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REV-09-22-2415, 100 NE 101st StMiami Shores Village mac,, y- Building Department 'SEP 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 1I Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (30S) 762-4949 BUILDING PERMIT APPLICATION ❑BUILDING dELECTRIC ❑ ROOFING FBC 20��G'"�D'� Master Permit No. Sub Permit No. ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP AlCONTRACTOR DRAWINGS JOB ADDRESS: ! O0 �G L0 City: Miami Shores County: Miami Dade Zip: 5313 Folio/Parcel#: Is the Building Historically Designated: Yes NO _ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Address: City: State: Tenant/Lessee Name: Email: Phone#: Phone#: CONTRACTOR: Company Name: oO J I Phone# Address: 603 N 21Sfi' 0 Email: Zip: Qualifier Name: Phone#: _ State Certification or Registration M Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: _ Address: City: State: Value of Work for this Permit: $ , !i!00 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Zip: ❑ Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ _ .:y.; CCF $ CO/CC $ Scanning Fee $ DCA Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ P&Z Review $ Bond $ TOTAL FEE NOW DUE $ (Revised04/05/2022) 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 the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature OWNER o(,r'�4�F,i The foregoing instrument was acknowledged before me this day of 20j, by nUro 116who is personally known to me or who has produced 2y1 WX�R as identification and who did take an oath. NOTARY PUBLIC: Print: Mn L I I w Seal: wwwwwww*w+rwwwww APPROVED BY (Revised04/05/2022) MERUNE CHERY MY COMMISSION A HH 262206 EXPIRES: April 12, 2026 Signature CONTRACTOR The foregoing instrument was acknowledged before me this d�6- 20, by �ol�n a� who is personally known to me or who has produced On Verd- 1 Ce U--P—as identification and who did take an oath. NOTARY PUBLIC: Sign: (9 lS zt,�Ao Print: Iry Seal: s MERUNE CHERY n a MY COMMISSION # NH 252206 '��or ,?••• EXPIRES:Apr912,2026 wwwwwwwwwwwwwwwwwwww wwwwwwwwwwwww Plans Examiner Zoning Structural Review Clerk Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 100 NE 101ST ST, Miami Shores, FL 33138 Permit No.: REV-08-22-241 5 Permit Type: Revision Work Classification': Electric Permit Status: Approved Issue Date: 09J2312022 Expiration: 03/22/2023 Parcel Number 1132060132020 Contacts BRYON THOMAS Owner MOODY ELECTRIC INC Contractor 136 NE 101 ST, MIAMI SHORES, FL 331382321 JOHN MOODY bryon.thomas@gmail.com 3812A N 29 AVE, hollywood, FL 33020 Business: 3057582000 barney@moodyelectric.com Description: REMOVE & REPLACE OUTLETS, REWIRE & REPLACE Valuation: $ 1,900.00 Inspection Requests: LIGHT FIXTURES SUB PANEL INSTALL, LIGHTED MIRRORS 1305-762-4949 Total Sq Feet: 0.00 Fees Amount CCF (Manual) $1.20 DBPR Fee (Manual) $2.00 Education Surcharge (Manual) $0.60 Notary Fee $5.00 Permit Fee (Manual) $100.00 Scanning Fee (Manual) $3.00 Technology Fee (Manual) $10.00 Total: $121.80 Payments Date Paid Amt Paid Total Fees $121.80 Credit Card 09/23/2022 $121.80 Amount Due: $0.00 Building Department Copy 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,at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoni Futhermore, I authorize the above named contractor to do the work stated. D 2 ®22 Authorize Signature: OVtefl/ applicant / Contractor / Agent Date October 04, 2022 Page 2 of 2 �..�� MOODY-1 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) �,_...-- 12127/2021 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 pollcy(ies) 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). r RODUCER 561-392-3300 W.cT Workers Compensation Group W. Workers Compensation Group PHONE 561-392-3300 FAX 561-361-1132 0 Box 410 (AIC, No, Ext) iAiC. No)! ioca Raton, FL 33429-0410 A t&ss certs@worke►scompgroup.com INSURER{$) AFFORDING COVERAGE NAIC 0 INSURER A: Bridgefieid Employers Ins 10701 i U ED , INSURERS Il�laSo y Electric, Inc 603 N. 21 st Avenue INSURER c Hollywood, FL 33020 INSURER D INSURER E _ INSURER F •rn A/•C'C ^• WNGI^ATO &1/Ii1DCn. DC�llelna.I RII Ia#DCD• 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 REOUIREMENT, 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, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _EXCLUSIONS INSRL.M TYPE OF INSURANCE AODLtso SUER_WVO POLICY NUMBERPOLICY EFF 111 POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE , $ __....., CLAIMS -MADE '.. OCCUR , DAMAGE TO RENTED ?t3EMl$E`�.LEa Qs urtfln&e1 .... MED FJtP jAny one pe{son.g. , PERSONAL_6 ADV_INUURY_._... .$._. -, GENL AGGREGATE LIMIT APPLIES PER POl ICY jE t CtC - , _PRODUCT5, COMPlOP AGG .- OTHER ' i AUTOMOBILE LIABILITY, COMBINED SINGLE LIMIT ANY AUTO - OWNED SCHEDULED AUTO, ONLY AUTOS 80DILY INJURY (P r eent)�$ $ HIRED NOy..,TpVNEU ONLY Pr20PE!iTYpAMAC'E f ;. e«ccanf} ;_$.. AUIc1& Orn y AUTOS ._ . ._ UMBRELLA LIAB OCCUR _EACH OCCURRENCE EXCESS LIAB ., CLAIMS -MADE '.,_AGGREGATE DIED RETENTION$ A WORKERS COMPENSATION - X MUSE. AND EMPLOYERS' LIABILITY Y/ N X 830.2it673 01101/2022 0110112023 _$ :_ERH- -- - --- ,00 1,0000 ANY PROPRIE70PJ"RTNERlEXECUTIVE N I A EACH EACH ACCIDENT _ _ ff OMFFICan�EERAB H} EXCLUDED^ 9 000,000 ire EL DiSERSE - EA FJ+dPLOYEE.$.... ye5. descruDe under DESCRIPTION PRAT NS 1,000,000 E.L. DIS E - I LIMIT DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES (ACORD 101, Addi tonal Remarks Schedule. may be coached If more space Is required) Electrical Contractors 'A blanket waiver of subrogation is provided under workers' compensation in favor of Village of Miami Shores. MIAMIS3 Village of Miami Shores Fax:305-756-8972 10050 NE 2nd Ave. 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. AUTHORUED REPRESENTATIVE ACORD 25 (2016103) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDDrvYYY) 12/29/2021 r I , CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS EF TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. i the certificate holder Is an ADDITIONAL INSURED, the Po Icy ies must be endorsed. , su ect 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). NAVE: AndrewStenberg CMH Risk Partners A/C No.-Ext): 613-400-2720 j No): 813-440-2747 P.O. Box 271788 _ MAIL ADDRESS: andrew(&cmhriskpartners.com INSURER(S) AFFORDING COVERAGE NAIL # Tampa FL 33688 INSURER A FCCI INSURANCE COMPANY 10178 INSURED _ — _- INSURER B : ................... . FCCi Insurance Company 10178 Moody Electric, Inc. INSURER C 603 N 21 st Ave INSURER D : INSURER E ' Hollywood FL 33020 INSURER F COVERAGES rr-0TIcIrATC ►Ol"Mon. 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. AODL SUSR POUCYEFF POIICYE7P -- -- SR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIpp MM10D LIMITS )( COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAkTAGE7pRENTED" ` __.._ _ ai1dS MADE X OCCUR PREMISES (Ee occurrence $ 100,000 MED EXP (Any one person) $ 5,000 Y Y CM100064955-01 12/31 /2021 12/31 /2022 PERSONAL 6 ADV INJURY $ 1,000,000 _ __......_. . _ ._... _. . ____._ . --- - - -- GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT lOC PRODUCTS - COMPrOP AGG S Z000,000 OTHER _..._..... _ . $ AUTOMOBILE LIABILITY (Ee accident).... $ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ —' ALL OWNED SCHEDULED 8 , AUTOS _ AUTOS CA 100064957-01 12/31 /2021 12/31 /2022 BODILY INJURY (Per aewoent1 $ X i HIRED AUTOS X! NON-0SwNEO PROPERTY DAMAGE y —_ (Per accident) %( UMBRELLA LU+B X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LiA6 ................ -- CLAIMS -MADE CP100064960-07 1 Z/31 /2021 12/31 /2022 'AGGREGATE $ 3,000,000 DED X ! RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITYOut- YIN STATUTE ER ANY PROPRIETORIPARTNEWEXECUTIVE -- OFFICERIMEMBER EXCLUDEDP ❑ NIA E.L EACH ACCIDENT $ (Mandatory in NH) __ `..._. _ - IP yes, des�Ge under E.L DISEASE .EA EMPLOYEE! $ DESCRIPTION OF OPERATIONS oeWo, E.L. DISEASE - POLICY LIMIT $ SCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule. may be attached If more spate Is required) nl ` hnras Village is listed as an additional insured. CERTIFICATE HOLDER CANCELLATION 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 Avenue AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 riwPw AD IZU14ful) The ACORD name and logo are registered marks of ACORD ®BPR On -Line Services If you need to mail additional information to DBPR please include this coversheet. License Type: Registered Electrical Contractor Application Type: Registered Electrical Contractor - Initial License File Number: 21093 Application Number: 59599 License Number: Application Date: 09/22/2022 (mm/dd/yyyy' Last Name: Moody First Name: John Middle Name: Bernard Mail To: Department of Business and Professional Regulation Central Intake Unit 2601 Blair Stone Road Tallahassee, FL 32399-0783 If you have any questions please call our Customer Contact Center at 850-487-1395. L