ELC-12-316Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 170318
Permit Number: ELC -2 -12 -316
Scheduled Inspection Date: March 21, 2012
Inspector: Devaney, Michael
Owner: SKLAR, ARI & OSCAR
Job Address: 9400 NE 2 Avenue 9400
Miami Shores, FL 33138 -0000
Project:
<NONE>
Contractor: COMPDESIGN INFRASTRUCTURE SOLUTIONS INC
Permit Type: Electrical - Commercial
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number (786)326 -2747
Parcel Number 1132060132780 -00
Phone: (954)938 -9977
Building Department Comments
INSTALLING CAT 5 E CABLING FOR COMPUTERS AND
EQUIPMENT RACK INSTALLING IN ASSOCIATION WITH
SPRINT STORE BUILT OUT
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
March 20, 2012
For Inspections please call: (305)762 -4949
Page 12 of 23
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
FEB 2
Permit No.'dC 1 / CD
Master Permit No. C_C - 23P-6
Permit Type: Electrical
OWNER: Name (Fee Simple Titleholder): •S16 1 LL . Phone#: S--q 2.S•q 21 Z
Address: ''2.1, o tletk oce o 154.4.2o City: t6 IWCM® State: Zip: 336240
Tenant/Lessee Name: yr.1 ii % Phone#:
Email: P' a 4101442441tga. c s1►4 / 0544-- e 9.41440,1 1.1 V4 , urm .
JOB ADDRESS: RPONC rdAe
City:
Miami Shores County: Miami Dade Zip: 33 13 2
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO K Flood Zone:
CONTRACTOR: Company Name: (r,.0v�iinA S �Sw Phone #: 954- (3�' 1? 77
Address: 6.5-55 Al Pow f iN e NI • * 406
City: r --. i_.ar•..fe�a(e,(e. state: FL- Zip: .3'3
Qualifier Name: 3+f i/A.1,‘ 140" \ Phone #: 9SY °In' `ri 77
State Certification or Registration #: OD PP Certificate of Competency #:
Contact Phone#: Chci wears. 551(41:527.197-7 Email Address: c ado .,Js a ecvy-vies•5e, e.-1c. . ce,
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ 3, 690 Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alterattii�on New ❑Repair/Replace
Description 1�• den of Work: � e f ers i f <.c
n l j 4
❑Demolition
m+x**x *** * * * * ** *m **+ x*m ****+x+x+x*w*** ** * * * *Fees*+x**x **** ****** ********* * ** ********+x*m******
Submittal Fee $ Permit Fee $ /0''®i' 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 N/
City State Zip
Mortgage Lender's Name (if applicable) /V l.A ,
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 be approved and a reinspectionf ill be charged.
Signature
Owner or Agen Contractor
The fore of g instrument was acknowl�� ged before me this .2� ' -/� " , The foregoing instrument was acknowledged before melkilbalidilha
day of , 202-, by
who is personally known to me or who has produced
R1 L..�k1cr , day of ,20%4by = 5.1 $ 1
g
who is ► ers: : y known o me o6r who has produced g o ° 1
As identification and who did take an oath.
NOTARY PUB AM
Si
Print: 0 J1'•eS
My Commission Expires:
APPROVED BY
JACKEUNE TORS
NOTARY PUBLIC
STATE OF FLORIDA
Comm# EE118857
peg �c '/'Z.
Plans Examiner Zoning
Sign:
t:
entification and who did take
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9.,
My Commission Expires:
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15109)
Clerk
A °® CERTIFICATE OF LIABILITY INSURANCE
D 02/20IDD /YYYY)
o2 /zo /zolz
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 pollcy(les) 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 1 -727- 797 -4190
Arthur J. Gallagher Risk Management Services, Inc.
4904 Eisenhower Blvd., Ste 250
Tampa, FL 33634
alla_grach @ajg.com
CEACT Gini Morgan
PHONE
IA 727-796-6216 IFA/C. No. Extl: (A/CX , No): 727 - 791 -1613
E-MAIL ini mor aa@a com
ADDRESS: g g jg-
INSURER(S) AFFORDING COVERAGE
NAM #
INSURERA: ZENITH INS CO
13269
INSURED
ComDesign Infrastructure Solutions, Inc
9850 16th St North
St. Petersburg, FL 33716
INSURER B:
INSURER C :
INSURERD:
$
INSURERS:
$
INSURER F :
1 CLAIMS -MADE I I OCCUR
COVERAGES
CERTIFICATE NUMBER: 25625014
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
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICY NUMBER
POUCY EFF
(MM/DDIYYYY)
POLICY EXP
(MMIDDIVYYY)
LIMITS
GENERAL
UABIUTY
COMMERCIAL GENERAL UABIUTY
EACH OCCURRENCE
$
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
1 CLAIMS -MADE I I OCCUR
MED EXP (Any one person)
$
'PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPUES PER:
—I POLICY I-I PCT I- LOC
PRODUCTS - COMP /OP AGG
$
$ ,
AUTOMOBILE
LIAWLITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
SCHEDULED
AUTOS
NON-OWNED
AUTOS
COMBINED SINGLE UMIT
(Ea accident)
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Peraccldent)
$
UMBRELLA LIAB
EXCESS UAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED 1 1 RETENTIONS
5
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? N
(Mandatory In NH)
Eyes, escribe under
DESCRIPTION OF OPERATIONS below
N / A
X
141067802
12/08/11
12/08/12
XITORYLIAMRSI IER
E.L EACH ACCIDENT
$ 500,000
E.L DISEASE - EA EMPLOYEE
$ 500,000
E.L DISEASE POLICY UMIT
$ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
CERTIFICATE HOLDER
CANCELLATION
City of Miami Shores
10050 N.E. and Avenue
Miens Shores, FL 33138
USA
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
O
ACORD 25 (2010/05)
lgregory
25625014
1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACORD. CERTIFICATE OF LIABILITY INSURANCE
DATE /YYYY)
2/28/2011
PRODUCER Phone: 727 -461 -6044 Fax: 727 - 442 -7695
Brown & Brown Insurance - Clearwater
P.O. Box 2456
Suite 660
Clearwater FL 33757 -2456
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 POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
ComDesign Infrastructure Solutions, Inc.
9850 et St N
St. . Petersburg FL 33716
INSURER AlZurl.Ch American Ins Co of IL
27855
26247
wsuRERB:American Guarantee & Liab Ins
INSURERC:Zurich American Insurance Co.
16535
INSURER D:
•
INSURER E:
3/1/2012
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR [ADM
LTR INSRD
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE(MM/DD/YYI
POUCY EXPIRATION
DATE(MMIDDIYYI
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABIUTY
CP04887694
•
3/1/2011
3/1/2012
EACH OCCURRENCE
$1,000, 000
5300,000
PREMISES Ea mourners)
CLAIMS MADE X OCCUR
MED EXP (Any one person)
810,000
PERSONAL&ADVINJURY
$ 1,000.000
$2,000.000
$ 2. 000, 000
1, 000, 000
GENL
7
GENERAL AGGREGATE
AGGREGATE LIMIT APPLIES PER:
POLICY IX Ta n LOC
PRODUCTS - COMP/OP AGG
EBL
A
AUTOMOBILEUABIUTY
X
X
X
X
X
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNEDAUTOS
CP04887694
3/1/2011
3/1/2012
COMBINED SINGLE LIMIT
(Ea accident)
81,000,000
BODILY erprs m)
(Per parson)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Peracxldenl)
$
GARAGE
LIABILITY
ANY AUTO
AUTO ONLY- EA ACCIDENT
$
OTHER THAN Ep,ACC
$
AUTO ONLY: AGO
$
B
EXCESSNMBRELLAUABILITY
X
X
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $ 0
UMB488876500
3/1/2011
3/1/2012
EACHOCCURRENCE
$10,000 000
AGGREGATE
$ 10,000,000
$
$
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTNE
OFFICER/MEMBER EXCLUDED?
!ryes, describe under
SPECIAL PROVISIONS below
I
TORY LIMITS 1 I ER
E L EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L DISEASE -POLICY LIMIT
$
A
C
mm
Equipment Floater
Professional Liability
CP04887694
GLC4887695
3/1/2011
1
3/1/2011
3
3/1/2012
3/1/2012
Rented /Leased Eq
Deductible
professional Liab
Retention
$25,000
$1,000
$2,000,000
#25,000
DESCRIPTION OF OPERATIONS / LOCATIONS (VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
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CERTIFICATE HOLDER
CANCELLATION
City of Miami Shores
10050 NE 2nd Avenue
Miami Shores FL 33138
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 OBLIGATION OR LIABILITY OF ANY KIND
UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001108)
@ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute 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 policies listed thereon.
ACORD 25 (2001/08)
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487 -1395
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399 -0783
VAN HORN, JEFFREY ALLEN
COMDESIGN INFRASTRUCTURE SOLUTIONS INC
602 S MAIN ST #823
CRESTVIEW FL 32536
Congratulations! With this license you become 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.myfioridaiIcense.com.
There you can find more information about our divisions and the regulations that
impact you, subscribe to department newsletters and team 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
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BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954 - 831 -4000
VALID OCTOBER 1, 2011 THROUGH SEPTEMBER 30, 2012
DBA: Receipt #:181 -3225
Business Name: COMDES IGN INFRASTRUCTURE SOLUTIONS Business Type' :ELECTRICAL /ALARMS /CONTRACTOR
INC (ELECTRICAL SPEC LOW VOLTAGE)
Owner Name: JEFFREY ALLEN VAN HORN Business Opened:ll /03/1995
Business Location: 6555 N POWERLINE RD STE 406 State /County/Cert/Reg:ES0000141
FT LAUDERDALE Exemption Code:NONEXEMPT
Business Phone: 954-938-9977
Rooms
Seats
Employees
200
Machines Professionals
For Vending Business Only
Number of Machines:
Vending Tvue:
Tax Amount
Transfer Fee
NSF Fee
Penalty
Prior Years
Collection Cost
Total Paid
150.00
0.00
0.00
0.00
0.00
0.00
150.00
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:
JEFFREY ALLEN VAN HORN
6555 N POWERLINE RD STE 406
FORT LAUDERDALE, FL 33309
2011 - 2012
Receipt #04A -10- 00013565
Paid 09/29/2011 150.00
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954 - 831 -4000
VALID OCTOBER 1, 2011 THROUGH SEPTEMBER 30, 2012
DBA: Receipt #: 181 -3225
Business Name: COMDESIGN INFRASTRUCTURE SOLUTIONS Business Type: ELECTRICAL /ALARMS /CONTRACTOR
INC (ELECTRICAL SPEC LOW VOLTAGE)
Business Opened:11 /03/1995
State /County/CertlReg: ES 0 0 0 0141
Exemption Code:NONEXEMPT
Owner Name: JEFFREY ALLEN VAN HORN
Business Location: 6555 N POWERLINE RD STE 406
FT LAUDERDALE
Business Phone: 954 - 938 -9977
Rooms
Seats
Employees
200
Machines
Professionals
Signature
Number of Machines:
For Vending Business Only
Vending Tvue:
Tax Amount
Transfer Fee
NSF Fee
Penalty
Prior Years
Collection Cost
Total Paid
150.00
0.00
0.00
0.00
0.00
0.00
150.00
Receipt #04A -10- 00013565
Paid 09/29/2011 150.00