EL-11-781Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
—Itlicy
Inspection Number: INSP - 159179 Permit Number: EL -5 -11 -781
Scheduled Inspection Date: January 18, 2012
Inspector: Devaney, Michael
Owner:
Job Address: 180 NW 103 Street
Miami Shores, FL 33150-
Project: <NONE>
Contractor: GREEN LIGHT ELECTRIC SYSTEM
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (305)825 -7080
Parcel Number 1131010230020
Phone: (305)822 -5657
Building Department Comments
ELECTRICAL PANEL REPAIR
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
/g
i7L
January 17, 2012
For Inspections please call: (305)762-4949
Page 3 of 49
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (30) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: Electrical
Permit No. EL 1" 7 81
Master Permit No. 72-e — 1/ / / p
OWNER: Name (Fee Simple Titleholder): '
&DJ PEl2.4‘e , Lte_ 304j (Pzr_ 7dge,
Phone #: (04
.
Address: 5-0 0 (a) / PE J (2t)/t Li 302
City: I 4,a -t.t_ l r g f State:
4
Tenant/Lesseeame:
Email: 4vtVcZ
Zip: 3 349/(/
Phone #:
736(.0. Cvw , 44-
JOB ADDRESS: 0 (�1 10 ?% S' 1 ,
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel #:
Is the Building Historically Designated: Yes NO ✓ Flood Zone:
CONTRACTOR: Company Name: C, /24%& 1j664-'
-4 6 T U[ •C -(4Lf C J J1 T It Phone #: ,(30r)'$.�
1
Address: 2 9' 6,r GJ , �� Q
' State: 9�o ? 34
City: � � Ca- ' Zip: 0
Qualifier Name: 1204,L4,0 hi,14 CO Phone #: ?O r- 30o- (i, ,9--
State Certification or Registration #: EC - / 30o 2 3 7 0 /Certificate of Competency #: N/4
Contact Phone #:�3OJ' '30-0 - 6-C7 )- Email /Address: I`i1 ee e 6 /2-eeet ii, �.f'deek(LS Se` /S , Cc4 & .
DESIGNER: Architect/Engineer: OSCi9 -fit_ u7t9' 2ccf%e. 1___ Phone #: 30r 392 - `I or?
l
Value of Work for this Permit: $ 000. Square/Linear Footage of Work:
Type of Work: ❑Address
❑Alteration
New ORepair/Replace
❑Demolition
Description of Work:
******* ** * * * *** * * * * * * * * *** * * * * * * * * * * ** *Fees * * * * * * * * * * * * * * * * * * * * * * ** ** * * * * * * * * * * * *** * **
Submittal Fee $ Permit Fee $ -' ` c° G CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ `
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
NIA
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 • 'ection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection , ill ; t be a roved and a reinspection ee will be charged.
Contractor
The fi' go .: instrume was ac owledged b e 's 14- The foregoing instrument was acknowledged before me this 08
day o ,20 l ,b ! /: ��.1 I �l ..& day of ,20 , by leci riab€ )
who is persona y known to me or who as roduced who 's personal kno r o me or who has produced
As identification
As and who did take an oa t' as identification and who did take an oath.
NOT ` , P 1: LIC: • i � c-.- y'S
II . i+...� a.:� c,• Sign:
Print: \'/(/410 Pd-t2.2.,
Sign:
Print:
My Commission Expires:
NOTARY PUBLIC:
*********************
APPROVED BY
My
******************************************
u 64411AN PEREZ
MY COMMISSION # DD 710761
EXPIRES: September 3, 2011
" Bonded Thw Notary Public Underwriters
,fix * * * * * * * * * **
NUL Y Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07XRevised 06 /10 /2009XRevised 3/15/09)
rsz'
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
07,17 3r °,
MM 0 4 2011
BY:.e•.••.ee o•oa e••eo
BUILDING Permit Nod- -\ f 16)
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: Electrical
OWNER: Name (Fee Simple Titleholder):.4LJOA/ / /6i rieu '« Phone#: (. 4Ver ,7.s' 70,41
Address: t 5-00 Coin, ,/ ' # 4 ,5-ed / TL 3e.2
r
City: /22 if4/7l o G /c)& .€1.5- State: FL Zip: -430/ 9'
Tenant/Lessee Name: -ii /'4 Phone#: s-.rl4
Email: 7✓ __ '. >T
JOB ADDRESS: 1 u c J `'d 103-511
City: Miami Shores
County:
Miami Dade
Zip: ,?®
Folio/Parcel #: / /-' 3/0/ - a 2-3 - add-e,
Is the Building Historically Designated: Yes NO L Flood Zone:
CONTRACTOR: Company Name: C�n�� LIT f 5,65-) C Phone #: - a- 5,�
Address: / 10 SI
'p
City: t'l 1 JL� State: cl Zip: 3-W 1 q
5%
Qualifier Name: fK(bt) �.3,..O Phone#:
State Certification or Registration #: .0 1 Z) 251 0 Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: {� 1� Phone#:
Value of Work for this Permit: $ 0 l) ' U D Square/Linear Footage of Work:
Type of Work: ❑Address OAlteration New / ' Repair/Replace DDemolition
Des ription of Work:
_ &C4 i(- G'Q (&i PiWg
Lx� ** ** * *** ***x** x'************************* Fees************* **** ******w* ******* ** * ***** ** **
Submittal Fee $ O V L% Permit Fee $ /2'� c° J CCF $ CO /CC $
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
DBPR $ Bond $
Technology Fee $
TOTAL FEE NOW DUE $ I l ." (° 1
*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 CONDTTIONERS, 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 firs `. section wh'_ < •ccurs seven (7) days after the building permit is issued. In the absence of suc posted notice, the
inspection approved and a reinspection fee will be charged.
Owner or Agent
The foregoi g instrument was acknowledged before me this 7
day of rt/ , 20 ill bys%dd'6/ L. (ff1's? a/ti Z
w o is personally known ti.mOor who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign: 1
Print: !;I ,4,,Q
My Commission Exp
* * * * * * * * * * * * * * **
APPROVED BY
et p"t Notary Public State of Florida
. Clara Martinez
My ommission
'40 attom E pires 05/01 /201 DD784587 2 •
* * * * * * * * * * * * * * *i*
*
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of AfFiZA L- , 20 lL, by , O p ial_ dQA40
who i ersonally knoto me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Lig I .. VMAN PERQ
i MY COMMISSION # DD 710781
I y Bonded Thru
My Commission Expires:
************************* * * ***** *******m********** ** ****
Y7/ Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Zoning
Clerk
CERTIFICATE OF LIABILITY INSURANCE
DAVE MEM,
PRODUCER Wed Holiday Insurance
W. 4th Ave.
Math, F1. 33014
none Xt5) 028-5855
Fix (306).
GREEN LIGHT ELECTRIC SYSTEM
2520 West 70 St
Hialeah, R.330113-
CISSIVICATE 13 ISSUED A AMATTEROF INFORMATION
OILY AND CONFERS IV RIGHTS UPON THE CERTIFICATE
WILDER. TIC CERTIFICATE DOMNOTA BMW OR
AR1 THE�AEF{ 0 YTHE: l :011ll.
INSURERS AFFOIN3ING COVERAGE NAB It
INSURER WEStURN WORLD INSURANCE
D SUA INSURANCE
ANAIROS
INSURER D:
INSURER E:
COVERAGES
It
THE POLICIES OF DICE LISTED HAVE MEN WEED TO THE MISLED NAMEDABOVE FORME POUCY PERIOD INDICATED. NOTWITHSTANDING
ANY R r, Tam OR N wart comma atar ERDOCUMENTtwITHRESPECTTOVf lTHECERTIRIOATEMAYBE as= OR
MAT PERTAOL THE =won AFPDRDEDST THE POWER DESCRIBED FBIISSUSJECTTOALL`IHETERIMS.EXC AND CONDITIONS OFSUCH
PUB. AGGREGATE WARS SHOWN MAT HAVE MEN R IDETPAIDCIARM.
paw TYPE oFw 11I E =WM
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MEDAL
. GENERAL uABttITY
00 *WAS MADE EZ OCCUR
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09123//0
016123/11
EA= OCCURRENCE
pEaENTED
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MED EXP (Anyone pee*
PERSONAL &ADV INJURY
GENERAL
PRODUCTS - COMP/OP AGG
1,0,000:00
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1,000,00000
2,000,000.E
1,x,000.00
AUTOMOBILE LABIUM
❑ ANY AUTO
o Au. ammo AUTOS •
AUTOS EMEDULED ❑
O NIREDAUTOS
D NomovaaDAinos .
0
GARAGE LIABLITY
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ODER
met THAN EA ACC
AUTO ONLY;
EACH OCCURRENCE
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12129/10
12/29!11
ARM 0 PP
EL EACAIT
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f:00,0
100,000
EL D - POLICVLMIT
DISCI BRION OF EMIRATE= iLoCA TIONSlWM=fECCUNtIONSAI BY ENDORMINEff/ SPBdAL
cERTIRCATSHOLINGt
500,000
CANCELLATION
CITY E MIAMI MORES
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
SHOULD ANY oPTF ABOVE POLICES =CANCELLED NEON THE
EXPIRATI0II DAM mason m I$8U is MdmatvaL ONEAVORTOBUMS.
33 vs mums Na TOME CREMPICATENCLUSINAORM TO
TODD SOWL WON NON$ iGA IONORlI*BI UIY
y O
1=DISIDIEFL fl5AGENMSOR REPRESENTATIVES.
EYE
T00/T00R
w—�aw -'t1 L1I :lfl?1 aI r9%I1
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IBM
�ACORDcaRPOINGW$ 1988
SSZSSES208 IVA 38 :ttT TTOVRE /t0
Oh _bT TTGT_ 1RT. fb6l (1- 4117111A1
E3� s41) COUNTY
'.
2010 LOCAL BUSINESS TAX RECEIPT 2011
MIAMI -DADS COUNTY - STATE OF FLORIDA
EXP ES SEPT. . C, 2011
MUST BE DISPLAYED AT PLACE OF BUSINESS
TO COUNTY CODE CHAPTER 8A - ART. 9 & 10
i (T 'BILL — ill T AY
562726 -1 'RENEWAL
• U I : S NA;:1E I
LOCATION -
RECEIPT: :5869:0
GREEN L IGHT $YSTEMS L ,_
:2285 W 76 ST
HIALEAH
FIRST CiASS.
U.S. POSTAGE
PAID;
MIAMI, FL
PERMIT Na. 231
NER
GREEN LIGHT ELECTRIC SYSTEMS INC
CAL CONTRACTOR
f Type of easiness
1.96 ELECTR1
CIS /E ONLY A LOOM,
"ttirr.',ISES TAX RECEIPT. I
YF;-S PERMIT ThE
O i: TO IO f ANY
ReoutATtRY
ZONIN L;aS OF THE
fi r "°',7.?T THE
FRO1 ; i4NY OTHER:.
paRrarr OR SENSE ,.
REQUIRED -13 A:'s ': T} S
NOT A .; :; TIOb OF
'THE HOLDER
PAYMNT RECEIVED
cu .
cac:.
10/05/2010
02290005 ?0;1
000054.00.
SEE OTHER SIDE
DO NOT FORWARD
GREEN LIGHT ELECTRIC SYSTEMS INC
ABEL DEMIEN PRES
2285 W 76 ST
HIALEAH FL 33016
II stt iss tt nit t to tti ttt tt tit tfb
FSC
Mixed Sources
M N .
GREEN INNS umewoa►a..r
City of Hialeah
Business Tax Receipt
Mayor Julio Robaina
2010 -11
DA TE BATCH NUMBER
1
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
Parcel Number
Applicant
180 NW 103 Street
Miami Shores, FL 33150-
1131010230020
Block: Lot:
MAERLIN DORMEUS
Owner Information
Address
Phone
Cell
MAERLIN DORMEUS
180 NW 103 Street
MIAMI SHORES FL 33150 -1236
1
Contractor(s) Phone Cell Phone
GREEN LIGHT ELECTRIC SYSTEM (305)822 -5657
Valuation:
Total Sq Feet:
$ 700.00
0
1
Type of Work: ELECTRICAL
Additional Info: PANEL REPLACEMENT
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
00.60
$2.25
$2.25
$0.20
$150.00
$3.00
$0.80
$159.10
Pay Date Pay Type
Invoice # EL -5-11 -40780
05/04/2011 Credit Card
05/11/2011 Credit Card
Amt Paid Amt Due
$ 50.00 $ 109.10
$ 109.10 $ 0.00
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.
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
May 11,2011
Date
May 11,2011
1
RECEIVED 07/22/2011 11:14 0411 GREEN LIGHTELECTRIC
a002/005
002/005
07/22/2011 11:04 FAX 3058289283 WHI
Ai
CERTIFICATE OF LIABILITY INSURANCE
DATE aldIVIIDNY)
07
PRODUCER West Hotiday IneutanCe
M5 W. 4th Ato.
Huh, FL 33094
Phone (385)828-5855
Fax )
INSURM:t GREEN LIGHT ELECTRIC-SYSTEM
2620 West 79 St .
Hiateah,.FL 33016-
THIS CERTIFICATE ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON 771E CERTIFICATE
HOLDER. TKIS.C�TE DOES NOT AMEND, EXTEND OR
ALTER THE COQ AFIRMWED 8YThE POUOIES BELOW;
INSURERS AFFORO08COVERAGE RAC
INSURER A: VVESTURN WORLD INSURANCE
INSURER s SUA INSURANCE
INSURER C:
mar
INSURER E:
COVERAGES
INSURER F:
THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIE POLICY PERK INDICKIED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANYOONTRACT OR OTHER DOCUMENT WITH RESPECT TOWN H TIBS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT to ALL TIE TERMS, EXCLUSIONS AND CONDITIONS OF
POLICIES. AGGREGATE LNMNTS SHOWN MAY HAVE BEEN RE UCLA BY PAD CLAWS.
1Pgant g 7S/B�YY� E
OMR ADD'L
;INS.
TYPEQ II S IRANCE
POLICY WADER
. GIEIIERAL. LIABILITY .
COMMERCIAL GENERAL LIABILITY
❑❑ CLAIMS MADE ® OCCULT
0
❑•
GEN'LAGGREGATEIJMIrAPPUES PER
• ocuicy ❑ PRoJecr ❑ Los
GFCPH -U
•
06123/11 06/23/12,
EACH OCCURRENCE
DAMAGE TO RENTED
DAISES tEa off)
PEW EXP (Afyon )
1,000,000.00
PERSONAL &ADV INJURY
50,000.00
5,000.00
1,000,000.00
GENERAL AGGREGATE •
PRODUCTS - COMP/OP T
2,000,000.00
1,000,000.0
AUTOMOBILE L AM .ITY
❑ ANY AUTO
❑ Au. •ow= Amos •
❑ SCHEDULEDAmos
❑ HIRED AUTOS
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COMBINED SINGLE LIMIT
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12/29/10.
12/29111
ganga . ❑
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EL.. DISEASE - EA EMPLOYEE
100,000
100,000
EL. DISEASE - POLICY LIMIT
500,000
OTHER
DESCRIPTION OF OPERATIONS /LOCATIONS; I VEHIOLE8 / ExcI.UMON SADDED BY /SPECIAL PROVISIONS
CERTIFICATE HOLDER
CAM EU..ATKON
•
MIAMI SHORES VILLAGE
• BUILDING DEPARTMENT
•
1 NE2 ND_ AVE
• MIAMI' SHQRES,FL. 33136
SHOULD ANYF THE ABOYEDESCRIBIEI POLICIES 5E CANCELLED BEFORE THE
EXPIRATION DATE TISEREOP, THE IS LING INSURER WILL ENDEAVOR To MAIL
30 DAYS WRTTIERNOTICE TO THE CERTIFICATE HOLDER NAMED TO
, Tim LEFT, � I -1olOSO SHALL IMPOSE NO OBLIGATION OR UAeu.ITY
OF .. '' THE , ff5AG NTS OR REPII5SENTATNEB. .
;,M3I.k1, -- A .
+t
® ACORD CORPORATION 1980
Jun 24 2011 10:05AM HP LRSERJET FAX
p.1
ACQREL CERTIFICATE OF LIABILITY INSURANCE
1 °"0812 2011
PRODUCER Serial # 100154
MUTUAL INTEREST ASSURANCE,UIIC
MU TUA V�dLIRA
1295 CORAL WAY
MIAMI FL 3314.1
THIS CERTIFICATE IS ISSUED AS A MATTER of INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE L10E5 NOT AMEND. EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUC ES BELOW.
INSURERS AFFORDING COVERAGE
MICR
*OLD
M,V.ELECTRICAL SERVICES, INC
18311 NW 82ND CT
MIAMI, FL 33015
I
INSURER A: ASCENDANT U30LsRWRITERS, LLC
IrlsurteR o:
II•140ER c:
NUMER O.
INSUnia s:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWLTHSTANDIP4
ANY REOUIRENIENT. TERM OR CONDITION 9F ANY CONTRACY OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIRCATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCWSIONS AND cow/ :NS OF SUCH
POLICIES. AO REOAYE LOOTS SHOWN NAY HAVE BEEN REDUCED EY PAR) CLAW S,
DIE
/YPE OF otBURANCB
POLICY NUMBER
VWCOMOM
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GL./50105 -1
9/23/2010
B/232011
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OE5CRIPYION OP OFBRATLONSILOCATIONSNEHICLESISXCLUSIONSADDED EYEMCORSOMENT /SPECIAL PROV1zIONS
ELECTRICAL WORK•
•
CERTIFICATE NOLDEIS CANCELLATION
M.V. ELECTRIC
MIAMI SHORES VILLAGES
10050 NE 2ND AVE
MIAMI, FL 33138
FAX 305 - 6584904
ADORD EB 19O6IttMN
sHOLUD ANY OF Twg ABOVE OHSCRIBD POUGES SE CANcELLED BEFORE THE E)(PIRNITot
oars roake00, •1HE Immo Mum w4L LNI mvOR 70 MAD, 30 nAYSVAin -r
NOTICE TO IRE CERTIFICATE SOLDER NAMLO TO THE LEFT. BLIT FAILURE TO CO SO SHALL
laool a NO usuoArloN c se UAaluTY as ANY HIND LIFN THs U L Ek ITS AMA; OR
, RLiPRS9pft1'ATINE;4.
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Jun 24 2011 1O:O6AM HP LASERJET FAX
MV ELECTRICAL SERVICES INC
MARIO A VALDES PRES
18311 NW 82 CT
MIAMI FL 3301E
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Jun 24 2011 10:05AM HP LASERJET FAX
2610 I:OCAL SU$1NE'S!>r 'AE ROSI ►»T 1i
10AM1••ADE COUNTY - STATE or FLo tIDA
UST at D Y D APILACE OP
;BVSINES& SEPT, 34111
PNSSUANT fiO -CO. i1NTY
CODE.DtiAPP 1.0A - ART, 9, & 10
FIRST -CLASS
U.S. POSTAGE
PAID
MIAMI, FL
PERMIT NO. 231
577238 O THIS IS NOT A BILL — DO NOT PAY
BUS NAME /LOCATION RENEWAL
.MV ELECTRICAL SERVICES INC CC * e 0 E 00405 60190 # -6
18311 NW 82 CT
33015 UNIN DADE COUNTY
OWNER
MV ELECTRICAL SERVICES INC
Soo. Type of Business
10AcACTRICAL L CONTRACTOR
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OR 1'HB
sa re�
ANY % OTMEN
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v
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SEE OTHER SIDE
WORKER /S
1
DO NOT FORWARD
MV ELECTRICAL SERVICES INC
MARIO A VALDES PRES
18311 NW 82 CT
MIAMI FL 33015
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Jun 24 2011 10:05AM HP LASERJET FAX
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Jun 24 2011 10:05AM HP LASERJET FAX
ALEX SINK
CHIEF FINANCIAL OFFICER
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW
03-24-2010
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 05/20/2010 EXPIRATION DATE: 05/19/2012
PERSON: VALDES MARIO A
FEIN: 204242530
BUSINESS NAME AND ADDRESS:
M V ELECTRICAL SERVICES INC
18311 NW 82 CT
HIALEAH FL 33015
SCOPES OF BUSINESS OR TRADE
1- ELECTRICAL
P.3
IMPORTANT: Farman to Chapter 440. 06(141, P.3.. on a11lrw 01 a oarpaistihe who elects exemplify film this chapter by Itling a certificate of election under this
socials may rem recover benefits or Compensation seder 111. chapter. Pursuant to Chapter 440.06(12), F.8., Certificates al election to be exempt.. apply omty within Ike
scope of the business or trade fisted on the notice 0 election 10 be exempt. Pureusai to Chapter 440.06(131, P.S., Notices of election to be exempt sad certificates d
election to be *neaps shell be subject to revocation if, at toy erne alter ma ItBag of the notice or the Issuance of the certificate, the person named as he satin or
cortifIcele no longer meets IM tequiromeate of Ibis section for tasusoce of a minima. The depertnesl shell revoke a certificate a may time Ior Idlers of the person
named on the cannieste to meet the requirements of this auction.
OWC -2$2 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -0S
QUESTIONS? (8STO 413—
HP LASERJET FAX
CTQB
Canstructhn Trades Qualifying Bard
BUSINESS CERTIFICATE OF COMPETENCY
06E000405
MV ELECTRICAL SERVICES INC
MBA.:
V MAIRIO
15 ram carder Ito provisions of Comer 10 of Miami -Dao1e County
VALID FOR CONTRACZiNG UNTIL09/3C/2011