ELC-10-87nspection Number: INSP - 133803
Permit Number: E LC- 1 -10 -87 I
Inspection Date: January 22, 2010
Inspector: Devaney, Michael
Owner: CHURCH, ST ROSE OF LIMA CATHOLIC
Job Address: 415 NE 105 Street
Project: <NONE>
Contractor: MOODY ELECTRIC INC
Building Department Comments
16 CARNIVAL TENTS
Passed
Failed
Correction
Needed
Miami Shores, FL
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspector Comments
GV
Permit Type: Electrical - Commercial
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (305)758 -0539
Parcel Number 1122310430010
Phone: (305)758 -2000
For htsportif017E tease cape 4305)762 -4949
January 22, 2010 Page 1 of 1
Owner Information
Fees Due
CCF
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$0.60
$0.20
$1,000.00
$3.00
$0.80
$1,004.60
Authorized Signature: Owner
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
Applicant
Building Department Copy
January 22, 2010
Address
ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD
MIAMI FL 33138 -2970
Contractor(s)
MOODY ELECTRIC INC
Phone Cell Phone
(305)758 -2000
PRO V_
Expiration: 07/21/2010
Parcel Number
Project Address
415 105 Street
Miami Shores, FL
1122310430010
Block: Lot:
ST ROSE OF LIMA CATHOLIC CI
/ Contractor / Agent
Phone
(305)758 - 0539
Applicant
Type of Work: ELECTRIC CONNECTIONS
Additional Info: CARNIVAL TENTS
Classification: Residential
Invoice it
ELC -1 -10 -36850 $ 1,004.60 $ 1,004.60 $ 0.00
Check #: 2246
Total Amt Paid Amt Due
Cell
For Inspections please call:
(305)762-4949
Available Inspections:
Inspection Type:
Final
Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Underground
W. W.
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.
January 22, 2010
Date
1
BUILDING
PERMIT APPLICATION
FBC 20
City / // S0D.e-,5 State 02_
Permit Type: ELECTRICAL
Owner's Name (Fee Simple Titleholder) 57'. /2495z. ®� G'4 * Phone # Oar 75-0--- 05:39.
Owner's Address 4/46" ///,
Tenant/Lessee Name
Email
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade Zip ...3/ .3
FOLIO / PARCEL #
Is Building Historically Designated YES NO
Contractor's Company Name
Contractor's Address X09 4.11(.2 9,e9 S�
City ,?7 9rn/ State
Qualifier Name L -*/.t/7.1 ��y pp/J Phone #
State Certificate or Registration No. ,C ®e2/ /9?
Value of Work For this Permit $
Type of Work: ['Addition EAlteration ❑New
Describe Work:
Permit No.
Master Permit No.
Zip �3/3�
Phone #
Zip &/ ,57e;
MIZgIIMM {�
JAN 2 2010 a
BY:
Flood Zone
Phone # 70 ePNazze
g/J3- 7�- - .,,2®eR®
Certificate of Competency No.
Contact Phone to $ 758 cl000 E -mail (1i . 'CV
Architect/Engineer's Name (if applicable) Phone #
Square / Linear Footage Of Work:
❑ Repair/Replace
❑ Demolition
******** * * * * * * * * * * * * * *** * * * * * * * * * * * * * ** F * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee s -. ) l� CCF $ 0 • (. pjJ CO /CC $
Notary $ Training/Education Fee $_f •
Scanning $ t'' 50 Radon $ DPBR $
Double Fee $ Violation date:
Structural Review. $ Total Fee Now Due $ ) V)
Technology Fee $
Bond $
See Reverse side
o -'6o
Bonding Company's Name (if applicable)
Bonding Company's Address
City • State Zip
Mortgage Lender's Name (if applicable)
•
Mortgage Lender'sAddress
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 ap i oved and a re- inspection fee will be charged.
Signature
Owner or Agent Contractor
The foregoing instrument was ackno edged before me this.)(..) The foregoing instrument was acknowledged before me this D6
day of� �.c1 201 , by , day of , 20tO, by
who is personally known tone or who has produced 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:
Sign:, C
Print: \•...'(` c1� -• -�-
My Comm : ; io.:'' 4,ires: NICOLE A BERGERT
_* ' ) .*- MY COMMISSION If DD 892259
= ' ., - ` EXPIRES: July 2, 2013
4111, �°� wed Thru Notary Public Undenvrftum
* * * * * * * * * * * * * * * * * * **
APPROVED B
(Revised 07/1 0/07)(Revised 06/10/2009)
>G
47 Plans Examiner Zoning
Engineer
111111111
NOTARY PUBLIC:
Sign:
Print:
My
o > A. BERGERT
€ MY COMMISSION 8 DD 892259
EXPIRES: July 2, 2013
•, ;: ∎` Bonded Thru Notary Public Undenvdters
°miul
* * * * * * * * * * * **
Clerk checked
Jan 22 10 09 :27a
Workers Compensation Group
ox 410
:a Raton FL 33429 -0410
Phone:561- 392 -3300 Fax:561 -361 -1132
INSURED
COVERAGES
MoodyElectric Inc
669 Northwest 30th Street
Miami FL 33150
TYPE OF INSURANCE
GENERAL LIABIUTY
CERTIFICATE HOLDER
COMMERCIAL GENERAL LIABILITY
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY JECT f LOC
AUTOMOBILE LIABIUTY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE UABIUTY
ANY AUTO
CLAIMS MADE n OCCUR
EXCESS / UMBRELLA LIABILITY
1 OCCUR n CLAIMS MADE
DEDUCTIBLE
RETENTION
WORKERS COMPENSATION
AND EMPLOYERS' UABIUTY Y / N
A ANY PROPRIETOR)PARTNERIEXECUTI
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
it yes, describe under
SPECIAL PROVISIONS below
OTHER
Village of Miami Shores
10050 NE 2nd Ave.
1 Mama Shores FL 33138
ACRD O 26 (2009101)
Moody Electric Inc
, 1 ..... „,0 6 „R 19 CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
B
830 -29673
POLICY NUMBER
DATE (MMIDOITYYY)
OP ID GC
MOODY -1 12/14/09
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ALTER THE COVERAGE AFFORDED BY HE POLICIES BELOW
INSURERS AFFORDING COVERAGE
INSURER k
INSURER 8;
INSURER C:
INSURER D:
INSURER E:
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NUR ADD
LTR INSRS
DATE ( MM/D memo's
01/01/10
DESCRIPTION OF OPERATIONS! LOCATIONS! VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
8 /27 /07- increase EL Limits to $500,000/$500,000 /$500,000
CANCELLATION
Bridgefield Emplyers Ins
DATE (MM/DDIYYYYY )
01/01/11
305 -758 -2000
UMITS
EACH OCCURRENCE 5
UAMAtit I V Nt.NI tU
PREMISES (Ea occurence) $
MED EXP (Any one person) $
PERSONAL B ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
(Per accident)
AUTO ONLY . EA ACCIDENT
OTHER THAN
AUTO ONLY:
EACH OCCURRENCE
AGGREGATE
X ITORY UMR3 I I
E.L EACH ACCIDENT
EA ACC
AGG
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
$
$
$
$
$
5
$
5
NAIC #
$ 500000
$ 500000
$ 500000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
MIAMIS3 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 010 ORUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHO REPRESENTATIVE
■ 1988 -2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
p.1
CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
InSource, Inc.
9500 South Dadeland Blvd., #200
F.O. Box 561567
rf-- ni FL 33256 -1567
nes305- 670 -6111 Faxt305- 670 -9699
INSURED
Mood Llectrjc, Inc.
669 lW 90 Street
M am FL 33150
OP ID 1 1 12/29/09
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
INSURER A: FCCI Insurance Company
INSURER B: FCCI Commercial Ins . Co .
INSURER C:
INSURER D:
INSURER E:
DATE (MM/DD/YYYY)
NAIC #
10178
33472
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRADD"C
LTR INSRC
Jan 22 10 09 :27a
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERIEXECUT
OFFICER/MEMBER EXCLUDED?
(mandatory In NH)
If yes, PROVISIONS below
OTHER
COR
X
GARAGE LIABILITY
ANY AUTO
X I DEDUCTIBLE
RETENTION
CERTIFICATE HOLDER
ACORD 25 (2009/01)
TYPE OF INSURANCE
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE [ X J OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY X JEG . LOC
AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X NON -OWNED AUTOS
EXCESS / UMBRELLA LIABILITY
X 1 OCCUR U CLAIMS MADE
$10000
Y/N
Village of Miami Shores
10050 NE 2nd. Avenue
Miami Shores 3'L 33138
Mcod Electric Inc
POLICY NUMBER
CPP00056945
CA00067795
VL4B00047874
VILLMIO
POLICY CTIVE
12/31/09
12/31/09
12/31/09
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
*10 days notice of cancellation applies for non - payment of premium.
CANCELLATION
AUTHORIZED REPRESENTATIVE
PA.I Cl
12/31/10
12/31/10
12/31/10
305 -758 -2000
EACH OCCURRENCE
OAMAI3t 1U HI-N I tU
PREMISES (Ea occurance)
MED EXP (Any one person) $ 5000
PERSONAL $ ADV INJURY $ 10 0 0 0 0 0
GENERAL AGGREGATE $2000000
PRODUCTS - COMP /OP AGG $ 2000000
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
(Per accident)
OTHER THAN
AUTO ONLY:
LIMITS
AUTO ONLY - EA ACCIDENT $
EA ACC $
AGG $
EACH OCCURRENCE $1000000
AGGREGATE $ 1000000
$
I TORY LIMITS I 1 ER
E.L. EACH ACCIDENT $
E.L DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
$1000000
$
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 0050 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
098 2009 ACORD
The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved.
$1000000
$ 100
p.
Jan 22 10 09:27a Moody Electric Inc
•
a.
96 6 7 CI -$TAT
wolts,4a9EzgATNG P2ssIoNAL Eciot (;) 8 8,02 4.4 .'
DATE ' BATCH NUMBER 4 .4.-;AND
AC# .3
•
• ,
EC0-00
The. EI;ECTRI.CAL.!:i.F:b*TRACTO,,,
of
Undex! '" the/ provi afA. on :
Expiration: date : • AVG: • 31 ;:
• • • •
• • • • I:11'e..
MOODY; JOHN J
MOOD ..- • • 'r isktiV:' • '
oDy ELECTRIC
13700' ROAK' $TRErg,, •
DAV•E
'-craRram
• * vE04■R#;!;':-.F...,P
•
SEE OTHER SIDE
DO NOT FORWARD
MOODY ELECTRIC INC
JOHN J MOODY
669 NW 90 ST
MIAMI FL 33150
305-758-2000
' cHAIRI4ES W. DRAGO
- 4 ECRETARY
I
92
p.3
•