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EL-10-2126Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: I NSP- 153861 Permit Number: EL -12 -10 -2126 Scheduled Inspection Date: April 21, 2011 Inspector: Devaney, Michael Owner: DUBOFF, PATRICIA Job Address: 795 NE 95 Boulevard Miami Shores, FL 33138- Project: <NONE> Contractor: ALLSITE ELECTRIC LLC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Pool - Private Phone Number (305)758 -7402 Parcel Number 1132060142180 Phone: (954)632 -6146 Building Department Comments POOL ELECTRICAL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments April 20, 2011 For Inspections please call: (305)762 -4949 Page 6 of 12 02/03/2011 07:43 9546364288 ALEX SINK STATE OF FLORIDA giiEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. PATRICKSON CANOVILLE PAGE 01/01 12 -03 -2010 EFFECTIVE DATE: PERSON: FEIN: 12/03/2010 CANOVILLE 263143858 BUSINESS NAME AND ADDRESS: ALLSITE ELECTRIC LLC 10757 NW 12TH DR PT LAUDERDALE FL 33322 SCOPES OF BUSINESS OR TRADE: 1- ELECTRICAL CONTRACTOR EXPIRATION DATE: 12/02/2012 PATRICKSON IMPORTANT_ Pursuant to Chapter 440 . 05(+4), F.S., en officer of a corporollan who elects exemption from Ibis chapter by tiling o certificate of election under this section may not recover benefits or terapeasation ender Ibis chapter. Purulent to Chapter 440.05(12), F.S., Certificates of election ce be exempt... apply only natbto the scope of the business er trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F,.S., Notices of election to be exempt and certificates of electtoa to be exempt shalt be subject to revocation it, at any lime otter the tiling of the entice or the issaance of the certificate, the person named on the notice or Certificate ea longer meets the requirements of Ibis section for Issuance of a certificate. The department shall revoke 5 certificate et any time for lailbre of the person named on the certificate to meet the teeeire0)ents of this section, QUESTIONS? (850) 413-16 OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL. SERVICES DIVISION OF WORKERS' COMPENSATION INDUSTRY CONSTRUCTION TIFICATE OF ELECTiN T OE EXEMPT PROM FLORIDA WORKERS' COMPENSATION LAW (EFFECTIVE: 12/03/2010 EXPIRATION DATE: 12/02/2012 PERSON: PATRICKSON CANOVILLE FEIN: 2133149858 BUSINESS NAME AND ADDRESS: ALLSiTe ELecituc uc 10757 NW 1271+ DR FT LAUDERDALE, FL 23322 SCOPE OF BUSINESS OR TRADE: - ELECTRICAL CONTRACTOR IMPORTANT O Pursuant to Chapter 440.05(141 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. H Pursuant to Chapter 440.05112), F.S., Certificates of election to be exempt,., apply only within the scope of the business or trade listed on the notice of election to be exempt. 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. QUESTIONS? (850) 413 -1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records, DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 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 BUILDING PERMIT APPLICATION FBC 20 Permit Type: Electrical Permit No. 0 1 2010 Master Permit No. AS.4.40# OWNER: Name (Fee Simple Titleholder): V u U a a p K iliti a Phone #: (3e2A 290 as " Address: 79s /V. e". 9s- City: AA/Anri sty-ere s Tenant/Lessee Name: /14- / `O n/� Email: 044,6. /ao, rr ea State: P*L Zip: 3313y Phone #: JOB ADDRESS: 7 9S' /V. C' City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: /I r .?D(o D/ Si— Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: (T /Q / < / C Ile C Phone#M 54)6,31 - 6/7e Address: City: ?ICI / z9/17 State: F/ Zip: '-mod Qualifier Name: 474 7'ii 1 cKSZYV l ,�/1%�%.�/ Phone #: �� ��� 66G� State Certification or Registration #: CMG I3 7 .0e2 5 Certificate of C mpet cy #:: Contact Phone( 5 -4)6 2 6/�6 Email Address: 5ery/ CG1. al p 1 fr el e.G177G.. DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 4 O Square/Linear Footage of Work: Type of Work: OAddress DAlterration Description of Work: of, C ORepair/Replace ODemolition * ***** a**** * * * ** a**** * *** ********** **** Fees*+ x************* +x****** * * * *** * *** ****** ****** Submittal Fee $ � ' `3 Permit Fee $ 7'' �` CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Train_ in_g/Education Fee $ Double Fee $ Structural Review $ Technology Fee $ TOTAL FEE NOW DUE $ ♦ � r ' 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 b pproved and a reinspection fee will be charged. Owner or Agent The foregoing instrument was acknow gged before me this day of Sear/ , 20 /V, by I A' tGrQ Zo‘a who is personally known to me or who has produced Qin'Jef.s /4 ° -L( As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: 3 -/ • 5* ` *: MY COMMISSION # DD 633067 o= EXPIRES: March 11, 2011 ,pru;Q° Bonded Thru Notary Public Underwriters Signature Contractor The foregoing instrument was acknowledged before me this "e2 day of Ah l / , 20 /0, by Ater C..04/01// // e who is personally known to who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Conunission Expir ****** Reid'*W*ik**********3+ Rik***** ik*********+ i*********& *+ kH: *****M ***# ******* ************* *Sb**+kw***********+k*** ** o� APPROVED BY �o Plans Examiner Structural Review (Revised 07 /10/07)(Revised 06/10/2009)(Revised 3/15/09) Zoning Clerk ACORDD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/23/2010 LTR PRODUCER Phone: 407 -696 -1333 Pontell Insurance and Financial Group, Inc. 1484 Tuskawilla Road Oviedo, FL 32765 License #: D051255 THIS CERTIFICATE IS ISSUED AS A MATTER OF ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, ALTER THE COVERAGE AFFORDED BY THE POLICIES INFORMATION EXTEND OR BELOW. INSURERS AFFORDING COVERAGE NAJC # INSURED Allsite Electric LLC 10757 N. W. 12th Drive Plantation, FL 33322 CAVCDA etre INSURER A: Nationwide Mutual Fire Insurance Company INSURER B: uIUTY COMMERCIAL GENERAL LIABILITY INSURER C: 08/27/2010 INSURER D: $ 1.000,000 $ 100.000 INSURER E THE ANY MAY POLICIES. INSR POLICIES REQUIREMENT, PERTAIN, ADD'L OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DDMfI POUCY EXPIRATION DATE (MM/DD/YYI 08/27/2011 UMITS A GENERAL X uIUTY COMMERCIAL GENERAL LIABILITY 77AC861064 -3001 08/27/2010 EACH OCCURRENCE $ 1.000,000 $ 100.000 PREMISES (Ea ocairence) CLAIMS MADE X OCCUR MED EXP (My one person) $ 5.000 GEN'L i1POLICY PERSONAL &ADV INJURY $ Included GENERAL AGGREGATE $ 2.000.000 $ 2,000,000 AGGREGATE LIMITAPPLIESPER: n JCRCT n LOC PRODUCTS - COMP/OPAGO AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ EA OTHER THAN ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR I CLAIMS MADE DEDUCTIBLE RETENTION $ AGGREGATE $ $ $ $ WORKERS COMPENSATION AND EMPLOYERS• LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, desaibe under SPECIAL PROVISIONS below WC STATU- OTH- TORY LIMITS ER EL EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ EL DISEASE - POUCY LIMIT $ OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS rcemet^a -rim Ise. ... -.. CANCELLATION Miami Shores Village Building Department 10050 NE 2nd Ave Miami Shores, FL 33138 ACORD 25 (2001/08) 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 DO SO SHALL. IMPOSE NO OBUOATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHO REPRESENTATIVE art (DMS) ©ACORD CORPORATION 1988 Printed by DMS on November 23, 2010 at 11:55AM STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487 -1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 CANOVILLE, PATRICKSON M ALLSITE ELECTRIC LLC 10757 NW 12TH DR PLANTATION FL 33323 -5214 Congratulations! With this license you Pecome one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myflorldalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and leam more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE s 12 -12 -2008 ALEX SINK STATE OF FLORIDA ckrar niuticut. OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW . * * CONSTRUCTION• INDUSTRY EXEMPTION This certifies than the individual listed below has elected to be exempt from Florida Workers' :Compensation law. EFFECTIVE DATE PERSON: FEIN: 12/1212008 EXPIRATION DATE 12112/20(0 CANOVILLE 263149858 BUSINESS NAME AND ADDRESS: ALLSITE ELECTRIC LLC 10757 Nil. 12TH. DR T'T LAUDERDALE FL 33322 SCOPES OF BUSINESS OR TRADE 1 CERrxFXED ELECTRICAL CONTRALTO PATRICKSON INFORTfiffT: Pursuant to Chapter 448: 331141, F.S., an officer of a cerperotion who elects exemption from this chapter by filing a certificate of election ander Mit section tiny oil recover benefits or compensation under this chapter. Pursuant to Chapter 440.06(12), F.S.,. Certificates of election to be exempt... apply only within the scope of the business or trade listed an the notice of election to be exempt. Pursuant 'to Chapter 440.05031, f.3., Notices of election to -he exempt and certificates of election to be exempt shall he subject to revocation if, at any time after the tiling of the notice ar the issuance of the certificate, the person named on the notice or certlicate no Sanger 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 aimed on the certificate to meet the requirements of this section. QUESTIONS? (850) '$13 -1609 OWC -252 CERTIFICATE OF ELECTION TO RE EXEMPT REVISED 09 -06 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUT RE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES ffSLDN OF WORKERS` COMPENSATION UMISTtBJCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS .COMPENSATION LAW EFFECTIVE 12/12/2008 EXPIRAT/ON DATE: 12/12/2010 PERSON PATRICKSON CAN0VILLE j 263446858 BUSINESS NAME AND ADDRESS: ALLSRE ELECTRIC LLC 10/51 NW 12TH OR Fr LAUDERDALE. -FL -33322 SCOPE OF BUSINESS OR TRADE CERTIFIED ELECTRICAL CONTRACTO IMPORTANT Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who ® elects exemption from this chapter by `filing 9 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 fisted on the notice of election, to be exempt E Pursuant to Chapter 440.05113). F.S.. Notices of election to be exempt and certificates of election to be exempt shall be subject to rev ocation 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 Ali revoke a certificate at any time for failure of -the person named on the ceFtificate to- meet the requirements of this section. QUESTIONS? (850) 413 -1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. OWC -252 CERTIFICATE OF ELECTION TO SE EXEMPT REVISED 09 -06 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954- 831 -4000 VALID OCTOBER 1: 2010 THROUGH SEPTEMBER 30, 2011 DBA: Business Name: ALLSITE ELECTRIC LLC Owner Name: PATRICKSON M CANOVILLE usiness Location: 10757 NW 12 DR PLANTATION Business Phone: Rooms Seats Employees 1 Receipt #:1131 -3470 Business Type:ELECTRICAL /ALARMS /CONTRPi (ELECTRICAL CONTRACTOR) Business Opened:o1 /09/2009 State/County /Cert/Reg:EC13 0 04 02 3 Exemption Code:NONExEMPT Machines Professionals THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non - regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: ?ATRICKSON M CANOVILLE L0757 NW 12 DR ?LANTATION, FL 33322 2010 - 2011 Receipt BLIT -09- 00424596; Paid 07/27/2010 27.00 11 'OR For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0..00 0.00 -. 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non - regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: ?ATRICKSON M CANOVILLE L0757 NW 12 DR ?LANTATION, FL 33322 2010 - 2011 Receipt BLIT -09- 00424596; Paid 07/27/2010 27.00 11 'OR