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EL-18-104Permit No. EL -1 -18-1,04 sy°ids y Miami Shores Village Permit Type: Electrical - Residential 10050 N.E. 2nd Avenue NE Pen ' Work ClaSsiflcation: Addition/Alteration Miami Shores, FL 33138-0000 Permit Status: APPROVED Phone: (305)795-2204 F+<O RtDA issue note 1/1612018 Expiration: 07/15/2018 Project Address Parcel Number Applicant 10007 NE 4 Avenue 1132060170490 Miami Shores, FL Block: Lot: JOHN &CRISTINA BUTLER WMANEWMWNRACM owner Information Address JOHN & CRISTINA BUTLER 10007 NE 4 Avenue MIAMI SHORES FL 33138- 500 NE 102 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone KELLY BENSON ELECTRIC INC (954)921-5400 e of Work: TOTAL DEMOLITION OF EXISTING ELECTR itional Info: TOTAL DEMOLITION OF EXISTING ELECTR ssification: Residential nning: 1 Fees Due Amount CCF 31.80 DBPR Fee 27.81 DCA Fee 18.54 Education Surcharge 10.60 Permit Fee - Additions/Alterations 1,854.13 Scanning Fee 3.00 Technology Fee 42.40 Total: 1,988.28 Phone Cell Valuation:$ 52,975.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # EL -1-18-66123 01/12/2018 Credit Card $ 50.00 $ 1,938.28 01/16/2018 Check #: 118 $ 1,938.28 $ 0.00 Avauame inspections: Inspection Type: Final Relocation Fire Alarm Service Change Review Electrical W. W. Underground 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 requireVor ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNS JFFT VIT fy thajalWthe foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constr ctio an onin t ermor I uthorize the above-named contractor to do the work stated. January 16, 2018 Authorized SigWturN' Owner / Applicant / Contractor / Agent Building Department Copy January 16, 2018 Miami Shores Village REC -' . 11 Building Department JAN 1 zos 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY:-- __L Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 201 1 s} BUILDING Master Permit No. RC I1— 148Z PERMIT APPLICATION Sub Permit No. CL 1-16-104 BUILDING ELECTRIC ROOFING REVISION EXTENSION RENEWAL PLUMBING MECHANICAL PUBLIC WORKS [:]CHANGE OF CANCELLATION SHOP c 11 CONTRACTOR DRAWINGS JOB ADDRESS: (000-4 iV l " p V &y) VA,. City: Miami Shores County: Miami Dade Zip 3( 38 Folio/Parcel#: 0(-4 — ©Y(o Is the Building Historically Designated: Yes NO Occupancy Type: Q,—, Load: Construction Type: WU Flood Zone: ) BFE: 01A FFE: 10 OWNER: Name (Fee Simple Titleholder): —%V\ t CX' 5A r\& ?M l ktA* Phone#: 3015 — ORO --1 4 ( 01 Address: Wb--:!- 0E 4& p %)ex\LLk, City: V A Qnti a S\1\0 f V\ , State: V11- Zip: 3313 3 Tenant/Lessee Name: {lJ Email: GI '-A+ttr CONTRACTOR: Company Name: (,l\ Address: P 0 bOX aa34 h 0 e#: i& TANG Phone#: -! y4 - 444 — 44 1 City: 4 0«y U1 tj . 2 State: rt/ Zip;2ai5150 . Qualifier Name: F (I1y i!Jw5Glr\ p Phone#: __15 4' Ljg q-yq q 9 State Certification or Registration #:( iC 00 •1` 15 Certificate of Competency #: qDESIGNER: Architect/Engineer:` p Y aA lJw Phone#: 305 Address: 013M N • W "k" p ' 33i G VV City: M,1(SZ1N lt State: Zip. Value of Work for this Permit: $ °! 5 Square/Linear Footage of Work: Type of Work: Addition Description of Work: Alteration New s vykou Repair/Replace Demolition is'kifV, P'topmci-P SVs+-,o "rV1 Qelf v1 p C12, PYC, Llq"'oa Specify color of color thrulile: R i Submittal Fee $ t Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Technology Fee $ Structural Reviews $ Revised02/24/2014) Radon Fee $ Training/Education Fee $ DBPR $ Notary $. Double Fee $ _ Bond $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) 4 ) l A Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) 0 A x 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 th ce of such posted notice, the inspectionw of be approved and a reinspection fee will be charged. r ! t Signature Signature OWNER or AGENT The foregoing instrument was acknowledged before me this I() day of/ ` (, 20 Z d by who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: G44J.' G--1 hPb (/ Seal: zci APPROVED BY Revised02/24/2014) The foregoing instrument bs acknowledged before me this 16 `'dray of ; A h i N 20/3 by ell-GivS O 1V who is personally known to as me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: / Print: 4cr 1A tjU S as Seal: CATHERINE A. DUFFIN Notary Public - State of Florida '.+i_ " •.,, CATHERINE A. DUFFIN Commission k GG 104296 Notary Public -State of Florida e**QrA Ys6ii Ni4GK1 k*** ************** Bondvd through National Notary Assn. My comm. Expires May 14, 2021 t3onu<lthroughNalionalNotaryAssn. c X/0-A/Alans Examiner Zoning Structural Review Clerk A V CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 01/10/2018 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(les) 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 CONTACT Jadyn StamperNAME: Corporate Insurance Advisors PHONE E ( 954)315-5000 ac No : (954)315-5050 M. FMAILs: JStamper@ciafl.netADDRE1401EBrowardBlvd INSURER(S) AFFORDING COVERAGE NAIC # Suite 103 INSURER A: Monroe Guaranty Insurance Co. Ft. Lauderdale FL 33301 INSURED INSURER 8: FCCI Insurance Company 10178 Kelly Benson Electric, Inc. INSURER C: FCCI Insurance Group PO BOX 223425 INSURER D: INSURER E: MED EXP (Any one person) $ 5,000 Hollywood FL 33022 INSURER F: COVERAGES CERTIFICATE NUMBER: 18-19 Master Cert 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. INSRLTR TYPE OF INSURANCE AOULSUOK INSO WVD POLICY NUMBER POLICY EFF MMIDD POUICYEXP MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 CLAIMS -MADE FX—I OCCUR DAMAGE ToRENTEIT PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000ACPP00065521207/26/2017 07/26/2018 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PO- X POLICY JET [_—] LOC PRODUCTS - COMP/OP AGG $ 2.000,000 Employee Benefits $ 1,000,000OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000Eaaccident BODILY INJURY (Per person) $ ANYAUTO B OWNED SCHEDULED AUTOS ONLY AUTOS CA100003111-02 07/26/2017 07/26/2018 BODILY INJURY (Per accident) $ HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY acaderdPZ PIP -Basic $ 10,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 5,000,000 C REXCESS LIAR CLAIMS -MADE UMB100014962-01 07/26/2017 07/26/2018 AGGREGATE $ 5,000,000. DED X RETENTION $ 10,000 WORKERS COMPENSATION X PER OTH- IANDEMPLOYERS' LIABILITY Y / N STATUTE I ER E.L. EACH ACCIDENT $ 1,000,000BANYPROPRIETOR/PARTNER/EXECUTIVE NIA 001WC18A50543 01/01/2018 01/01/2019OFFICER/MEMBEREXCLUDED? Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below 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) Except 10 Day Notice of Cancellation for Non Payment of Premium EC0001385/Electrical Contractor SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 f11 `w_k 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 AFFIDAVIT FOR 30 DAY TEMPORARY -ELECTRIC SERVICE NOTE: ELECTRIC SERVICE WILL BE DISCONNECTED "WITHOUT NOTICE" UPON 30 DAY TERMINATION UNLESS APPLICATION IS RENEWED. It is understood that the temporary -electrical approval by the Miami Shores Village, Building Department given in connection with the bnuilding being constructed under: Building Permit N: rNG F 400, k Electrical Permit N: At Address: 4' Miami Shores, FL For Owners: 8412AR and is being given only for construction pyrpose or for testing the ;pllowinaequipment in said structure: G 1 H9'1r6ZI, 0VtJ T!' The owner does herby agree to ass me the responsibility of maintaining the installation in such manner that there is no hazard to life or property. Such approval is in no event to be considered a RELEASE of said structure for the purpose of use and occupancy, and no occupancy shall be granted or permitted until further inspections have been called for and approved by the inspection divisions concerned, and/or a Certificate of Occupancy or Completion is obtained. The undersigned also understands that the temporary electric approval is subject to rescission and nancellation and electric power can be cut off at the discretion of the building official and will be disconcerted of ie building concerned is occupied before final inspections are approved and/or obtained a Certificate of Occupancy or Completion. Note: Failure to comply with the provisions of this affidavit will result in your beinunable to obtain future Temporary for Test permits. I, t'l5tl Pk Fobt+ •X , being first duly sworn, depose and say that I am the owner of the above described property, and that I agree that the structure covered in this agreement shall not be occupied 8bing il the building contractor has obtained approval of final inspections and/or obtained a Certificate of cupanc f mpletion. Note: Failure to comply with the provisions of this affidavit will result in our n bl t ob a' future Temporary for Test permits. v"' t 4N E A. t F ar at f Florida natur her ighslon;r IT I 134M E. Expires May 14, 2021 Bonded through National Notary Assn. I, ,\being duly sworn, depose and say tha a ec rlca ontractor for the ab v - crib d property and'that the electrical installations as now e s ing will not create a safety hazard if tem s i e is connected. OS,PY PU . MAWAD.— SiR6ature0 lectrical Contractor Ig at -f d ryMYCOMMISSION #cco44so2 EXPIRES: Noyember2, 2020BondedThn, imm being first duly sworn, depose and say' of the above described proWerty and that I will not permit occupancy of this building until final iI been called for by the contractors and sub -contractors concerned and final aper al by the ins obtaine and at I have the au hority insofar as the owner of said property is c n erne until u Jin a I spe ions ar btae d an /or Certificate of Occupancy or C pleti gnature of B ilding Contra Signaturf o Notary Signature of Inspector Signature of Notary division 4y COMMISSION # GG 238273 EXPIRES: September 3, 2022 MW nw Notairy Nk llklde„„ m