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REV-07-22-1809, 29 NE 102nd StMiami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Parcel Number 29 NE 102ND ST, Miami Shores, FL 33138 1132060131650 Contacts Christian Ulvert & Carlos Andrade Owner WELL ELECTRIC TECHNOLOGY Contractor 29 NE 102ND ST, Miami Shores, FL 33138 TONY WELL Mobile: 3053363631 christian.ulvert@gmail.com 4310 NW 11 ST, MIAMI, FL 33126 Business: 3057267098 wellelectrictech@gmail.com Other:7864738455 Inspection Requests: Description: REVISION FOR EL-04-21-924 - INSTALLATION OF ValuLFeet: $ 5,000.00 f IE f EM OUTLETS AND LIGHTS Total2,000.00 Fees Amount Payments Date Paid Amt Paid Revision: Major Change of Plans $90.00 Total Fees $90.00 Total: $90.00 Credit Card 07/25/2022 $90.00 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 that all the for regulating' constFction a�'^d zoning^ Futhermore, I , accurate and that all work will be done in compliance with all applicable laws named contractor to do the work stated. i Z Authorized Signature: Owner / Apo'cant / Agent July 25, 2022 Page 2 of 2 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 JUL 18 ?022 BY FBC 20201"1 BUILDING Master Permit No. PC— /P'f ! ' z—? PERMIT APPLICATION Sub Permit No. ❑BUILDING LECTRIC ❑ ROOFING EVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS:,? I NG /0L 4al 5- o City: Miami Shores County: Miami Dade ZiP:33/3Q Folio/Pa Occupancy Type: Load: Construction Type Is the Building Historically Designated: Yes NO Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholl�der): ff.�/�� /�lnG�/� WK Phone#: In 1-57 �b 0114 � //te Address: Z e I(/z 492( J� O City: 1, 0kell-I;VI-e State: /47:41f Zip: Tenant/Lessee Name: Email CONTRACTOR:: Company Name:: VX& ae G7/z Phone#: `7 Address: &z V // zlfe / 99 City: /y/W1W1 State: Zip: Qualifier Name: To/% 1 Phone#:,01;0,7 �4!!/ State Certification or Registration #: j!!�Z /2100//(T / Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: Value of Work for this Permit: $ -1'**994PV Square/Linear Footage of Work: Zip: Type of Work: ❑ Addition ❑ Alteration 9-Kew // ❑ Repair/Replace ❑ Demolition Description of Work: y.,e Specify color of color thru tile: Submittal Fee Scanning Fee $ Technology Fee $ Structural Reviews $ Permit Fee $ Radon Fee $ Training/Education Fee $ CCF $ CO/CC $ DBPR $ Notary Double Fee $ Bond $ TOTAL FEE NOW DUE $ Oa (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 qpp ved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this � day of 20 �, by 6wjlg� , who is personally known to me or who has produced as 0.7 day of /,S 20 ZZ by aey who is personally known to me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: 1�,��� ��. Print: ' Seal: <'YP� • MARIADELAFE Seal: :,; .; MARIA DE LA FE MYCOMMISSION#HH117172 MY COMMISSION # HH 117172 EXPIRES: June 26, 2026 "••forF�Q.� EXPIRES: June 26, 2025 °fyF4••' Bonded Thru Notary Publk Underwriters Bonded ************* ' .ThruNota auxim ************************************************************** APPROVED ,Mans Examiner Zoning Structural Review (Revised02/24/2014) Clerk `CO CERTIFICATE OF LIABILITY INSURANCE °AT,,18,2o2s ' ACORO 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(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). PRODUCER CONTNAME: PAULETTE BROWN IMPACT INSURANCE SERVICES LLC PV , o EX : 954 885-3884 Fvc No: 954 885-3885 18064 SW 33 Court nDORLEss: im actserymsn.com Miramar, FL 33029 INSURERS AFFORDING COVERAGE NAIC # INSURED WELL ELECTRIC TECHNOLOGY, INC. 4312 NW 11 STREET MIAMI, FL 33126 INSURER B : INSURER C : INSURER D : C(AVFRAGFS CERTIFICATE NUMBER! 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. INSR LTR OF INSURANCE ADDLTYPE INSD SUER POLICY NUMBER MMIDDPOLICY /YYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE RENTED PREMISESTO Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A CL 1799478CD 3/16/2022 3/16/2023 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GEN'L XPOLICY ❑ PRO - POLICY ❑ LOC PRODUCTS - COMP/OP AGG $ 29000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAB DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? r N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ELECTRICAL WORK r PI?TICI!`ATr- Uni 1111=0 rAAIr FI I ATIAW SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORE VILLAGE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd AVENUE ,MIAMI SHORES,FL,33138 TEL:(305)756-8972 AUTHORIZED REPRESENTATIVE r� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ^ O® A J l` (I/^ CERTIFICATE OF LIABILITY INSURANCE ^ATEn8/20snoD/YYYY) 0722 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(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). PRODUCER CONTACT Amanda Nogues NAME: Eastern Insurance Group, Inc. o Ext : (305) 595-3323 a/C, No): (305) 595 7135 A C, No, E-MAIL amanda@easterninsurance.net ADDRESS: 9570 SW 107 Avenue INSURER(S) AFFORDING COVERAGE NAIC it Suite 104 INSURER A : RetailFirst Insurance Company 10700 Miami FL 33176 INSURED INSURER B : INSURER C : Well Electric Technology, Inc. INSURER D: 4312 NW 11 th St INSURER E : INSURER F : Miami FL 33126 COVERAGES CERTIFICATE NUMBER: Master 20-21 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. INSR LTR TYPE OF INSURANCEADULIbUIS INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY XP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ RENTED CLAIMS -MADE DOCCUR PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JPRO- POLICY PRO ❑ LOC PRODUCTS - COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAB DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE - OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A 12361 07/29/2022 07/29/2023 X STATUTE ERH E.L. EACH ACCIDENT 1,000,000 $ 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) Electrical Work CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORE VILLAGE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd AVENUE, MIAMI ,SHORES,FLORIDA, 33138 ACCORDANCE WITH THE POLICY PROVISIONS. TEL:(305)756-8972 AUTHORIZED REPRESENTATIVE @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Ron DeSantis, Governor STATE OF FLORIDA Halsey Beshears, Secretary ma DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD THE ELECTRICAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES WELL, TONY WELL ELECTRIC TECHNOLOGY INC 4310 NW 11 STREET M IAM I FL 33126 LICENSE NUMBER: EC13001181 , EXPIRATION DATE: AUGUST 31, 2022 Always verify licenses online at MyFloridaLicense.com ' Do not alter this document in any form. '1" T This is your license. It is unlawful for anyone other than the licensee to use this document.