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EL-10-362 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP 138265 Permit Number: EL -3 -10 -362 Scheduled Inspection Date: March 18, 2010 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: SCHMIDT, MIKE Work Classification: Alteration Job Address: 10300 N MIAMI Avenue Miami Shores, FL 33150 -1254 Phone Number (305)299 -1255 Parcel Number 1121360131020 Project: <NONE> Contractor: Building Department Comments Replace and rewire 5 rooms Inspector Comments Passed Failed Correction ❑ Needed Re- Inspection ❑ S� Fee % No Additional Inspections can be scheduled until ( /D re- inspection fee is paid. March 17, 2010 For Inspections please call: (305)762.4949 Page 19 of 20 Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 E Phone (305)795 -2204 f Expiration: 09/0712010 Project Address Parcel Number Applicant 10300 MIAMI Avenue 1121360131020 MIKE SCHMIDT Miami Shores, FL 33150 -1254 Block: Lot: Owner Information Address Phone cell MIKE SCHMIDT P.O. BOX 11438 (305)299 -1255 FT. LAUDERDALE FL 33339 - Contractor(s) Phone Cell Phone Valuation: $ 6,7 50.00 _.,...:. _ Total Sq Feet: 1000 Type of Work: rewire Available Inspecti Additional Info: 5 rooms Inspection Type: Classification: Residential Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $4.20 Invoice # EL -3-10 -37228 Education Surcharge $1.40 Permit Fee - AddftionstAlterations $236.25 03108/2010 Check #: 4393 $ 50.00 $ 200.45 Scanning Fee $3.00 03/12/2010 Check #: 4402 $ 200.45 $ 0.00 Submittal Fee $50.00 Submittal Reversal Fee ($50.00) Technology Fee $5.60 Total: $250.45 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 March 12, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy March 12, 2010 1 Miami Shores Village Building Department >0050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING Permit No. PERMIT APPLICATION Master Permit No. FBC 2004 Permit Type Electrical Owner's Name (Fee Simple Titleholder) Mike Schmid Phone # 305-299-1255 Owner's Address 10300 N. Miami Avenue City Mi mi bores State F1 on do Zip 131 50 Tenant/Lessee Name Phone # E-MAIL: der— m1ipf fiVghnn _ rnm Job Address (where the work is being done) 10300 N Miami Ave Miami Shores', F 1 33150 City Miami Shores Village County Miami -Dade Zip 1 03 n FOLIO / PARCEL # 1 1-91 - 1 c ()go Is Building Historically Designated YES NO X Contractor's Company Name Electric Service & Repair I nphone# 305- 256 -9793 Contractor's Address 13335 SW 88' Ave. City _ b l am i State F l o r i d a Zip 1 7 h Qualifier Name Jesu Jimenpy Phone 1 05 - 256 -9793 State Certificate or Registration No. E C 13 0 0 3 5 7 3 Certificate of Competency No. E-MAIL: electr ics er i an repair_n Architect/Engineer's Name (if applicable) NA Phone # Value of Work For this Permit $ 6 7 5 0 0A Square / Linear. Footage Of Work: I n Type of Work: DAddition DAlteration ONew X] Repair/Replace ❑ Demolition Describe Work r ei 1 a r e a nd r- a w irk o ld a l$4�z i n in 5 g n A m s Submittal Fee $ Permit Fee $ t� CCF $ CO /CC Notary $ TrainhWEducation Fee $ M p k o 0 Technology Fee $ 5_ L&M Scanning $: 0 Radon $ DPBR $ Zoning $ Bond $ Code Enforcement $ Double Fee $ Structural Review. $ Total Fee Now Due $ See Reverse side "-� 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, BEATERS, 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be c�proved and a reinspection fee will be charged X Signature ( — C - Signature Owner or Agent o atractor The foregoing instrument was acknowledged before me this The foregoing ' was acknowledged before me this day of s 20 �, by Q day of t h WX 20 VD by ? who is personally known to me o r who has produced who is personally known to me or who has produced `� t As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: ,O °�el►.Y ?d��i. Karen Ott Nei le 9 Y NOTARY PUBLIC: a °. S Commission # DD636885 Expires: FEB. 05, 2011 'h ® ° WW Sip: Sign: .....•,, Print: Print' a yg iv My Commission Expires: `�) My Commission Expires APPLICATION APPROVED B Engineer Zoning (Revised 02(08/06) 1 A t- 3 �0k1A1"[ LO C11 SU'Si1�+ M TJ� R� tP t y �p�0 ; r Pi�ST -O�SS k M Af*bA'tW 00ONW7 1, 1� F�t.O@R MUST I�� 315PLA1f�A /y►T 13tA4� OF t�UStM�SS LL` � r IId1iAN11, FI: r 44112 2 t WA . ; Tk E / = TIOId IPA` C-$ R PAIR � STATE# 13410115- sw 08, AVM E�.EC7RIC SERVICE 4 REPAIR INC WORI�ERIS ,- ELM, "RACAL CONS RACE {} I =! THIS ,ONL 'A LOral. MMMUS TAX RECEIPT: cr DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXIS7tNG REGULATORY OR zONING LAW$ OF ' THE, DO NOT FORWARD COUNTY OR `:WIE& OR': DOES ff EXEMPT, THE HOWER FROM ANY OTHER PtiMfT OR . LICENSE REQUIREOWY LAW. T"Is ELECTRIC SERVICE & REPAIR INC NOT -A CERTFFrCAATION OF THE HOLDER'S OUALi"- CARMEL JIMENEZ PRES Tlonls PO BOX 1014 PAVMENTR � MIAMI FL 33256 6I0AMFDA0E CQUNTY T COF�EGTOR; 09129 2 09 a — 09t�3fT2��01 91 SEE OTHER SIDE i 1� ® CERTIFICATE OF LIABILITY INSURANCE OPID vB DATE Or"" ELECT03 03/08/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Wilson, Washburn and Forster ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Suite 300 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 10301 South Dixie Highway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Pinecrest FL 33156 Phone:305- 666 -6636 Fax:305- 662 -7778 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A Redland Insurance Comp INSURER B: Travelers Xnde=+ Co. of a. 25674 El ric mice and R ePa l r INSURER C: 131A SW ! 6AVe 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE Raw LTR TYPE OF INSURANCE POLICY NUMBER DATE D E LETS GENERAL LIABILITY EACH OCCURRENCE $ 2000000 B X COMMERCIAL GENERAL LIABILITY I- 660- 0857P67A 10/05/09 10/05/10 PREMISES 9 - Cm j M $100000 CLAIMS MADE X] OCCUR MED EXP (Any one person) $ 5000 PERSONAL &Am INJURY $2000000 GENERAL AGGREGATE $ 4000000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OPAGG $ 4000000 POLICY X JEC LOG AUTOMOBILE LIABILITY COM BINED A MYAU O RICFL0003358 09/09/09 01/29/10 (F- � SINGLE LIMIT $1, 000, 000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (P -P ) X HIRED AUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Peracddent) PROPERTY DAMAGE $ (Per aoddent) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WCSIA AND EMPLOYERS' LIABILITY Y / N TORY LIMITS I I ER ANY PROPRIETOR/PARTNERAD(ECUTIVF----r E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? M In KH) E.L. PLO DISEASE - EA EM $ u nder If SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS ! LOCATIONS 1 VEHICLES! EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Electrical Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION MIASHOl 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 LIABILITY OF ANY MND UPON THE MURER, ITS AGENTS OR Miami Shores Village REPRESENTATIVES. 10050 ICE 2nd Ave TIVE Miami Shores FL 33138 AUTHIPPAW ACORD 25 (2009/01) m i988-2W9 ACORD CORPORATION. All rights resarved. The ACORD rtsm and logo are registered matt of ACORD > 3/8/2010 09:58 Lion Insurance LION INSURANCE COMPANY- >ELECTRIC SERVICE 1/1 Dat CERTIFICATE OF LIABILITY INSURANCE 3/8/2010 Producer. Lion Insurance Company This Certlflcate is i ssued as a matter of information only and confers no rights 2739 U.S. Highway 19 N. �� t r. ThisCert atedowm*antmtd exboutorafter rage afforded by the policies below ' Holiday, FL 34691 Insurers Aiford'ing Coverage NAIC * Insured South East Personnel Leasing, Inc. 2739 U.S. Highway 19 N. InswerB: Holiday, FL 34691 InwrerC: Insurer D: Insurer E: Coverages TITS cl esofinsoarwA Istedbelowhave been issuedroft insured nernsd above for ft polcVpedod 1rdc9KL mWitionalanycontradoroffmdoaninadvM r to ttasca� ssuedwra�Dertatn. �ir�ranwaEardedbythepoHa��scr�edE�eieissubjedtoe® the�ns .o:es.�dccucittau�s:xhpotdes.A •c2awens�r.t�e�enaedoCedlaK peld claims. MR ADDL Policy Effective Policy Expiration Date Limits Lnt INSRD Type of insurance Policy Number Date (MM/DD/YY) (MM/DD/YY) G ENERAL LIABILITY Eadnocaunence Commercial General Liability Damage Claims Made � occur o jremed premises (EA Mod EV Personal Adv Injury ku'l eral aggregate limit applies per: General AggregM poky p 0 LOC Products- CortptUPA99 O MOBILE LIABILITY C«naredS1r&Llmtt �� jEA Acdde*- AU OrsnedAutos eodMi Sdtedul� Autos (Per Person) Wed Autos �* NMOYmad Auras (Per Accident) 0 Prop"Damsge (Per Acciddanl) EXCESS/UMBRELLA LIABILITY Eachocnurer:ce -R Ocau Claims Made Aggregete Dsu!Mble A Workers Compensation and WC 71949 01 /01/2010 01/0112011 x WC Statu- OTH EmptoyeW Liability to r Limits I ER Any propristor/Pa tturJeuecutive officedmember E.L. Each AccWard $1,00000 exdudadT E.L. Disease - Ea Emphtyea $1,00DpW If Yes, describe rudder sped provisions below. E.L. Disease - Poky Limits S1.000.0m Other !l ion Imurance CornWy Is Ad4. Best Company rat" A- € A149 # IMS Descriptions of Ope ratioris/Locatioms/Vehldes/Exdusions added by Endorsement/Spectai Provisions: Client M: 31- 65-251 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. that are leased to the following "Client Company": Electric service & Repair, Inc Coverage only applies to Injuries incurred by South East Personnel Leasing, Inc. active employee(s) , while woridng in Florida. Coverage does not apply to statutory employee(s) or Independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by farting a request to (727) 937 -2138 or by calling (727) 938-5562. Project Name: FAX: 305- 234 -0597 / ISSUE 03 -0 8-10 (SD) Ben in Date: 8/17/2009 CE"FICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE should ar yroithe abovedesaibed potdes be cancelled before ft eugrlatlon die Mersof,thsissung Insurer vill eadw"to mail 30 dWswrithn notice to ft m0cate hdder named to t K but faausto do sostgH Impose no oNgsdon or fiabi6tyof mytdn d upon th Insurer, its exerts or Wesentatives. 10060 NE 2 AVE MIAMI SHORES, FL 33139 r acs 1 9 STATE QF _ DEPARTMENT of BU T S AND PROFESSIONAL REGULATION ELECTR CALi TO�T'PRACTORS LICENSING BOARD .. y 11:4M LICENSE NBR tJ80011521 JEC130035 13 The ELECTRICAL CONTRACTOR Named below SS CEE,TIFIED Under the provisions of Chapter. 489 FS. Expiration date: AUG 31, 2010 JIMENEZ" JESUS ELECTRIC SERVICE & REPAIR C 12701 SW 84TH AVENUE - MIAMI FL CHARLIE CRISP CHUCK DRAGO GOVERNOR _:` INTERIM SECRETARY sp- LAY AS REQUIRED BY LAW j - _ Receipt Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -494 Permit Number: EL -3 -10 -362 Invoice Number: EL -3 -10 -37228 Applicant: BANK NEW YORK Company Name: Date Payment Type Check Number Amount Change 03/08/2010 Check 4393 $50.00 $0.00 Total Payment: $50.00 Monday, March 8, 2010 Page 1 of 1