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EL-11-1282Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 162088 Permit Number: EL -7 -11 -1282 Scheduled Inspection Date: January 18, 2012 Inspector: Devaney, Michael Owner: RODRIGUEZ, JOHN Job Address: 5 NW 106 Street Miami Shores, FL 33150- Project: <NONE> Contractor: TBM ELECTRICAL Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Pool - Private Phone Number (305)776 -0889 Parcel Number 1121360060240 Phone: (954)741 -1004 Building Department Comments ELECTRICAL HOOK UP FOR POOL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments /2- January 17, 2012 For Inspections please call: (305)762 -4949 Page 11 of 49 0 •0. 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. a., I _' 1 Master Permit No. P f I '®' 1 BUILDING PERMIT APPLICATION FBC 20 31J1 1 & !;''EC Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): t S 4-e b cr �� 4 L) l 6 0 Phone #: `1 ar i - (041._ Address: 5 `V M, (1 (/, S City: C CI W. k Ot State: Zip: 3 L.6 (3 Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: S Li Lt k 0 C6, A- City: Miami Shores County: Miami Dade Zip: 3 1 Sb Folio/Parcel #: \ " Di - li' '' r7111 °' 6046* Is the Building Historically Designated: Yes NO ✓ Flood Zone: CONTRACTOR: Company Name: C krP r--1--r; t c, \ 4 . ,� Phone #: -3j .. Jq, "2R Address: ‘ 0 1 ciS L) t .1 S - SE- City: .S t,tnr�( �j-� State: U L/"- Zip: 33,1 1 r Qualifier Name: ,CC (�c (� VA i j �y E�k� Phone#: 45L.f� il 3) _ 5Z State Certification or Registration #: 'Gj' 3(,)0( 3 L 15 Certificate of Competency #: Contact Phone#: Ct i.A-- apt+ -- 1 161÷(i (i Email Address: DESIGNER: Architect/Engineer: k„/V Ctt i h r rn, 1f dr Q (I A uP ,- Phone #: S64— ( `;l3 - ?q,Z7 Value of Work for this Permit: $ � (� Square/Linear Footage of Work: Type of Work: ❑Address Oration ❑Nee1w ❑Repair/Replace ❑Demolition Description of Work: .2,\e a- 5 t r. c l ©n k u r r'n o L * * ** x******** +x*+x+x** ************* * * * ** * Fees *** * * * * ** x* ****** * * * * * * * * * *m * * ******* **** * ** Submittal Fee $3O. Permit Fee $ 3 ,Pf' ' 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 inspection which occurs seven (7) days after the building permit is ed. In the absence of such posted notice, the inspection will not be approved anal a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 \\ , by 1K5-4-@ bi.Y1 ‹+c , who is personall known to me or who has produced PL-0 L- As identification and who did take an oath. Signature Contr The foregoing instrument was acknowledged before me this 46 day of , 20 A!„,_, by 12 ‘7i� M`C1 SG who is personally known to me or who has produced as identification and who did take an oath. ROBIN E HUGLI Notary Public - State of Florida Commission D079 My Gommissier ._ v ►sires rr Print: My Commission Expires: * * * * * * * * * * * * * * * * * * * * ** APPROVED BY PUB ROBIN E HUGLI Notary Public - State of Florida Commission # De in; M, Gom .,. . ******** **************** ************ *** ******** * * ** x* *********** *+ x***********+x*** *** 774^ /4 %n°°1S' Plans Examiner Zoning Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Clerk � 04/81/2011 13:12 5616410235 • JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EX PT FROM FLONIOA WORKERS' COliiIFI ISATI®Gll LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the indivlduat Iisted below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 03/13/2011 EXPIRATION DATE: 03/17/2013 PERSON: TBM ELECTRICAL SERV PAGE 03 \tt, 1 03 -18 -2011 iltrlAJDOWSKI RICHARD FEIN' 850234668 A BUSINESS NAME AND ADDRESS: T R 14 ELECTRICAL SERVICES INC 4392 HUNTING TRAIL LAKE WORTH FL 33487 SCOPES OF BUSINESS OR TRADE: 1— ELECTRICAL CONTRACTOR IMPonyAnT. Paraunnt in enamor 44U . MHO, (.S„ ea aHIcar of a carPoratlsa who elncre exemption Isom Ibis ab victim way not (Damn( hematite nr campnanalloa not title (,beater. Parsaaat to Caeplar 440.01412), F.S,. Carlllltalae al nla0lon to be • v.. ►caPe ell Ihn ba'Iness w Iraae Ilagd as Ipe eatice al Marlins to be eanaeai, Pereaant to Caspenr 44fl.fl61131. T.S., Nn kesyaf114Iestlao0 oIllhetexem t two cart lit Ipls elnhttmr io hn exempt 31011 Pin sealed la raracalloo 11, at any I1110 niter the (this of the Batten ar the ltsaeacn 01 lbe enrtptI ae. eh4 Nsraa.n'na ind only wmi IM minicab. hn Inept tartar, the rte ulrements al Ala !merino tar lunar? al a t'Indicate. Tha gamma, shell t aaae r olnI N nema4 no ihn retteHrmn In team the rerputememn el Ibfr !AWOa. P onl ^d Oa the node! s of p" n esnlltate at aay this for Igllare al the pores" CWC -252 CERTIFICATE OF ELECTION TO RE EXEMPT REVISED 01 -11 I I CENSE ''W )7/07/2010 _1080.02474' RC130 .'.031:; he ELECTRICAL: CONTRACTOR Earned below IS CERTIFIED Ender the provisions : of Chap.ter'. :xpiration date: AUG 31, 2.012 QUESTIONS? 18501 413 -1605 SEQ# Li 0670:701001 MAJDOWSKI, RICHARD .; .,ANTHQTyT T.B.M. ELECTRICAL" SERVICEI. N107.95' NW53 ST .t SUNRISE FL 33351 CHARLIE CRI$T GOVERNOR DISPLAY ASREQUIRED =BY sI ARL I E : LI EM 'RIM SECRETARY..' 04/01/2011 13:12 5616410235 TBM ELECTRICAL SERV 115 S. Andrews Ave., Rm. A -100, Et. Lauderdale, FL 33301-1895 — 954 -831 000 VALID OCTOBER 1, MO THROUGH SEPTEWIBER 30, 2011 DBA: Receipt #:181 -299 Business Name: T B M ELECTRICAL SERVICE INC ELECTRICAL /ALARMS /CONY Business Type. (ELECTRICAL CONTR) 0 Business Opened: 0 9/ 25 /19 8 9 State /Cou my /Cerf/Reg :E c i 3 0 01315 Exemption Code :NONEXEMPT PAGE 02 Owner Name: RICHARD MAJD0WSKI Business Location: 10795 NW 53 ST 209 SUNRISE Business Phone: 741 -1004 Rooms .Seats Tax Amount 27.00 Number of Machines: Transfer Fee 0.00 Employees 1.0 For Vending Business Only Machines Professionals 0:00 Vending T pe: Prior years Collection Cost '0;00 0.00 Total Pald 27.00 THIS RECEIPT MUST BE POSTED CONSPICU'•,USLY 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 WHEN VALIDATED and zoning non-regulatory requirements. Business Tax Receipt pt 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 Taws and regulations, Mailing Address: RICHARD MAJDOWSKI 10795 NW 53 ST #209 SUNRISE, FL 33353. 2010 - 2011 Receipt #15B -09- 00003734 Paid 07/22/2010 27.00 AC)R® CERTIFICATE OF LIABILITY INSURANCE OP ID: HP DATE (MM /DD /YYYY) 02/09/11 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 POLICIES 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 policy(ies) must be endorsed. If SUBROGATION IS 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 561487 -6001 CONTACT Global Insurance Services, Inc NAME: 21301 Powerline Road #211 561-451 -9825 L /CC.NN Ext): Boca Raton, FL 33433 E -MAIL Eric Klein ADDRESS: - PRODUCER - TBMELEC CUSTOMER ID #: INSURED TBM Electrical Services Inc Mr. Richard Majdowski 10795 NW 53rd St #209 Sunrise, FL 33351 INSURER(S) AFFORDING COVERAGE INSURER A : Bankers Insurance Group INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : FAX .(A /C, No): NAIC 5 COVERAGES • THIS INDICATED. CERTIFICATE EXCLUSIONS IN S-121 LTR 1 -- IsI- „IJIVI. IIIOIVIOCfR. IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY PERIOD TO WHICH THIS ALL THE TERMS, -. ___. ... ._ _._ S $ 1,000,000 $ 100,000 $ 5,000 $ 1,000,000 TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER I 090005324932805 POLICY EFF - JMM/DD/YYYYUMM 02/10/11 POLICY EXP /DD /YYYY) 02/10/12 -- -- LIMIT EACH OCCURRENCE DAM -K aE TO RENTED PREMISES (Ea occurrenceL A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR X CLAIMS -MADE X 1 MED EXP (Any one person) I X $250 PD Ded PERSONAL & ADV INJURY 4 - GEN'L 1 GENERAL AGGREGATE $ 2,000,000 $ 1,000,000 $ AGGREGATE LIMIT APPLIES PER — LOC PRODUCTS - COMP /OP AGG PRO- POLICY JECT - -- I AUTOMOBILE JANY LIABILITY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) — { $ BODILY INJURY (Per person) I $ -------- ______ BODILY INJURY (Per accident $ PROPERTY DAMAGE (Per accident) I $ $ UMBRELLA LIAR EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ $ -$ -- -- -- AGGREGATE DEDUCTIBLE RETENTION $ - - -- -- - -- . -- — -- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A WC STATU- OTH- _TORY LIMITS ER $ $ $ E L. EACH ACCIDENT below E.L. DISEASE - EA EMPLOYEE - -- _ E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CANCELLATION Miami Shores Village Building Department 10050 Northeast 2nd Ave Miami Shores, Fl 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD