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ELC-12-99Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 169002 Permit Number: ELC- 1 -12 -99 Scheduled Inspection Date: February 01, 2012 Inspector: Devaney, Michael Owner: BRACKEN, STEVEN Job Address: 9458 NE 2 Avenue Miami Shores, FL 33138 -0000 Project: SUBWAY Contractor: PROTECT -O -LARMS INC Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number (305)828 -1098 Parcel Number 1132060132780 -58 Phone: 305 -944 -9218 Building Department Comments burglar alarm instalattion Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comm 57/- 0,72 January 31, 2012 For Inspections please call: (305)762 -4949 Page 24 of 39 BUILDING PERMIT APPLICATION Fsc zo 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 Permit No. qr- Master Permit No. Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): Phone #: Address: City: State: Zip: Tenant/Lessee Name: Phone#: Email: r , MiaMMi'for Vl1iacks JOB ADDRESS: bw Cy 4o YZe,* (Q' " q1-16q N City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated: Yes CONTRACTOR: Company Name: Address: City: NO Flood Zone: Le- --0 —LaH vn5 i is d /400)0e- Oily wOo State: F1L Qualifier Name: Bernarc ..,. >� e gcb iQ0 State Certification or Registration #: IE F-00400 O5C Certificate of Competency #: Contact Phone #: ° 2202_ Email Address: 71�f- i'C�C,�'1 -6 l aerY) J m e_ a) bet 150 (doh .1'l 4-- DESIGNER: Architect/Engineer: Phone#: Phone#: q ° qzl ' (22 Z41-1,c121 5�1 Phone #: ° 2 O2.. Value of Work for this Permit: $ Work: °Address !iii llon'of u �?r r 1J t fll 1615. ©o Square/Linear Footage of Work: °Alteration AiNew ORepair/Replace 1ak lc- -la n *********** x*+ a***** **+ x**+ x****w****+x****Fees **+x**** **+ x*** s**** * *** * ********* ***** ***x:*** °Demolition Submittal Fee $ Permit Fee $ /MCP C' % Goa 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 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 inspecti i 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 rei ' ection fe, ill be charged. Signature .6AAS)rcy wner or Agent The foregoing instrument s kno day of A^Ni ,2 II' by who is personally kn wn to me o NOTAR Sian: — Print: «-,'f&/ Signature (c Contractor s ‘g The f going instrument was ackn pledged befo day o V. who is pers nally known t. me or who has produced ,20kt_ ,by 4 &tification and who did take an oath. J \ , As identi cation and who did take an oath. UBLI L- My Commissiol. Emil ROBIN * MY COMMISSION # EE 133802 EXPIRES: October 24, 2015 forme Boned Thu Budget Way Sotto NOa ARY PUBLIC: Sign: ' Print: My Commission * ***,xw,x,x,x** *******,x **** *a,**********,x ****, **** *********** *****+x******+ *** APPROVED BY "76e-Q- �/� r�Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) * * * ** * * * * * * * * ****** Zoning Clerk DO NOT FORWARD PROTECT 0 LARMS INC BERNARD H ROBIN PRES 1123 S 21 AVE HOLLYWOOD FL 33020 • ii. ,-,wiliiitusiini1i „.x.iiiti,im i,i.. inn 3ATC1.-i NuMBER .. .:*i0!,*T:" .•:::i!k i �. afr ® CERTIFICATE OF LIABILITY INSURANCE OP ID KT DATE 03/15/11 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATION I WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER wN i AL' i NAME: Newman Insurance Agency, Inc. (EA/CNNo� Ext): (A/C, No): 5700 Stirling Road ADDRESS: Hollywood FL 33021— CUSTOMER !DM PROTECT Phone : 954- 963- 962 6 INSURERS) AFFORDING COVERAGE NAIC # INSURED INSURER A: Bridgefield Casualty Ins. Protect- O- Larms, Inc. 1NSURERB: Hartford Insurance Company 29459 1123 S. 21 Avenue Hollywood FL 33020 INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSR maw WVD POLICY NUMBER (MMID� DryYYYY)F (M POLICY EXP M/DD/YYYY) LIMA B GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR 21UENKY0628 02/05/11 02/05/12 EACH OCCURRENCE $ 300,000 X PREMISES(Ea occurrence) $ 300,000 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSR maw WVD POLICY NUMBER (MMID� DryYYYY)F (M POLICY EXP M/DD/YYYY) LIMA B GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR 21UENKY0628 02/05/11 02/05/12 EACH OCCURRENCE $ 300,000 X PREMISES(Ea occurrence) $ 300,000 CLAIMS -MADE X MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 300,000 GENERAL AGGREGATE $ 300,000 GEN'L AGGREGATE LIMIT POLICY n JECT APPLIES PER PRODUCTS COMP/OP AGG $ 300,000 LOC $ 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) $ $ $ UMBRELLA UAB EXCESS UM OCCUR CLAIMS -MADE EACH OCCURRENCE $ _ AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXEC OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS Y/N UT N / A 196 -04186 02/23/11 02/23/12 TORYS LIMITS OTH- ER E.L. EACH ACCIDENT $ 1000000 E.L. DISEASE -EA EMPLOYEE $ 1000000 below E.L DISEASE - POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES Attach ACORD 111, Additional Remarks Schedule, If more space Is required) alarm and alarm systems installation or servicing or repair CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department A SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009109) 19 -200 ORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD