EL-09-178479 97 Street
Miami Shores, FL 33150-
Owner Information
BETTY ROZIER
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138-0000
Phone: (305)795 -2204
Contractor(s) Phone Cell Phone
FLORIDA MECHANICAL A/C BREFRID (954)782 -3150 (954)275 -0567
Fees Due
CCF
Education Surcharge
Permit Fee - Additions/Alterations
Permit Technology Fee
Scanning Fee
Submittal Fee
Submittal Reversal Fee
Amount
$1.20
$0.40
$160.00
$4.00
$3.00
$50.00
($50.00)
Total: $168.60
Address
79 97 Street
MIAMI SHORES FL 33150 -1732
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
irk Otassftca
Pe 5t
ration'I
PR A
Expiration: 05/0212010
Phone
Type of Work: ELECTRICAL
Additional Info: NC SYSTEM RE WIRE
Classification: Residential
Invoice # Total Amt Paid Amt Due
EL -10-09 -36259 $ 168.60 $ 118.60 ;
EL -10-09 -36259 $ 168.60 $ 168.60 $ 0.00
Check #: 1869
0
Cell
For Inspections please call:
(305)762 -4949
Available Inspections:
Inspection Type:
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.
November 02, 2009
Date
November 02, 2009 1
11/10/2009 15:51 FAX 1 800 685 7530 DATA SCAN FIELD SERVICES QD 004 /012
Inspection Number: INSP- 128961
Scheduled Inspection Date: November' 10, 2009
Inspector: Devaney, Michael
Owner: ROZIER, BETTY
Job Address: 79 NW 97 Street
Miami Shores, FL 33150-
Project: <NONE>
Contractor: FLORIDA MECHANICAL AIC &REFRID
Building Department Comments
November 09, 2009
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
For Inspections please call: (305)762 -4949
o-pq-i 8
Permit Number: EL -10 -09 -1784
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Alteration
Phone Number
Parcel Number 1131010330260
Phone: (954)782 -3150
WIRE 3 TON CENTRAL NC WITH 7.5 HEAT STRIP WITH
WEATHER PROOF RECEPTACLE
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
Page 21 of 29
BUILDING
PERMIT APPLICATION
FBC 2004
Permit Type: Electrical
Owner's Name (Fee Simple Titleh lder) �C a�,l� Phone #' ' S* � 5 - �� �
C'�
Owner's Address 1
City 1 P c State Pk : 4; Zip J S 6
Tenant/Lessee Name
E -MAIL:
City
Job Address (where the work is being done)
Miami Shores Village County Miami -Dade Zip 3
FOLIO / PARCEL # _ jt ^.g.IC't ^ 6260
Is Building Historically Designated YES
Valve of Work For this Permit $
Type of Work: ❑ Addition
l
Describe Work: W p f:
Submittal Fee $
Bond $
Miami Shores Village
Building Department
/0050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972 r�
Permit No. d.
Master Permit Not: lC 5 °n 1?
NO
Contractor's Company Name t v% g e, £ L,C el C Phone #' S4 SGCa
Contractor's Address bS 16• • 2.
City hr4 State I 1 Zip
Qualifier Name ( AS 'FI C_ pp ..1 Phone # - °'� Q �
eal
State Certificate,or Regis 'on No.Z l� Certificate of Competency No. Z c 6 ' -t-
E-MAIL: 5(-.. .• a ®
Architect/Engineer's Name (if applicable) Phone #
['Alteration . ❑New
4 Q P 1L
Permit Fee $ /60 6'P
Notary $ Training/Education Fee $ 4 • OS
Phone #
Square / Linear Footage Of Work:
❑ Repair/Replace
to 0 9 ** * *** *, * **** * * * * ** * ** * * ** * * * * * * **, F ,**,* * ** *** * * * * * **** * * ** * ******
CCF $ \ 7 A ) CO /CC
Technology Fee $ a,0 0
Scanning $ Radon $ 7 BR $ " Zoning $
Code Enforcement $ Double Fee $e
Structural Review. $ Total Fee Now Due $ ! ig . (a 0
See Reverse side ->
ITECMTV
!a OCT 2'32009 U RE
['Demolition
Bonding Company's Name (if applicable)
Bonding Company's Address
City. State Zip
Mortgage Lender's Name (if applicable)
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 Signature
Owner or Agent
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of , 20 , by , day of e t __, �� b)(�a3l AI\
who is personally known to me or who has produced ho is personally known for who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Si
Print: Print:
My Commission Expires: My Commission Expires
*************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY'
(Revised 02/08 /06)
Contractor
Zoning
Engineer
c/2._ 9
Plans Examiner
10/27/2009 09:29 9545667978
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
% lottgage Lender's Name (if applicable)
Mortgage Leader's Address
City Std,
Application is hereby made to obtain a permit to de drama k 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 he performed to meet the standards of all tail regulating
construction in this jtaisdietion. t understand that a separate permit must be secured for ELECTRICAL WORK. PLUMBING, SIONS„
WELLS, POOLS, FURNACES. BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC.....
OWNER'S AFFIDAVIT: 1 certifyilrat all the foregesinittforstiation is aocarate andthatatl c. be done in compliance with all
applicable laws regulating construction and wing.
"WARNYNG TO OWNER: YOUR FAILURE TO RECORD A NOTICE GE 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
COMMENCEMj rr?
Notice - to Applkortt: As a condition to the i,Scucvtee of a building permit with an estimated value exceeding $2500, the applicant must
promise in goodfaith athat a ropy of the notice of coormeneemenr and construction lien law brochure will be delivered to the person'
whose property it *abject tv attachmea also. a certified car of tfte recorded mike of commencement must be posed at gird)alt
Pr 'the s '
All inspect*" wlrkh occri seven (7) days after the building permit is issued In the absence of such pososd Vie~, t
inspection will not be approved and reinspection fee will be charged.
ature
Sign:
"11
e ."3
,
Print:
My Commission expires:
APPLTCATION APPROVED BY:
(Revised 07l08l05)
^� Contractor
'g oing instrument was acknowledged before me this ! The foregoing instrument wed acknowledged before me this 2 7
day off ia, by L1C0'4 S . day of ( d '142t, . by t r l 1. J''
L3
'wbo is personalty lcnot+vn to me er wlio has produced s who is personally known to me or who has produced .
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
CW FISCHER ELECTRIC PAdE 02/02
ziP
Signature at„.02
Sign:
Print::
Rumania li l ^�!'
Florida .w' N ^ . ^ .,
********- k ins y Commi F
* A***ft* t****** * * * **
* 0***1 * fr it* WM ,�M m st***+k**** ***& *****A***** # * *****A @A.O * * ** W #gyp
Plans Examiner
Engineer
Zoning
PER `" 7,} T
�t: I �
Miami Shores Villag-
APPROVED
BY
DATE
ZONING DEPT
BLDG DEPT
Zr� /
SUBJECT TO COMPLIANCE WITH ALL FEDERAL
STATE AND COUNTY RULES AND REGULATIONS
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Telephone (954) 566 -5689 • (954) 565 -8007
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4057 Northeast 5th Terrace
Oakland Park, Florida 33334
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Telephone (954) 566-5689 • (954) 565-8007
4057 Northeast 5th Terrace
Oakland Park, Florida 33334
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APPROVED BY
ZONING DEPT
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SUBJECT TO COMPLIANCE WITH ALL FEDERAL
STATE AND COUNTY RULES AND REGULATIONS
f ie; I -7/4
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• • • •
• •
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Qualifier Name:
/tic Vino * live Vaddia,Vepit&rote
10050 NE 2 Ave Miami Shores, FI 3313
Phone 305-795-2204; Fax 305.762 -5253
www.miamishoresvillage.com
CONTRACTOR LICENSING/ REGISTRATION REQUIREMENTS
FOR ALL CONTRACTORS TO REGISTER IN THE VILLAGE OF MIAMI SHORES THE FOLLOWING
REQUIREMENTS ARE NEEDED:
DADE COUNTY CONTRACTORS:
A. Certificate of Competency
B. Dade Municipal Occupancy
C. Dade Occupational Occupancy
D. State Registration
E. Liability Insurance Certificate
F. Workers Compensation Insurance or Exemption
STATE CONTRACTORS:
A. State License
B. 1,..---' Occupational License
C. p '� Liability Insurance Certificate
D. V Workers Compensation Insurance or Exemption
* * * * * * * ** *ALL INSURANCE CERTIFICATES MUST BE MADE OUT TO THE FOLLOWING * * * * * * * * * **
Miami Shores Village
10050 NE 2 AVE
Miami Shores, FI 33138
ALL PERMIT APPLICATION REQUIRE THE QUALIFIERS NOTARIZED SIGNATURE
********************************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * *** * **
Business Name: 1 F _ z ity - I, -
Business Address: L k 15 51 `At- S 1�G ca-s4t4 VO: Nr -F ` -
Business Telephone5A1 5 1 Fax Number: 566-1919
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL. SERVICES
DIVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW
EFFECTIVE: 07/19/2008 EXPIRATION
.PERSON: CHARLES W FISCHER JR
FEIN: 591209589
BUSINESS NAME AND ADDRESS:
C W FISCHER ELECTRIC INC
2662 NE 4 STREET
POMPANO BEACH, FL 33082
SCOPE OF BUSINESS OR TRADE:
1- ELECTRICAL CONTRACTOR
DATE: 07/ 18/2011
CUT HERE
IMPORTANT
F O Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who
elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chapter.
Pursuant to Chapter 440.05(12), F.S., Certificates of election to be
H exempt.. apply only within the scope of the business or trade listed on
E the notice of election to be exempt
R
E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt
and certificates of election to be exempt shall be subject to revocation
if, at any time after the filing of the notice or the issuance of the
certificate, the person named on the notice or certificate no longer meets
the requirements of this section for issuance of a certificate. The
department shall revoke a certificate at any time for failure of the
person named on the certificate to meet the requirements of this
section.
* Carry bottom portion on the Job, keep upper portion for your records.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06
1
QUESTIONS? (850) 413 -1609
AC#
DATE BATCH NUMBER
LICENSE BR
07/21/2008 080049000 EC000158
The ELECTRICAL CONTRACTOR
Named'. below IS CERTIFIED
Under the provisions of Chapter 489:F
Expiration date: AUG 31, 2010
FISCHER, CHARLES WILLIAM
C.W. FISCHER ELECTRIC ti , INC,.
4057 -NE 5° TERRACE
FT LAUDERDALE FL 33334
CHARLIE :CATS
GOVERNOR
The Sunshine State
• LICENSE NUMBER
F260- 159-68 -384 -0
CKARLESVIr1LLU►M FISCHER JR
262 NE FOURTH ST
POMPANO BEAM FL 06 - 19
BIRTH DATE SEX MGT. REST. ENDORSE.
10-2468 M 603
ISSUED EXPIRES
0803 10 -2409
DUPUCATE
00-0
SAFE DRIVER
6 peTadonofamatarvehicle constitutes consent toartys ryTest B4uiredby
STATE OF FLORIDA
DEPARTMENT ori Eios SS AND PROFESSIONAL REGULATION
ELECTRICP -42; - NTRACTORS. LICENSING BOARD : SEQ# LOSO7iooa94
CHUCK DRAGO
INTERIM SECRETARY
9
STATE OF FLORIDA AC# 38666'9
DEPARTMENT OF= BUSINESS AND
PROFESSIONAL ¢ REGULATION
EC0001578 07/21/68 080049000
CERTIFIED ELECTRICAL CONTRACTOR
FISCHER, CHARLES WILLIAM
C.W. FISCHER ELECTRIC, INC.
I8 CERTIFIED under the provieions of Ch.489 Fe
xpiration date: AUG 31, 2010 L08072100894
ACORD
, CERTIFICATE OF LIABILITY INSURANCE
1 5/11e%2o 0
PRODUCER (813) 949 -2708 FAX: (813) 200 -2120
CGB Insurance, LLC
17894 US Hwy 41 North
Lutz FL 33549
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
CW Fischer Electric, Inc
4057 NE 5th Terrace
Oakland Park FL 33334
INSURER A: North Pointe Insurance Co
27740
INSURER B: Bridgefield
10701
INSURER C:
INSURER D:
INSURER E:
COVERAGES
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.
AGGREGATEI-IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR
LTR
ADD'L
INSRD
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MMIDDIYY)
LIMITS
A
GENERAL
%
LIABILITY
COM MERCIAL GENERAL LIABILITY
BW3538
5/22/2009
5/22/2010
EACH OCCURRENCE
$ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
CLAIMS MADE
X
OCCUR
MED EXP (Any one person)
$ 5,000
PERSONAL BADVINJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'L
AG OREGATE LIMIT APPLIES PER:
POLI JEC P LOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
A
AUTOMO
%
X
X
LIABILITY
ANY AUTO
ALL OWNED AUTOS
sCH EDULEDAUTOS
HIRED AUTOS
NON -OWNED AUTOS
BW3538
5/22/2009
5/22/2010
COMBINED SINGLELIMR
(Ea accident)
$ 1,000,000
BODILY INJURY
(Perperson)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
GARAGE
UABIUTY
ANY AUTO
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
AUTO ONLY: qGG
$
A
EXCESS/UMBRELLA
X
X
LIABILITY
I OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $ 10, 000
BW3538
5/22/2009
5/22/2010
EACH OCCURRENCE
$ 1,000,000
AGGREGATE
$ 1,000,000
$
$
$
B
WORKERS COMPENSATION AND
EMPLOYERS' LIABIUTY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
830 -42103
5/22/2009
5/22/2010
X
TORY LIMITS I I ER
E.L. EACH ACCIDENT
$ 1,000,000
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER
Miami Shores Village
10050 NE 2nd Ave
Miami Shores, FL 33138
ACORD 25 (2001108)
lucmc ,n1„s, non
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORREDREPRESENTATIVE
Amanda Yoder /SUE
@ACORD CORPORATION 1988
Pone 1 ,d
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing
insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001108)
INS025 (0108).08a
Page 2 of 2
Tax Amount
Transfer Fee
NSF Fee
Penalty
Prior Years
Collection Cost
Total Paid
$ 27.00
$ 27.00
DBA:
Business Name:
Rooms
C W FISCHER ELECTRIC INC
Owner Name: FISCHER CHARLES W /QUAL
Business Location: 4057 NE 5 TERR
OAKLAND PARK 33334
Business Phone: (954)566 -5689
THIS BECOMES A TAX RECEIPT
WHEN VALIDATED
Mailing Address:
C W FISCHER ELECTRIC INC
FISCHER CHARLES W /QUAL
4057 NE 5 TERR
OAKLAND PARK FL 33334
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 - 954- 831 -4000
VALID OCTOBER 1, 2009 THROUGH SEPTEMBER 30, 2010
Seats Employees
Far Vending Business Only
2009 - 2010
Receipt # 181- 0007318
Business Type:
Business Opened:
StatelCounty /CerUReg: 78CME511 -X
Exemption Code: NON EXEMPT
Professionals
8 UNITS
Machines
Vendlnsr T
ELECTRICAL CONTR
000 0000002700 0000001810007318 1001 6
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
This tax is levied for the privilege of doing business within Broward County '-`; A
and Is non- rr in nature. You must meet all County andlor municipality r° 7f
planning
transferred a nd
ed whenn the business is sold, business name has changed has oA
have moved the business locatlon. This receipt does not indicate that. the
business is legal or that it is in compliance with State or local laws"aind
regulations. y
MAILING ADDRESS ISSUED DATE: August 03, 2009
FISCHER ELECTRIC INC
CW FISCHER ELLECTRIC INC
4057 NE 5 TER
OAKLAND PARK, FL 333344000
NAME AND LOCATION OF LICENSEE
C W FISCHER ELECTRIC, INC
4057 NE 5 TER
OAKLAND PARK, FL 33334
THE PERSON OR FIRM NAMED ABOVE IS HEREBY LICENSED TO ENGAGE IN THE BUSINESS
PROFESSION OR OCCUPATION LISTED BELOW IN THE CITY OF OAKLAND PARK FLORIDA.
BUSINESS CODE
BUSINESS DESCRIPTION
RESTRICTIONS
BUSINESS TAX RECEIPT
CITY OF OAKLAND PARK
2009 -2010
06470
LICENSE NUMBER
ORIGINAL NUMBER
LICENSE EXPIRES
ELECTRICAL CONTRACTORS
LICENSE MUST BE CONSPICUOUJSLY POSTED AT THE PLACE OF BUSINESS SHOWN
2010000063
7701462
9/30/2010
1 f.4