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EL-18-1079y! Miami Shores Village `ggortFs 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 FCORLDA Permit No. EL-4-18-1079 Permit Type: Electrical - Residential Perilinit Work Classification: Alteration Permit Staters: APPROVED issue Date: 4/26/2018 1 Expiration: 10/23/2018 Project Address Parcel Number Applicant 133 NE 100 Street 1132060132050 ROBERT STOUT Miami Shores, FL Block: Lot: Owner Information Address Phone Cell ROBERT STOUT 133 NE 100 Street (954)789-4173 MIAMI SHORES FL 33138- 133 NE 100 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone UNLIMITED ELECTRICAL CONTRACT (954)481-8250 of Work: REINSTALL 26 LIGHT FIXTURES, INSTAL onal Info: ification: Residential Tina: 1 9 Fees Due Amount CCF $2.40 DBPR Fee $3.38 DCA Fee $2.25 Education Surcharge $0.80 Permit Fee - Additions/Alterations $225.00 Scanning Fee $3.00 Technology Fee $3.20 Total: $240.03 Valuation: $ 3,500.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # EL-4-18-67275 04/26/2018 Credit Card $ 240.03 $ 0.00 Available Inspections: Inspection Type: Review Electrical :J: 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, PLPYBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: Ire+ that I the oing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. uth rrr1ore, onze the above -named contractor to do the work stated. April 26, 2018 Authorized Sig Building De / Applicant / Contractor / Agent nt Copy 1 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 Master Permit No. PERMIT APPLICATION BUILDING Fffi� ELECTRIC ROOFING F-IPLUMBING MECHANICAL DPUBLICWORKS JOB ADDRESS: 133 NE 100th Street _,NN/T--!� PR 2 A 2018 Fac 201")16`[� ,z.CIB-2o5 Sub Permit No. 107� 1 REVISION 0 EXTENSION RENEWAL CHANGE OF CANCELLATION SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-3206-013-2050 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: OWNER: Name (Fee Simple Titleholder): Robert Stout Address:133 NE 100 Street City: Miami Shores State: Tenant/Lessee Name: Email FL Flood Zone: BFE: FFE: Phone#: Zip: 33138 Phone#: CONTRACTOR: Company Name: Unlimited Electrical Contractors Corp Phone#: 954-481-8250 Address: 3500 Park Central Blvd. N City: Pompano Beach State: FL Zip: 33064 Qualifier Name: Mitchell Pagerey Phone#: State Certification or Registration #: EC0p000210,84�p /I ,ra '/� Certificate of Competency #: (, -�rchitec i'� Ivy- li�'�"''�'G' llrc u� Phone#: � 7t DESIGNEngineer: Address: 3 11 ME City: M 'S - State: Zip: Value of Work for this Permit: $ 3,500 Square/Linear Footage of Work: Type of Work: ❑ Addition M Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of work: Reinstall (26) light fixtures, install (2) new ceiling fans , and provide new 200 amp service Specify color of color thru tile: Submittal Fee $ Permit Fee $ yZ4n�' CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ DBPR $ Notary $ Double Fee $ Bond $ l L TOTAL FEE NOW DUE $ o 0 (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 appr d a d a reinspection fee will be charged. Signature Signature W"ELAGENT CONTRACTOR The foregoing instrume t was acknowledged before me this day of i 20, by who is ersonally known to me or who has produced identification and who did take an oath. NOTARY Sign: Print: , ��,�av DANETTE L. Seal: ,=o* °� Notary Public - State of Florida * * Commission # FF 190226 °_-F BondedthroughpNationaiNotary2019 ires Jan F�`�` F y Assn. APPROVED BY The foregoing instrumentwasacknowledged before me this b' 9 day of 20 )0 by lgmr% ��--rRl L� who is EinalEown to as me or who has produced identification and who did take an oath. NOTARY PUBLII Sign: Print.,' rin ' Seal: ####################### Plans Examiner _ Structural Review r*l n ,�tPR�P�a DANETTE L. ROBINSON Notary Public - State of Florida •- Commission # FF 190226 ''•�fe �6; My Comm. Expires Jan 15, 2019 Zoning 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 CONTRACTORS' REGISTRATION 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* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *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. rrrrrrrrrrrrrrarrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr�rrrrrrrrrrrrrrrrrrrrr• BUSINESS NAME::' BUSINESS ADDRESS:'356fJ fa to &, bellI dA,' TATE BUSINESS PHONE: ( ���� —' C� FAX NUMBER (r CELL PHONE (j QUALIFIER'S NAM` �C ' QUALIFIER'S LIC NUMBER: 9' RJOK SCOT% GOVERNOR " KEN LAWSON, SECRETARY DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD ECO002084 Ky A The ELECTRICAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 488 FS.� Expiration date: AUG 31 2018uw sx • 'PAGEREY, MITCHELL ROGE -' � ^^� �'�` y_. ^• ''� �� � � M UNLIMITED ELECTRIC `ATORSYCORP- �w�,ti' 3500 PARK CENTRAL; "POMPANO- BEAC-� r Q� •....� . ...:.y.:Y'eul" lfq. ii? . I �.�. ,1 .. sy ,1` 4 , '••n ...._ _ . ' iSSUED:._"J6�8)'!, (j' _ 'o."F1 � :•i- _ ...4i::'"° ,, •.. ., _..,•';• ..•''••,• �-, .. � ' ......._ _. ..;.:.. i'C.n'h"i7rrinrin•rrd...-.._.,�-� BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S, Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2Q17 THROUGI,,T,A,.FPTEMBER 30, 2018 DBA: UNLIMITED ELECTRICAL CONTRACTORS Receipt #:ELECTRICAL/ALARMS) Business Name: CORP Business Type: (ELECTRICAL CONTR) Owner Name:MITCHELL R PAGEREY Business Opened:08/07/1999 Business Location: 3500 PARK CENTRAL BLVD NORTH State/County/Cert/1109=0002084 POMPANO BEACH Exemption Code: Business Phone:954-481-8250 Rooms Seats Employees Machines Professionals 10 For Vending Business only Number of Machines: Vandrne Tuna: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collecdon Cast I Total Paid 27.00 0.00 0.00 0.00 1 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 Municipal€ty 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: MITCHELL R PAGEREY Receipt #108-16-00024565 3500 PARK CENTRAL BLVD NORTH Paid 09/19/2017 27,00 POMPANO BEACH, FL 33064 2017 - aois AC40j? a CERTIFICATE OF LIABILITY INSURANCE I DATE (MMI AE(MMI 111Y Y) 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 tEPRESENTATIVE 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 Bateman Gordon and Sands PHONE FAX 3050 North Federal Hwy AIL • 954-941-0900 Arc No : 954-941-2006 Lighthouse Point FL 33064 ADDRESS: hwhittingham@bgsagency.com INSURED UINLtLI INSURER B : Unlimited Electrical Contractors, Corp. 3500 Park Central Blvd. N INSURERC: Pompano Beach FL 33064 INSURERD: COVERAGES CERTIFICATE NUMBER: 1718830816 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. iLTRR TYPE OF INSURANCE AD L B POLICY NUMBER MN POLICY EFF Mt POLICY EXP LIMITS A GENERAL LIABILITY Y Y GL20536921001 5/1/2018 6/1/2019 EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR DAMAGE T RENTED PREMISES Ea occurrence $ 100,000 MED EXP (An one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 X Broad Form PD GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ POLICY X PRO- LOC AUTOMOBILE LIABILITY Y Y CA20536891001 5/12018 5/12019 COMBINED SINGLE LIMIT Ea accident 1,000,000 X BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per. accident $ HIRED AUTOS X NON -OWNED AUTOS A X UMBRELLA LIAB OCCUR Y Y CU20536930902 5/12018 5/12019 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED I X I RETENTION $ 0 $ A WORKERS COMPENSATION Y WC20636951101 5112018 5/12019 X WC STATU- I lOTH- ORY LIMITS I ER AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ 1,000.000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 A Rented & Leased Equipment CPP20536901002 5/12018 5/12019 Limit $130,000 Deductible: $1,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) General Liability: Blanket Additional Insured induding On -going and Completed Operations and Blanket Primary and Non -Contributory, as required by written contract, per Form CG7048(1015); Blanket Waiver of Subrogation, as required by written contract, per Form CG7049(1109). Automobile Liability: Blanket Additional Insured and Blanket Waiver of Subrogation, as required by written contract, per Form CA7171(0508). Umbrella Liability Blanket Additional Insured Primary & Non -Contributory, as required by written contract, per Form CU7467(1107); Blanket Wavier of Subrogation, per Form CU2403(0900); Umbrella policy extends coverage to General Liability (except General Liability per project aggregate), Automobile Liability and Workers Compensation(Employers Liability). Blanket 30 Days Notice of Cancellation as required by written contract, per Form IL7074(0116). Workers Compensation: Blanket Waiver of Subrogation, as required by written contract, per Form WC000313(0484). See Attached... Miami Shores Village Bldg Dept 10050 NE 2nd Avenue 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 IA�c0^C� /t//e-460^"' ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/06) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: UNLELI _ LOC #: A`oREY ADDITIONAL REMARKS SCHEDULE NCY NAMED INSURED ateman Gordon and Sands Unlimited Electrical Contractors, Corp. 3500 Park Central Blvd. N POUCY NUMBER Pompano Beach FL 33064 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE aLL COVERAGES SUBJECT TO THE POLICY TERMS, CONDITIONS AND EXCLUSIONS '.ontractor State License - EC0002084 Page 1 of 1 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD