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ELC-11-879Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 159807 Scheduled Inspection Date: June 13, 2011 Inspector: Devaney, Michael Permit Number: ELC -5 -11 -879 Owner: , SHORES SQUARE INVESTMENTS Job Address: 9017 Biscayne Boulevard Miami Shores, FL 33138 -0000 Project: <NONE> Contractor: LM ELECTRIC INC Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1132060110070 -17 Phone: (561)357 -7756 Building Department Comments CONNECTION OF LIGHT FIXTURES Passed CJ Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments /3 /4/7/2.-- ffir,"---r // June 10, 2011 For Inspections please call: (305)762 -4949 Page 7 of 19 • 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 JUN 0r BUILDING Permit No. Et—C.' ( -s19 PERMIT APPLICATION Master Permit No.CG t FBC 20 Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): ��•.1, ��•al -.,? Phone#: Address: 3s,50 `a k k0a? City: i1.�t�•• State: El. .Zip: 3314 Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: 'Yb, City: Miami Shores Polio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: County: Miami Dade Zip: 33137 -F r(e f � G T t L CONTRACTOR: Company Name: , Address: 0'1,1 e 1',1r\ City: l t -t_� o r`u d State: Qualifier Name: Q Y 1" \t�.t,•��C� State Certification or Registration � #: -71/3-4 �C.t O�-i (!5 Certificate off Competency #: Contact Phone#:1 T?' 1 Email Address: 3 rc \ r( et 'Ct' Ct c CAC • COM DESIGNER: Architect/Engineer: Phone Phone#: Ste( -2 S 7 - 775w _Zip: 33 '4C0'7 Phone#: Value of Work for this Permit: $ 21 Square/Linear Footage of Work: Type of Work: DAddress Alteration °New °Repair/Replace °Demolition Description of Work: ^ Ifck.,ic.,,,�LV D A,,. f1&. * * * * ** * * * * * * * * * * * * * * *** **** *** * ******F * * * ** * *** ******* ** ****** *** * ** ** ** *+ray**** ** Submittal Fee Permit Fee $ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $. r' 3 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 ubject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first ins # c1 on hich occurs seven (7) days after the building permit is issued In the absence o such posted notice, the inspection will y t b a roved a ' a reinspection fee will be charged. Signature Owner or Agent Signature Contractor The foregoing instrument was ackjemledged before me this /Sr The foregoing instrument was acknowledged before me this 3 ci J day of on on ,20 k k , by G re- c1 L . tm c rvi ® ; who is personally known to me or who has produced who is personally known to me or who has produced F L t) . As . + n� caho :, d who did take an oath. as identification and who did take an oath. NOT Y PUBLIC NOTARY PUBLIC: day of � ��. , 20 J1_, by My Commission Exp IMAM II NUM N Mg11r /. M1iC • Ilb 0 Flatlh *** ***** ** *** ** ********+k************+ +k**+N*******+k ******* ** * ** ** Cemitpeoplvitibritiveel **# *** (; <: CaninIsidon # EE WIN APPROVED BY Plans Examiner — s _ _ _ _ _ _ Zoning Structural Review Clerk (Revised 07 /10/07)(Revised 06/10t2009)(Revised 3/15/09) Miami Shores Viitage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel; (305) 795.2204 Goy; (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 BUSINESS NAME: COMPLETE CONTRACTOR'S INFORMATION r t4. Et c--hr( c_ Er' C. BUSINESS ADDRESS: C9 1 DD clencienin CITY w STATE ZIP CODE 13q BUSINESS PHONE: ) US� �� SUFAX NUMBER �t) CELL PHONE ( i) Ti'D'Ll QUALIFIER'S NAME: G(" C3 Mc`-(16v r QUALIFIER'S LIC NUMBER: EC_ t' OOi c.0 S E -MAIL ADDRESS (IF APPLICABLE): Onej 1 ntl.et,eC (�C t qtr . C Orv-1 Created on 3119109 BY M6.DV 1 RV 3128109 MLDV ) A CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDMfYY 05/31/2011 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 BEWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les)must be endorsed. If SUBROGATION 15 WANED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Risk Concepts Corporation 410 43rd Street West Suite N Bradenton FL, 34209 CONTACT NAME: 'PAX on, NO)' PHONE (A/C, No, Ext): 877-746-2209 E-MAIL ADDRESS: PRODUCER CUSTOMER ID#: INSURERS AFFORDING COVERAGE NAIL# INSURED Administrative Concepts Corporation 406 43rd Street West Bradenton FL, 34209 INSURER A a Southern Eagle Insurance Company 10151 INSURER B a !terra A AA- 3190829 INSURER c a Amon Bermuda A M-1460019 INSURER D °Aspen Insurance UK Ltd. A M-1120337 INSURER El Catlin Bermuda A M-3194161 INSURER F a Lloyds of London A AA- 1122000 ER: 86115 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !NSF( AUTHORIZED REPRESENTATIVE /-- i /,. - � , AWL SUBP POLICY EFF POLICY EXP GENERAL LU181LITY COMMERCIAL GENERAL LIABILITY LAIMS•MADE OCCUR EACH 9CCURRENCE $ UAMAtaat I o Kt1r4i I �Eu $ -FA1EX rn one person PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: ECT nLOC PRODUCTS- COMP/OP AGG $ TPOLucYn $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea ac dent) $ BODILY INJURY (Per Person) $ II UgUILLYt INJURY OW $ PRd$E Y DAMAGE (Per accident) $ _ $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS MADE EACH OCCURRENCE $ .— AGGREGATE — $ DEDUCTIBLE RETENTION $ $ $ A WORKERS COMPENSATION Y / N AND EMPLOYERS' LIABILITY ANY PROPRIETERIPARTNERIEXECUTNE N OFFICER/MEMBEREXCLUDED? (Mandatary in NH) H yes describe under flFRCRIPTION (IF APFRATMNR hgiew N /A 2011 -02682 -000 01/01/2011 12/31/2011 y ISTATU -TORY OTH- ^ JOTS I TER El. EACH ACCIDENT $ 1.000,000 .00 E.L DISEASE -EA EMPLOYEE $ 1,000000.00 E.L. DISEASE -POLICY LIMIT $ 1,000,000.00 B C D E Workers Compensation Excess Coverage Please note that Southern Eagle Insurance Company has reinsured ft's liabilities In excess of $250,000 under the policies of Insurance listed above with the underwriters listed A- or better at the time of placement of such reinsurance. Such reinsurance are subject to thelr own terms, condtfions and limits. This is for informational purposes and nothing shall create any right under such reinsurances. DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, U mare space Is required) Effective: Coverage is extended to the leased employees of alternate employer (Florida Operations Only): 01/31/2011 721075 I.M. Electric, Inc • DISCLAIMER: This Certificate of Insurance does not constitde 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 polices listed thereon. D Miami Shores Visage 10050 NE 2nd Avenue Miami Shores FL, 33138 Fax#: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE /-- i /,. - � , ACORD 25(2009109) - 20110525 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (M" Y ) 05/25/2011 TYNE of trvcuaeNr.N PRODUCER Phone: 4074964333 Ponteli insurance and Financial Group, Inc. 1484 Tuskawilla Road Oviedo, FL 32765 License #; D051255 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 POUCIES BELOW. INSURERS AFFORDING COVERAGE NAIC 5 INSURED 1 M Electric Inc 6922 Clendenin St Lake Worth, FL 33467-2911 I INSURER k. Depositors Insurance Company ACP5904948339 INSURER B: Allied P&C insurance Company 03/10/2012 INSURER C: $ 1,000,000 INSURER D: $ 100,000 INSURER E: CLAIMS MADE X OCCUR THE POUCIES OF INSURANCE LISTED BELOW HAW 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. INSR LTRANSRD A ADD'L N TYNE of trvcuaeNr.N POLICY NUMBER POLICY EFFECTIVE DATE RMMwnnn/Yr POLICY EXPIRATION DATE IMMIDD/YY1 LIMITS mow X LIAB1u y COMMERCIAL GENERAL LABILITY ACP5904948339 03/10/2011 03/10/2012 EACH OCCURRENCE $ 1,000,000 PROEM SEA ( ccuence) $ 100,000 CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5,000 X X GEN'L —1 Blanket Additional PERSONAL BADVINJURY $ 1,000,000 insured Endorsement GENERAL AGGREGATE $ 1,000,000 $ 1,000,000 AGGREGATE UMIT APPLIES PER: POLICY X .IE CT LOC PRODUCTS - COMP/OP AGO B N AuTGAAMLE X a Mury ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTO NON -OWNED AUTOS ACP5904948339 03/10/2011 03/10/2012 COMBINED SINGLE SIT $ , BODILY INJURY (Per person) $ BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LABILITY ANY AUTO AUTO ONLY EA ACCIDENT $ OTHER THiAN EA ACC $ AUTO ONLY: AGO $ EXCESS UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY RT ANY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? It yes, describe under SPECIAL PROVISIONS below KO STATU- OTH- TORY LIMITS ER EL EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ EL DISEASE- POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS t LOCATIONS / VEHICLES t EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS ERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NE 2nd Avenue Miami Shores, FL 33138 ACORD 25 (2001/08) SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE GAF/CELLS) BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE I.EFT. BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR,AABILTTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. :AR=(DMS) ® ACORD CORPORATION 1988 Printed by DA/1$ on May 25, 2011 at 0207PM 01/1'8(2011- 19. 07 9543409456 INNCVATI1,'E INSURANCE PAGE 1/02 ACt 'Y?� CE PRODUCER ., INNOVATIVE . INSURANCE CONSULTANTS, • 1NC • 5461 UNIVERSITY DRIVE CORAL SPRINGS. FL 33067 Phone: 954 - 340 -9551 TII*IC,A °'E OF LIABILITY INSURANCE OP ,® i oAoil1.8 /11 r #203 Fax: 954 -. 40 -9456 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATICE4 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OI.1 ALTER THE COVERAGE AFFORDED SY THE POLICIES BELON. POLICY NUMBER INSURERS AFFORDING COVERAGE NAIC 33172 # INSURED ALL_ _ON L! S 24 O C r� AT 330 rS# 114 . _- ...... . INSURER A: MCI OO+a nCYAL. veetiAhtaCB co, INSURER B: GPieRAt. X.aD OEMs.APeREOATE LIA91Lm INSURER C, 01/10/11 INSURER 0. EACH OCCURRENCE E 1 , 00 INSURER 5t PRE°`4 >icfE•eoacurK enn $ 300,' re�aRr�e�we THE PDUCI> S DP INSURANCE LISTED BELOW HAVE BEE 1 ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NDTWITHGTAMOtNG ANY RECUfREMENT. TERM OR CONDITION OF ANY CON'! LACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFIOATL MAY SE ISSUED OR WV PERTAIN, THE INSURANCE ,AFFORDED EY TI S POLL AS DESCRIBED HEREIN IS SURJRCT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OP SUCH . POLICIES, AGSRE>SAYE LIMITS RI•IDLVN MAY HAVE BEEN 'EDUCED BY PAID CLANS LTR 9N _ - TYPE OR INSURA.VOE • POLICY NUMBER DATE MM/DD DA I L' • 1,ItifBTS • " q GPieRAt. X.aD OEMs.APeREOATE LIA91Lm GL 008351 5 . , 01/10/11 01/10/12 EACH OCCURRENCE E 1 , 00 ,'000 PRE°`4 >icfE•eoacurK enn $ 300,' 00 OOMNRRC !AL SCHERALLIABILITY .CLA M ADE L IM$ x OCCUR OCkTIVIIAdtdid _' y- ' ' MED FXP (Any ens Person) . g 10 , C! ! 0. PERSONAL M., MN INJURY $ 1, 00 , 000 N T ADPL INSD 1SENERALAGGREGATE $2.00 , *000 '000 LIMIT APPLIES PER! PRODUCTS - CCNP10P AGO $ 2,0 )., # POIJCY.IX _ 7G7 ' 717 Lcc A AUTOMO8ILe X 1._ 1 C Pt . I LIABILITY ANY AUTO ALL OWNEtI AUtOS SCHEDULED AUTOS (-USED AUTI)G NQNV.C41/Nph AI ITOS - . .. '—' CA( 008351 5 .. 01/10/11 01/10/12 COMBINED GINCLE LIMIT (Ea:mefarxtt) S1, 00 ,000 HOD ILYINJURY (Peq po C) BODILY INJURY (Per ay.-Went) PROPERTY [(WAGE /Per eccitlent) GARAGE l";hNY- LIABILITY AIii'D ..: - _ l AUTO ONLY EA ACCIDENT: $ OT g�{ EA ACC. $ —I Au PILr: tS bTHAN ACC $ . , .... EXCESSIUMORRUA LIABILITY -• CLAIMS OCCUR AIM1MS MADE I1 DEDL'CTIRI.E ) RETENTION $ J _ �, _ EACH OCCURRENCE $ AOIRECIAAiE $ .._I S 4 A 1 WORKERS EMPLOYERS" ANY PROPRIETOR/PARTNEFKKF, OFFICERNEMBER I9 pC aw@PrROV OTHER PROPERTY EQUIPNENT COMPENSATION AND LIABILITY :UTNE. EXCLUDED? u8Of N S Nicer 35x9Y MAR 'A OPITRATIOUS ONLY 01/01/11 01/01/12 X Toro' wail X E.L. EACH ACCIDENT $ ,G0 ,1,000 G.L. DISEASE • EA EMPLOYEE $ 1 , 00 ! , 00 0 B L DI5EA6E -POLICY LIMIT $ 00# 000 CPC 003235 5 CMC D02872 5 01/10/11 01/10 11 01/10/12 01 10 12 10 DAYS NOT! 'I• CANC. FOP. NON M }I OEBakIPTtON or OPERATIONS /LOCATIONS 1 VEMCLE$ r E CLUSFON$ ADDED BY E>✓NDORSDMENT f SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION MIANM SHORES VILLAGE 8UXLl3ING DIEPARWMENT 10050 NE 2ND AVE MIAMI SHORES FL 33138 ACORD 2S (2001108) SHOULD ANY OF THE ABOVP. DESCRIBED PQUCIBS OE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL 2NDEAVgR TO MAIL 30 DA/ WRITTEN NOTICE TO THE cERTIRICATE HOLDER NAMED TO THE LEFT, BUT PAA.URE TO OP 90 $MALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY MO UPON THE INSURER. ITS ADEN I'S OR REPRESENTATIVES. t� ACORD CORPORA "ION T90$1