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EL-16-1242y� Miami Shores Village �s*`oRFs 10050 N.E. 2nd Avenue NE �'•�, ""'� Miami Shores, FL 33138-0000 Phone: (305)795-2204 FGOR�Dp' Permit NO. EL-5-16-1242 Permit Type. Electrical - Residential Work Classification: AdditiontAiteration Pen "t Permit Status: APPROVER Issue Date:12t2112016 I Expiration: 06/19/2017 Project Address Parcel Number Applicant 121 NE 96 Street 1132060132580 CK PROPERTY SOLUTIONS LLC Miami Shores, FL Block: Lot: Owner Information Address Phone Cell CK PROPERTY SOLUTIONS LLC 209 NE 95 Street (305)758-3133 MIAMI SHORES FL 33138- 209 NE 95 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone E I ELECTRICAL CONTRACTORS IN( (786)621-5215 of Work: ELECTRICAL WORK FOR ADDITION OF NEW itional Info: ssification: Residential nning: 1 Fees Due Amount CCF $8.40 DBPR Fee $6.88 DCA Fee $6.88 Education Surcharge $2.80 Permit Fee - Additions/Alterations $459.00 Scanning Fee $3.00 Technology Fee $11.20 Total: $498.16 Valuation: $ 13,700.00 Total Sq Feet: p Pay Date Pay Type Amt Paid Amt Due I Invoice # EL-5-16-59708 05/09/2016 Credit Card 12/21/2016 Credit Card $ 50.00 $ 448.16 $ 448.16 $ 0.00 Available Insoections: 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. Futhermore, I authorize the above -named contractor to do the work stated. December 21, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy December 21, 2016 1 4 Miami Shores Village Building Department M Y 09 2016 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 201�4 BUILDING Master Permit No. —ezl r. — PERMIT APPLICATION Sub Permit No. E. ( ( - ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING [:]MECHANICAL []PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS '7? ` JOB ADDRESS: C City: Miami Shores County: Miami Dade zip: 3 3 Folio/Parcel#: / / - 32y 6 U/ 3 - Z S �{O2Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):�� Address: Z- 0q C. S " T` 3 0 s-- 7 S-t 313 3 City: �A t Q. m t 5 h 0�-C' S State: f L Zip: 3 313041 Tenant/Lessee Name: �9 Phone#: lam Email: V i V . V1i-7 F—C- [+0 NEE-5 P Co CONTRACTOR: Company Name: C: /C��.y .�_/� /171UY Phone# (-450 4tF Address: City: CL�1� State: Z:::Z %- Zip: Qualifier Name: �`'/ ✓� i Phone#: State Certification or Registration #: b L2 ?19. Certificate of Competency #: e9e -'Ole: ' 7z DESIGNER: Architect/Engineer:, ,1 (-e- N, Wa r0 i n- 6 y) AJA Phone#: 1524 y g 3 3 V 3� Address: V is City: PCM6 14e PirICS State: F-(, Zip: 330 Z p Value of Work fo7Addition ermit: $ 3 7& l% Square/Linear Footage of Work: Type of Work: ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Desc iption of Work: n tJJ mp-- -r (- V c J r©p ems► F'--r— -f Specify color of color thru tile: Submittal Fee $ 0� Permit Fee $ 4e✓�9-' ay CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ �— Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ —r TOTAL FEE NOW DUE $ 0975,10 (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 the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature �f6 OWNER or AGENT The foregoing instrument was acknowledged before me this day of f 20 /� by lid �?yGc� who /iss personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: O�PFtV PLBI�'• Seal: JIM D. PAMPLIN ? 2+ : Notary Public - State of Florida «ate; My Comm. Expires Jan 13, 2017 Commission # EE 864892 ssrs*sssssss *s APPROVED BY Signature , If CONTRACTOR The foregoing instrument was acknowledged before me this day of s��'�! .C� 20 16 , by p20S , who is personally known to me or who has produced �ii�' �� as identification and who did take an oath. NOTARY PUBLIC: Sign Print Seal ssssss**s****s******rss*ss*s*s**rs***s**rrrssrsrsrsssrrsrrrs* Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) CERTIFICATE OF LIABILITY INSURANCE tine 1/11/2016 per; Plymouth insurance Agency 2739 U.S. Highway 19 N. Holiday, FL 346591 1�camna"Lsissue-asacrawof, al is uodyaidcmzrm w au an aHorrled ee bel��snatama�d,exb�d (727) 938-M Ir15tEm Etg age IWC Insured: South East Personnel Leasing, Inc. & Subsidiaries 2739 U.S. Highway 19 N. Holiday, FL 34591 hmferA: lion Insurance Company insmerB: 11075 1Bsurerc: usurer D: it 6WW EE: Coverages ofinsunmoollstadbelowhaVebmissuedtothalroured named abovelorthepoicyperiodindioetea �g y 8 . term orormd of re+Y confratl or other deaanerd With respect to which thf3 ceNOgte maybe issued or may pertain. the insurance alrorded bythe poftdes described herein is subject to all the terms, exclusions, and conditions of such policies, Aggregate limits shown may have been reduced by Paid daims. ILIR l� Type of Irmurance Policy Number Da PoGoy EENY)] Pofxy Expiration Date (MM�D/ UmBs LIABILITY Each clommance Commercial General LiabTdy claims Made E3 Occur Ito reted_pre(EA Mad Ev Personal Adv injury enerai aggregate iimi applies per. pww ❑ E ❑ IOC taeneal Aggregate Prodacts-corrorop age flMO81L£ttABHJTY (EA Acddent) AnyAum Ewft—kfiay AM ovmed Autos Scheduled Autos (E-E'—) Etodily bony Hied Autos Nan-Owmed Autm (PerAcddent) Property Damage (PerAcriderd) EXCESSIUMBREUA LiABIL" Each °ouirie"ce Aggregate ooau ❑ CW=Made oeaucbma 7 Workers Compensation and Empioyers' LiabMy Any pmpnetodpartnedexeculive officerimember WC 71"9 01/01/2016 01/0112017 X I WC state- to Limns OTH- LIM. E.L Each Accident ai mew EL Disease- Ea Employee $1.000.000 excluded? No if Yes, desaiW under special provisions below. E.L. Disease - Policy Limns 51.000.000 Outer Lunt In ranee CwnpwW Is A.M. Best CompmWrated A- . AMB # 12616 DescriPttons of Operstlons(Locadomsilebehm Exdusions added by EndanwmenWSPeciat PnwWozw aent &. 92-69-681 Coverdge-only applies to active-employegS) of South East Personnel Lasing, Inc:. & Subsidiades-Utat are leased to the Company°: I E I Electrical Contractors Inc Coverage only applies to injuries insured by South East Pesonnel teasing, Inc & Subsidiaries active eff&y*s,, while worldrtg im FL Coverage does not apply to stabrtoryr employee(s) or independent aontraaor(s) of the Client Company or any other Oft A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937--21" or by Oft M 9M-SM State of Florida #ER 0012819 Miami Dade C.C. #000018971 Bedn Date 91712M CEfiriMATEcNo1DER CANCBAAT M Village of Miami Shores 1050 N.E. 2Ave. Shedd arty of the above des<aib� pores be cancelled befaa the eWntion dale Owed, the issuing Isar,,a�,aaa„oro�melisodayawrat�,no�etou,a hederrIn,adWtneWE:t,Araw"tn desashMEmpmnoob0gagmorbbftofmybhWupmUobmnxer ftagentsorreptasentsdvm Miami Shores, FL. 33138