Dade) a County of Miami -Dade)
Sworn t subscribed before me this i Sworn to and subscribed before me is
day ,o 20 `° " ' day
of �.
' zR�� y ,20
z-1iZ,L
BY tenAgh�By_pf(lhap lud.
•r0�b
(SEAL) `• (SEAL) 3
Type of I entification produced �7'fj Tvpe of I entifrcation nroduced
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 8/22/2013 EXPIRATION DATE: 8/22/2015
PERSON: PURKIS MICHAEL
FEIN: 650412525
BUSINESS NAME AND ADDRESS:
POWER BY PURKIS INC
12222 SW 131 AVENUE
MIAMI FL 33186
SCOPES OF BUSINESS OR TRADE:
ELECTRICAL WIRING
WITHIN BUIL
Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may
not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S_, Certificates of election to be exempt.. apply only within the scope
of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation if, at arty time after the filing of the notice or the issuance of the certificate, the person named on the notice or
certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the
person named on the certificate to meet the requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609
POWER-3 OP ID- AA
CERTIFICATE OF LIA
THIS CERTIFICATE IS ISSUED'AS A MATTER OF INFORMATION ONL
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITI.
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, thE
the terms and conditions of the policy, certain policies may require an E
Certificate holder In lieu of such endorsements .
PRODUCER
MDW insurance Group Inc
362 Minorca Ave
Coral Gables, FL 33134
Thomas E O'Keeffe
INSURM Power by Purkis, Inc
Michael Purlde
12222 SW 131 Ave # 13
Miami, FL 331BM402
I,BILITY INSURANCE DATE(rAM/DDIr"
07/15/2014
Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
TE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
Policy(fes) must be endorsed. If SUBROGATION IS WAIVED, subject to
ndorsement. A statement on this certificate does not confer rights to the
NANNIEAC Ana Montane r0
PH°NE aos�4a-23z4 No a No): 305-444-4980
ADD s: amontene ro Indwinsurance.com
INSURE S AFFORDING COVERAGE
NAIC 4
MURER A: Travelers
10647
INSURER B
INSURER C :
INSURE k p ;
INSURER E.
INSURER F-
^ 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.
ItL R ADDL
TYPE OFINBURANCE PO
POLICY NUMBER MMUDD EXP LIMBS
GENERAL. UAEALnY
v I I EACH OCCURRENCE Is
MERCIALGENERAL LIABILITY
CLAIMS -MADE FRI OCCUR
LIMIT APPLIES PER:
AUTOMOBILELIABILITY
04/20/20141 04/20/2015
MED EXP (Any one
ANY AUTO
ALL OWNED
SCHEDULED
IN"
BODILY INJURY (Per person) S
AUTOS
AUTOS
NON -OWNED
BODILYINJURY(PeraocMent) _
HIRED AUTOS
AUTOS
D e S
PER P
UN6RELLALJAB
OCCUR
��� LIAR
EACH OCCURRENCE _
CLAIMS�rtADE
AGGREGATE ;
_-- --
WORKERS COMPENSATION
AND 11IMPLOYERS' UABIDTY WCANY STATU•
IN
OERR/MEI BER EgXCLUD D9 Y
FFICE❑ N / A E.L. EACH ACCIDENT
(Mandelory in NH)
N yes, describe under E.L. DISEASE - EA EM
DESCRIPTION OF OPERATIONS below EL DISEaRF _ pni er
SCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Adagl ACORD 101, Addroond Renwus schcaule, Ir more epwc Ls re lLamd)
ectriCal Wiring within buildings.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED, BEFORE
MIAMI SHORES VILLAGE BUILDING THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
DEPT_ ACCORDANCE WITH THE POLICY PROVISIONS.
FX#305 756-8972
10050 NE 2ND AVE AUiH►OOwEl)UPKsEWATIVE
MIAMI SHORES, FL 33139
01988-2010 ACORD CORPORATION_ All rights reserved-
25 (2010/05) The ACORD name and logo are registered marks of ACORD