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EL-11-20-2555, 174 NW 109th StMiami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Parcel Number 174 NW 109TH ST, Miami Shores, FL 33168 1121360100230 Contacts VICTORINA PALOMO Owner CITY LIGHTS ELECTRIC, INC. Contractor 174 NW 109 ST, MIAMI SHORES, FL 331684317 JORGE A CABRERA 16136 SW 66 TER, MIAMI, FL 33193 Business: 3054953198 cti Description: SERVICE REPAIR 150 AMP Valuation: $ 1,000.00Ins eon Requests: u Total Sq Feet: 0.00 d all Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $9.00 Technology Fee $2.50 Total: $116.30 Payments Date Paid Amt Paid Total Fees $116.30 Credit Card 11/19/2020 $66.30 Credit Card 11/05/2020 $50.00 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 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. Authorized Signature. Owner / Applicant / Contractor / Agent ------- Date November 19, 2020 Page 2 of 2 Location Address Parcel Number 174 NW 109TH ST, Miami Shores, FL 33168 1121360100230 Contacts VICTORINA PALOMO Owner CITY LIGHTS ELECTRIC, INC. Contractor 174 NW 109 ST, MIAMI SHORES, FL 331684317 JORGE A CABRERA 16136 SW 66 TER, MIAMI, FL 33193 Business: 3054953198 Inspection Requests: Description: SERVICE REPAIR 150 AMP Valuation: $ 1,000.00 305 76 4� Total Scl Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $9.00 Technology Fee $2.50 Tota I : $116.30 Applicant Copy Payments Date Paid Amt Paid Total Fees $116.30 Credit Card 11/19/2020 $66.30 Credit Card 11/05/2020 $50.00 Amount Due: $0.00 For Inspections, Call (305) 762-4949 or Log on at https://bidg.miamishoresvillage.com/cap/. Requests must be received by 3pm for following day inspections. NOTICE: In addition to the requirements of this permit, there may be AND THERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OTHER additional restrictions applicable to this property that may be found in the GOVERNMENTAL ENTITIES SUCH AS WATER MANAGEMENT DISTRICTS, public records of this county. STATE AGENCIES, OR FEDERAL AGENCIES. November 19, 2020 Page 1 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 BUILDING PERMIT APPLICATION ❑BUILDING VELECTRIC ❑ ROOFING I��=DIVED L3 FBC 20 (-";Q Master Permit NOT ._-- I ( --Zv - 2-5 SS Sub Permit No. ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1 3 y !y W (O`l S f City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE: OWNER: Name (Fee Simple Titleholder): Vic f0 r-;""C. PC,, I oin a Phone#: Address: 1 71� N1N )d q � City: A "'N M ; .3 Ac r` S State: FL Zip: 3 3 16 Z Tenant/Lessee Name: Phone#: Email: r''a `r r zf z. I',/& . cn m CONTRACTOR: Company Name: �-1 a yr 1ct1,4s &CIf Phone#: Address: li: 1 �6 ,S W 66 fe)-r City: M , o t M!, State: F L Zip: 33113 Qualifier Name: Tor'a e 6, brefA Phone#: %S6 -Ai LYo5 State Certification or Registration #: F_Gf / 3'y0 7rh 6 e'- Certificate of Competency #: DESIGNER: Architect/Engineer: Address: City: hone#: �Jn Value of Work for this Permit: $�, --�5 Square/Linear Footage of Work: Type of Work: El Addition ❑ Alteration ❑ New u Repair/Replace Description of Work: .1 er v"C G e poet M ❑ Demolition y Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $" Technology Fee $ Structural Reviews $ Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revi sed02/24/2014) 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." � l'u 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 Signatu _ OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this ��11 day of A0 t%¢M 2O. Z Q by �iGy,-z 2 �c+� ri✓y'! a who is personally known to me or who has produced✓4i✓ J t Ge "'f � as did take an oath. The foregoing instrument was acknowledged before me this 5 { day of � 20 a by J .C�re who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: MONTOYA W41]"/Seal: �rlw. Seal: J M Comm. Expires %tar tT. 2C22 MAGGIE M:GG DAssn 4cBonded through Na%ona NoWy Assn. ;=a•, Notary Public - S • : ` Commissior Bonded through Na: APPROVED BY Plans Examiner Structural Review Zoning Clerk (Revised02/24/2014) Halsey emjeas.secretav df oo'�' r CrAr r? ^Dtr%.% STATE OF OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD THE EUECTRIt-AL CONTRACTOR HEREIN IS CERTIFIED UNDER T14E PROVISIONS OF CHAPTER 489, FLORIDA STATUTES CABRERA, jORGE A CITY LIGHTS ELECTRIC, INC 16136 SW 66 TERRACE, MIAMI FL43193 Local Business Tax Receipt Miami=Dade County, Stater of Florida -THIS IS NOT A 811_L - DO NOT PAY 858908 N€tdEwr up- ELB T RENEWAL EXP ��tTv �I�r"FnVcT ELECCi ICING s„ozs9 SEPTEMBERE30, 2021 16136 SW 66 TER p4"_8 of eu any§ MIAMI, FL 33193 .. flur iVm41a GR afl4Y Gang Chapter IIA - AM 9 6 t o " gEgj TvIm APE avaINV68 PAYMENT sECEIVEq RINK€R CITY LIGHTS ELECTRIC INC 196 ELECTRICAL BY TAIL 49tkEC>'P p JORGE CABRERA PRES CONTRACTOR 75_00 W28i2020 Woi&er(sl I Er-13wiiitSO CREOITCARD-20-070692 tW tsarBsaisesaTa 9awiytaY►c akdaL wlawauTa�Toa It—ip I. weta fi a .' pwasud-w.rsydir+Iw.aNroo. wad "Id'a.r r.ne..ret arscaM++la`a.A ma6rwsaea MIM Ty ,NO. aiaa wwMdtaNa�i wl� '�iau._1Ws6-oie edsU. t4-zis. fat wnbd«*wWa.isiameel _ AcoRD0 CERTIFICATE OF LIABILITY INSURANCE °��`M"�DD"'"Y' 10/29/2020 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 N WET Adrian L Clavgo Mauri Excellence Insurance, LLC. DBA A&A Underwriters. PHONE (305) 220-7447 FAX (305) 220-4821 3801 SW 107th Ave aErPas- certificates0maunderwriters.com Miami INSURED City Lights Electric, Inc 16136 SW 66th Terrace FL 33165 1 111MRER At Associated Industries Insurance 23140 I Kendall FL 33193 INISilRER F _ I I CnVFRAnFS CFRTIFICATF NIIMRFR- RFVISN3N 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 LT TYPE OF INSURANCE IAD� SUM POLICY NUMBER POLICY EFF AID Y D� MIPOLICY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F] OCCUR q I EACH OCCURRENCE $ A EToRENTED PREMISES Ea occurrence S LIED EXP (Any one person) S PERSONAL & ADV INJURY S GEN'LAGGREG_ATE LIMIT APPLIES PER: POLICY '` PRO- JECT n LOC OTHER GENERAL AGGREGATE S PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMB SINGLE L1Mrr $ BODILY INJURY (Per person) S $ BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident S S UMBRELLA LJAB EXCESS LIAB OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYER5 LIABILITY ANY PROPRIETORRARTNER/EXECUTIVE Y J N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION PTION Oibe cu OPERATIONS be N rA AWC1139146 11%17 2019 11%17%2020 X ATUTE ER E.L EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE$ 1,000,000 EL DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace is required) License # EC13007060 1`FRT19:Ir-ATF Wnl nr-O !_ANP-F1 I AnnN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE VIR H THE POLICY PROVISIONS. MIAMI SHORES VILLAGE 10050 NW 2nd Avenue AUTt ORRED REPRESENTATIVE Miami Shores,. FI 33138 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD N Service Entrance 3 - #1/0 THWN MAIN Disconnect 150 AMP � cEIVD kW 05�;4 BY: r� Prop" Address: 174 NW 109th Street Miami Shores, FI 33168 Existing Circuit Breaker 3 - #1/0 Panel THHN or THWN Intersystem Bonding ELECTRICAL PEVIEW U 2 -5/8 x 8' grounding rods, #6 wire in 1/2" pvc conduit APPRO` -' 11..' _ larg-4-jATE Scope of Work: Service Repair 150 Amps Secure Grounding City Lights Electric Inc. "EC13007060" (786)281-8405 V S TS'y ��i 5 'vi Rll ee �