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CC-12-882Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 173721 Permit Number: CC -5 -12 -882 Scheduled Inspection Date: August 20, 2012 Inspector: Bruhn, Norman Owner: Job Address: 9899 NE 2 Avenue Miami Shores, FL Project: <NONE> Contractor: FINE LINE CONSTRUCTION & ELECTRIC INC Permit Type: Commercial Construction Inspection Type: Final Building Work Classification: New Phone Number Parcel Number 1132060134360 Phone: (404)593 -6897 Building Department Comments INSTALLATION OF ATM Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. August 17, 2012 For Inspections please call: (305)762 -4949 Page 5 of 33 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 Permit Type: BUILDING JOB ADDRESS: 9899 NE 2nd Avenue JUL 1 E :. 1,,, BY:_. FBC 20 Permit No, CC -5 -12 -882 Master Permit No. ROOFING City: Miami Shores Folio/Parcel #: 11- 3206 - 013 -4360 County: Miami Dade Zip: 33138 Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Southtrust Bank Phone #: Address: PO Box 2554 City: Birmingham State: AL Zip: 35290 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Fine Line Constrution Contractors, Inc Phone #: 561 -582 -7880 Address: 6500 Georgia Avenue City: West Palm Beach Qualifier Name: Joseph Hummel State: Florida Zip: 33405 Phone #: State Certification or Registration #: CGC060353 Certificate of Competency #: Contact Phone#: 561- 582- 78$(' Email Address: <V"'^ DESIGNER: Architect/Engi Value of Work for t I r it. $ Square/Linear Footage of Work: Type of World t3 tsil�, r'" ❑Alteration New ❑Repair/Replace Demolition Descript o Wq $ l ccunninghamefinelinecontractors .com Phone #: Color thru tile: ******* * * ** * * * * * * * * * * * * * * * * * * * * * * * ** ** . ************ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ �_ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ p9 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, BOIT.FRS, HEATERS, TANKS and AIR CONDmONERS, ETC OWNER'S Al '>h'I)AVIT: 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 reinspection fee will be charged Signature Signature Owner or Agent �} The foregoing instrument was acknowlec ed before me this f me or who has produce As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: ty ARq[ PUBLIC- STATE OF FLORIDA Brian Barkett . Commission *D1)856683 Expires: FEB. 01, 2013 BON LED TIIRU ATLANTIC BONDING CO.. INC. Contractor The foregoing instrument was acknowledged before me this 1 %�, by .5� Iris L° o me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: e "`. Brian Barkett My Commission BONDED YARD ATLANTIC BONDING CO.. INC. Commission # 1)D8S6683 esExpires: FEB. 01, 2013 ***** ************* ***+l<***********sk*% kph*** ****8s**Ka ************+'A8s*8s* Nks+ k**AaNs*** ******** ********Ks*#iN%s,k**+K**** APPROVED BY Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Zoning Clerk NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE .106 SITE AT TIME OF FIRST INSPECTION PERMIT NO. STATE OF FLORIDA: COUNTY OF MIAMI -DADE: T A X FOLIO NO3 (— 3 Q l3 y 3 c THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 111111111111 1 111111111 hill 111111111111111111 CFN 2012RO3 3141 OR Bk 28130 Ps 2367; lips? RECORDED 05/31f2012 12 :20:01 HARVEY 'RUVINr CLERK OF COURT MIAMI -DADE COUNTY? FLORIDA LAST PAGE � �,�9 Space above reserved for use of recording office • ( 1. Legal description of property and street/addressi `\ '°' ► r f 2. Description of Improvement t ,(1 l'16Y1 c MI-4 3.Owner(s) name and address: r , il : i. L i . t 6�_ • 11 . i,. >. �. I QiIi1 Interest in property: ._ .Qd Name and address of fee simple titleholder. N /A 4. Contractor's name, address and phone number: AP...- W-OB (e i L Awe. , 1 q.,0,R -- pa ,1 rya bon CPI , fze '34 -/AS. G(p l• SRC a • --/ kV) 5. Surety: (Paymen required by owner from contractor, if any) Name, address and phone number t ■A Amount of bond $ 6. Lender's name and address: Pr 7. Persons within -the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1Xa)7., Florida Statutes, Name, address and phone number. t A tsar .i[ OA Al .raw 8. In addition to himself, Owners designates the following person(s) to receive a copy of the Uenor's Notice as provided in Section 713.13(1Xb), Florida Statutes. Name, address and phone number. 9. Expiration date of this Notice of Commencement (the expiration date Is 1 year from the date of recording unless a different date Is specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13: FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. Signature(s) of Own - s �!y�� s)' A orized Officer/Director/Partner/Manager )(Prepared By f4 L��f[ Prepared By Print Name k*` Print Name Title/Office Lice AM, P, ► Title/Office STATE OF FLORIDA COUNTY OF MIAMI -DADE Tf ing mstrumernt w cckno tedged before me this day of � l ❑ Individually, or O as " for ,r1hersonally known, or ❑ produced the following type of identification _ /` Signature of Notary Public: Name: (SEAL) VERIFICATION PURSUANT 7O SECTION 92525 FLORIDA STATt S Under penalties of perjury, l declare that I have read the foregoing and that the facts stated in It are true, to the best of my knowledge and belief. NOTARY Brian Basket ••, , ,-_Commission #D1)856683 ,••` Expires: FEB. 01, 2013 DoNDEu Tau anal= tIIt s N Ail Signatu = s) »1; er(s) or Owner(s)'s Authorized Officer/Director/Partner/Manager who signed above: By `.i/_►„ 12341152 PAGE 3/10 By 37ATE OF FLORIDA, COUNTY OF DADE HpREB1► CERTIA ghatThiskettu+eaopytithe flarOld rnnrsOhs dayo, , AD. 20 Seat Cite taadCowtyCa tts ac. TANASHIA ARNOLD 1144 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 Typ ROOFING Permit No. Master Permit No. MOMENT- 1.:, W(,1 7 2�;�2 J. BY: - -® ---- e - - - - ®- -moo �L ®1, — 062., OWNER: Name (Fee Simple Titleholder)Sn L)-1 h Vi { S 4- TDc .lAie_ Phone #: Address:f 0 . �iS City: ? 1( Y1 11/1/3 V1 aI lryi State: At • Zip: 3 S _ ci 0 Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: q b cj 61 NE j\ 7I / vt, City: Miami Shores County: Miami Dade Zip: .331 3 '' Folio/Parcel #: 11 - 30- OLP " 01 3 ° Li 3 (0 U Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: P1 Y112 1 C Phone#: 901 - C7 a - 1 k V Address: (0E1 o- City: Vji ?cittyl State: Ft_._ , Qualifier Name: J1l.S P.�h ourn rYLQ -1 State Certification or Registration #: (' („1. C ( IQ O 36 3 Zip: 33LI 05 Phone #: Certificate of Competency #: Contact Phone #: - c� _ `1 AO Email Address: ct n LI.YI .L- �. 0 -�►� @ {A.i1 -�'- C .1ivt*i -hsYSS °r �C- rn DESIGNER: Architect/Engineer: GS 'y Arc kL4 GAS Phone #: , [ - I0 U — (00`-1 "1 Value of Work for this Permit: $ l¢Tt1J1i Square/Linear Footage of Work: Type of Work: ❑Addition Alteration ❑New ORepair/Replace ODemolition Description of Work: 1 filS-1 i'R L( Ct± uv1 GI- 1--\-1-M * ******************a+*+ *** *** * * *** ** *** ees********* ************* ** * ** ***************** _ 7}ov Submittal Fee $ • 0 v Permit Fee $ r7L) CCF $ CO /CC $ Scanning Fee $ r0 Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE Bonding Company's Name (if applicable) NVA" Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) 0/ /2\- 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 reinspection fee will be charged. XSignature The forego; day of who i Owner or Ag strument was acknowledged before me this , 20 lZ, by Signature Contractor The forego' . g instrument was acknowledged before me this 3) , day of , 20 ! , by to me or who has produced who As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: NOTARY PUBucSTA'1 Brims Barkett My Commission Expires:: Commission # D1T856b83 Y 3 i1 Expires: FEB. 01, 2013 BONDED TURD AmANTIC BONDING CO..1NC. me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: NOTARY PUBLIC -STATE OF FLORIDA Brian Darkest My Commission >J Z ,i Commission # DD856683 Expires: FEB. 01, 2013 ] o5nSD TURD ATLANTIC BONDING CO.. INC. .k*sN*ga+k**** ** k**************** *************** *+ k******* ****ykM *+k******+I+dt*******i *** *** **+ ksk****ik********** ****** APPROVED BY (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Plans Examiner Structural Review Zoning Clerk IVliami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. . COPY OF LOCAL BUSINESS TAX RECEIPT C. / COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. / COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: 1 yl Q_ COAS'ITLI CA -LOY1 C.61(171- laC. r(SYS,, BUSINESS ADDRESS: 1A0O Ci.e.k 10, "NIL .CITY I Foam ??C_CLC-k. , STATE E1,, .. ZIP CODE u OS BUSINESS PHONE: (6J(0 1 )5852 - -7 & FAX NUMBER (5(01) 68(3- Eci CELL PHONE ( ) QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: C- C_1 C- D (.Q O 3 5 3 ., k E -MAIL ADDRESS (IF APPLICABLE): Created on 3119109 BY MLDV I RV 3126109 MLDV ACC Ra? CERTIFICATE OF LIABILITY INSURANCE 4/27/2012 D 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 Bateman Gordon and Sands 3050 North Federal Hwy Lighthouse Point FL 33064 CONTACT NAME: PHONE FAX No. ex o:954-941-0900 954 -941 -0900 (A/C, No):954 -941 -2006 E,vc. a oREss:certs b sa en com � g 9 cY• INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Amerisure Insurance Co. 19488 INSURED FINLI5 Fine Line Construction Contractors, Inc 6500 Georgia Avenue West Palm Beach FL 33405 INSURER B :Amerisure Mutual Insurance Co 23396 INSURER C : 7/24/2012 INSURER D : $1,000,000 INSURER E : $300,000 INSURER F : COVERAGES CERTIFICATE NUMBER: 524532992 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 W VD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYTY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL. LIABILITY GL20779830001 7/24/2011 7/24/2012 EACH OCCURRENCE $1,000,000 DAMAGE PREMISES (Ea occurrence) $300,000 CLAIMS -MADE OCCUR MED EXP (Any one person) J000 $1,000,000 PERSONAL & ADV INJURY X XCU /Contractual GENERAL AGGREGATE $2,000,000 X Broad Form PD PRODUCTS - COMP /OP AGG $2,000,000 GEM. AGGREGATE LIMIT APPLIES 7 POLICY n JECOT PER LOC $ A AUTOMOBILE X X LIABILITY ANY AUTO AALLOWNED OS HIRED AUTOS X SCHEDULED NON -OWNED AUTOS CA20779810001 7/24/2011 7/24/2012 COMBINED SINGLE OMIT (Ea accident) $1,000,000 $ BODILY INJURY (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CU20779840002 7/24/2011 7/24/2012 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED X RETENTION $0 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR /PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC207798500 7/24/2011 7/24/2012 X WC STATU- OTH- TORY LIMITS ER E.L EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2nd Avenue 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 ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 HUMMEL, JOSEPH FINE LINE CONSTRUCTION CONTRACTORS INC P O BOX 1452 BOCA RATON FL 33429 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.myftoridalicense.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 (850) 487 -1395 CITY OF WEST PALM BEACH 2011 to 2012 LOCAL BUSINESS TAX RECEIPT / CERTIFICATE OF USE 027592. CONSTRUCTION OFFICE FINE LINE CONSTR CONTRACTORS INC CGC060353 GEORGIA AVE NOT TRANSFERABLE CITY OF WEST PALM BEACH P.O. BOX 3147, WEST PALM BEACH, FL. 33402 BUS. TAX ID. CATEGORY DESCRIPTION 55824 236220 GENERAL CONTRACTOR 86.81 THIS DOCUMENT NOT VALID UNTIL FUNDS ARE COLLECTED TOTAL.P " PAID 86.81 86.81 EXPIRES SEPTEMBER 30, 2012 BAL ** 0.00 1 Planning and Zoning Criteria Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fax: (305)756 -8972 Folio Number:1132060134360 Owner's Name: Job Address: 9899 2 Avenue Miami Shores, FL Owner's Phone: Total Square Feet: Total Job Valuation: 0 $ 12, 000.00 Contractor(s) FINE LINE CONSTRUCTION & ELECTRIC INC - Phone Primary Contractor Yes Planning and Zoning Criteria and Comments Approved: Yes Date Approved: 5/18/2012: Yes Comments: Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. V COPY OF QUALIFIERS STATE LIC CARD B. V COPY OF LOCAL BUSINESS TAX RECEIPT C. V COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. V COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTORS TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. _ COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: 'etQ, \-t f,ler, -IrtC, 11�1C, BUSINESS ADDRESS: 3(rl t wN CITY POD -vri kl 6 £Ct► STATE i , ZIP CODE ?730 (�� BUSINESS PHONE: (°I5 `-i) -'I $ (p- Z60 CO FAX NUMBER ( 994) 1 t Xo - 04 b3 CELL PHONE (51o1 ) '4 51-1,32B QUALIFIER'S NAME: IC z9V) k -Qc..a QUALIFIER'S LIC NUMBER: Ii',oOO2 4 t E -MAIL ADDRESS (IF APPLICABLE): f t)0(1,010 O V tt rl2l 1 neC.3 q7 . Lo rn Created on 3119109 BY MLDV 1 RV 3126109 MLDV Client#: 48655 FINLI ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/30/2012 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 ileu of such endorsement(s). PRODUCER Mark Grimaldi Bateman Gordon & Sands, Inc P O Box 127 0 Pompano Beach, FL 33061 CONTACT NAME: PI (A/C, No, Est): 954 941 -0900 FAX No); 954 941 -2006 E -MAIL ADDRESS. INSURER(S) AFFORDING COVERAGE NAIC S INSURERA: Amerisure Insurance Co. 19488 INSURED Fine Line Electric, Inc. 3071 N. Dixie Highway Pompano Beach, FL 33064 INSURER B; Amerisure Mutual Insurance Co. 23396 INSURER C: 07/24/12 INSURER D $1,000,000 INSURER E : $300,000 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 POL CIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE I�RL y yr POLICY NUMBER POLICY EFF (MM/DDiYYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY GL2071063 07/24/11 07/24/12 OCCURRENCE $1,000,000 EEAACCHH PREM ISEST$ERa nBnce) $300,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,000 X XCU /Contractual Liab PERSONAL & ADV INJURY $ 1,000,000 X Broad Form PD GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE POLICY X LIMIT APPLIES jEa PER: LOC PRODUCTS - COMP /OP AGG $2,000,000 PD Ded $250 A AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS X SCHEDULED AUTOS NON -OWNED AUTOS CA2071056 07/24/11 07/24/12 COMBINED SINGLE LIMIT (Ea accident) 000 000 $1,, BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B x UMBRELLA LIAR EXCESS LIAB X OCCUR CLAIMS -MADE CU2071058 07/24/11 07/24/12 EACH OCCURRENCE $2,000,000 $2,000,000 AGGREGATE DED X RETENTION $O $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below y/ N N N / A WC2071059 07/24/11 07/24/12 X TO STATU- TORY LIMITS (411- FR E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2 Avenue 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 © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S403688/M392791 AB STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 HDHMEL, JOSEPH FINE LINE ELECTRIC INC P 0 BOX 1452 - BOCA RATON FL 33429 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 Uireuvorli to improve fife way.we do business in order to serve you - beer: For information about our services, please log onto www.myfloridalicense.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 thq 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! (850) 487 -1395 DETACH HERE tyx.,auslio..47 il;14 -zoats,-31;wsofzAic,-coa_;);qAt,c.c-,-.1',,E,,,t !Loa., mos ,F# -20g-"A (7:me:Pak zos Its T... ..1., 4,. s ' ■ . . , , ,,. 4.7:01') a .7% : , .-144 , . , cosi-„Acsoa-,,,;;;ftznayqfozoa.1c,,, #, ...., • .• MIAMI -DADE COUNTY BUILDING AND NEIGHBORHOOD COMPLIANCE 11805 SW 26TH ST. SUITE 207 MIAMI FL, 33175 (786) 315 -2880 STATE CONTRACTOR'S CERTIFICATE OF VOLUNTARY REGISTRATION WITH MIAMI -DADE COUNTY ISSUED FEBRUARY 01, 2001 THIS IS TO CERTIFY THAT FINE LINE ELECTRIC INC CONTRACTOR CERTIFICATE NO.: EC0002419 TRADE: ELECTRICAL REGISTRATION EXPIRATION DATE: 08/31/2012 HAVING MET THE REGISTRATION REQUIREMENTS OF MIAMI -DADE COUNTY,. IS REGISTERED AS A STATE CONTRACTOR IN THE FOLLOWING CATEGORY(S): • 0001 ELECTRICAL WITH ALL WORK TO BE DONE UNDER THE SUPERVISION, DIRECTION AND CONTROL OF QUALIFYING AGENT HCUMMHL JOSEPH D S.S.N. - -3165 ALTERATION, REPRODUCTION OR TRANSFER OF THIS CERTIFICATE IS PROHIBITED. CHARLES DANGER, P.E. SECRETARY, CONSTRUCTION TRADES QUALIFYING. BOARD FINE LINE ELECTRIC .INC 3071 N DIXIE HWY POMPANO BEACH FL 33064 Form (Rev. December 2011) Department of the Treasury Internal Revel Service Request for Taxpayer identification Number and Certification Give Form to the requester. Do not send to the IRS. Name (as shown an your income tax return) Business name/cUsregarded enirly name. if different imm above FINE LINE ELECTRIC, INC Check appropriate box for federal tax rlaaclfication: ❑ IndividuaVsoleproprietor ❑ CCorporatton S corporation ❑ Partnership ❑ Trust/estate [] Limited Debility company. Enter the lax classification (C=C corporation, 0=3 corporation. P =partnership)1► ❑ Other (see Instructions) tr Address (number, street, and apt or suite no.) 3071 N DIXIE HWY City. state, and ZIP code POMPANO BEACH, FL 33064 Ust account number(s) here (optional) ❑ Exempt payee Requester's name and address (optional) Taxpayer Identification Number (TIN) Enter your TIN In the appropriate box. The TIN provided must match the name given on the "Name" line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a 77N an page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number 6 5 0 7 8 1 7 8 4 Certification Under penalties of perjury, I cattily that 1. The number shown on this form Is my correct taxpayer identification number (or 1 am waiting for a number to be issued to me). and 2. 1 am not subject to backup withholding beca (a) t am exempt from backup withholding. or (b)1 have not been notified by the Internal Revenue Service (IRS) that I am subject to backup wit ;' otding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that 1 am no longer subject to backup withholding, an 3. I am a U.S. citizen orother U.S. person (• j ned below). Certification Instructions. You must cross ; item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all in = 7' and dividends on your tax return. For real estate transactions. item 2 does not apply. For mortgage Interest paid, acquisition or abandonment f soured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than interest • •• ' idends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions on page 4. Sign Here Signature of U.S. person General instructions Section references are to the Intern noted. Purpose of. Form A person who is required to file an Information return with the IRS must obtain your correct taxpayer iden ficatlon number (TIN) to report, for example, income paid to you, _ estate transactions, mortgage interest you plaid, acquisition or abandonment of secured property, cancellation of debt, or contn'buttons you made to an IRA. Use Form W-9 only If you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are wafting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected Income. Deter. `-'t . 7—©. t'2 ue Code unless otherwise Note. if a requester gives you a form other than Form W -9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • M individual who is a U.S. citizen or U.S. resident alien. • A partnership. corporation, company, or association created or organized in the United States or under the laws of the United States, • M estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701 -7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W -9 has not been received a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, If you are a U.S. person that Is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No.1o231X Form W -9 (Rev.12 -2011) Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 12- Inspection Number: INSP- 177209 Permit Number: ELC -8 -12 -1515 Scheduled Inspection Date: August 15, 2012 Inspector: Devaney, Michael Owner: Job Address: 9899 NE 2 Avenue Miami Shores, FL Project: <NONE> Contractor: FINE LINE CONSTRUCTION & ELECTRIC INC Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1132060134360 Phone: (404)593 -6897 Building Department Comments LOW VOLTAGE FOR DATA AND SECURITY WIRING FOR ATM Passed D Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector ments August 14, 2012 For Inspections please call: (305)762 -4949 Page 22 of 34 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 ECEO E AUG 0 8 .F. 12 ® ®e FBC 20 (0 BUILDING Permit No. ELL i Z =1 51 : PERMIT APPLICATION Permit Type: Electrical JOB ADDRESS: 9899 NE 2nd Avenue Master Permit No. CC -5 -12 -882 City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel #: 11- 3206 - 013 -4360 Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Southtrust Bank Nat'l Assoc. Phone#: Address: 2000 C Shakerag Hill city: Peachtree City State: GA zip: 30269 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Fine Line Electric,Inc Phone #: 954-786-8006 Address: 3071 N. Dixie Hwy city: Pompano State: Florida zip: 33064 Qualifier Name: Joseph Hummel Phone #: State Certification or Registration #: EC0002419 Certificate of Competency #: Contact Phone #: Email Address: DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ $1.200 Square/Linear Footage of Work: Type of Work: Address DAlteration Description of Work: $[New ❑Repair/Replace Demolition ******** ***** * * ************* **** ** * * * ** Fees************* * * * ******* **** **** ******** * * *** Submittal Fee $ 40 ° , Permit Fee $ f ; '4" G1 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 CONDMONERS, 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 estima value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien 'w brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded no e of ommencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is sued In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Owner or gent The foregoing instrument was acknowledged before me this cf , 20 l2 , by ri— ,,.( `'-j1 >1--t to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: N0TARYINBLIC -STATE OF FLORIDA My Commission Expires: f" "N Brian Barked °,•..;DF1.;� Expires: FEB. 01, 2013 8ON) TORU ATLANTIC BONDING CQ.. INC. :k******:k*********** *: k**********: k*$ ::k******:k3c******:is**** *** * * *****ak*** k*******: ks k* **: ksk ****************** Commission #D118S6683 Signature The foreg, g instrument day of who is personall Contractor as acknowledged before me this , 201, by known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission E NUNE 1:)Mb er 11, 2013 �.•. � ��� 1e ri ers APPROVED B 5 9,2,,e� Plans Examiner Zoning Structural Review Clerk (Revised 3 /12 /2012)(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) , / A CERTIFICATE OF LIABILITY N U , /; CE DATE(MM7DDlYYYY) 7!18!2012 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 thls certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Bateman Gordon and Sands 3050 North Federal Hwry Lighthouse Point FL 33064 CONTACT NAME: flak° . E7tt1:954 -941 -0900 1 IkC, NoN954- 941 -200 E -MAIL ADDREBS :MGrimshawtanbgsagency.com INSURER(S) AFFORDING COVERAGE NAtC # INSURER A :Amerisure Insurance Co. 19488 INSURED FINLI Fine Line Electric, Inc. 3071 N. Dixie Highway Pompano Beach FL 33064 INSURERB:Amerisure Mutual Insurance Co, 23396 INSURER C: INSURER O: EACH OCCURRENCE INSURER E: PREMISES (Eaoccurrence) INSURER F : MED EXP (Any one person) COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR TYPE OF INSURANCE ADDL INSR SUER WWI POLICY NUMBER POLICY EFF {MM/DD/YYYYt POLICY EXP (MMIDOIYYYY) LlPAiT3 A GENERAL X LIABILITY C0MMERCIALGENERALLIABIUTY GL20710520201 7/2412012 7/24/2013 EACH OCCURRENCE 51,000,000 PREMISES (Eaoccurrence) 5300,000 MED EXP (Any one person) 510,000 CLAIMS -MADE © OCCUR PERSONAL & ADV INJURY 51,000,000 X Contrdctual/XCU GENERAL AGGREGATE 52,000,000 X Broad For} PD 52,000,000 PRODUCTS - COMP /OP AGG 1 GE P.11 AGGREGATE LIMIT APPLES 1 POLICY g: PER: 1 1 LOC $ A AUTOMOBILE X X LIABILITY ANY AUTO ALL OSWNED HIRED AUTOS X SCHEDULED NON -OWNED AUTOS CA20710560201 (712412012 x/24/2013 a ,IEIN SINGLE LIMI i 0 .000,000 BODILY INJURY 1Per person) 5 BODILY INJURY (Per accident) 5 PROPERTY DAMAGE /Per accident) $ B X UMBRELLA UAB EXCESS LIAB X OCCUR CLAIMS -MADE CU20710580103 /2412012 7/24/2013 EACH OCCURRENCE 52,000,000 AGGREGATE 52,000,000 5 DED X RETENTION 50 I A WORKERS COMPENSATION AND EMPLOYERS UABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Yi OFFICER/MEMBER EXCLUDED? (`• (Mandatory in NH) U yes, describe wider DESCRIPTION OF OPERATIONS below NIA WC207105903 7/24/2012 7/24/2013 X TORY TATU- ER E.L. EACH ACCIDENT 5500,000 E.L. DISEASE - EA EMPLOYEE 5500,000 E.L. DISEASE - POLICY LIMIT 5500.000 B Contractors Equipment 1M2071063010012 7/24/2012 7/24 /2013 i Scheduled Equip 5255.185 Rented & Leased 5100,000 Deductible 51,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space Is required) Document is not complete unless accompanied by the Acord 101 General Liability: See Attached... CERTIFICATE HOLDER CANCELLATION Miami Shores Village;Bullding Department 140 W. Flagler Street;Ste. 1603 Miami Shores FL 33130 -0000 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 REPP.ESENTATIVE ACORD 25 (2010/05) 1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: RNLI LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Bateman Gordon and Sands NAMED INSURED Fine Line Electric, Inc. 3071 N. Dixie Highway Pompano Beach FL 33064 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER. 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE 1. Blanket Additional Insured's as required by written contract including Products ongoing & Completed Operations, per CG 70 48 03 04. 2. Blanket Additional Insured FormCG7048 (03/04) will convert to Form CG2010 (11/85) if specifically required by written contract. 3. Blanket Waiver of Subrogation as required by written contract, per CG 70 49 09 05. 4. General Aggregate Limit Applies Per Project, per CG 70 49 09 05. Automobile Liability: 1. Additional Interest per Section II, Item 1. Who is an Insured part c of the Commercial Automobile, per CA 00 01 03 06. 2. Blanket Waiver of Subrogation as required by written contract, per CA 71 71 05 08. Workers' Compensation: 1. Blanket Waiver of Subrogation as required by written contract WC 00 03 13. Umbrella: 1. Waiver of Subrogation per CU74 67 11 07. 2. Umbrella follows form over the General Liability (excludes the general liability per project aggregate), Auto Liability & Workers Compensation, General Information: 1. The General Liability policy contains no specific residential exclusions. 2.30 days notice of cancellation for any reason other than non - payment of premium is provided per, IL 70 45 05 07 when required by written contract. IALL COVERAGE IS SUBJECT TO THE POLICY TERMS, CONDITIONS AND EXCLUSIONS. IF CERTIFICATE HOLDER WISHES TO REVIEW POLICY FORMS PLEASE CONTACT THE AGENT. ACORD 101 (2008!01) G 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 12 -Y'S/? nspection Number: I NS P- 173748 Permit Number: CC -5 -12 -883 Inspection Date: August 15, 2012 Inspector: Devaney, Michael Owner: Job Address: 9899 NE 2 Avenue Miami Shores, FL Project <NONE> Contractor: FINE LINE CONSTRUCTION & ELECTRIC INC Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: New Phone Number Parcel Number 1132060134360 Phone: (404)593 -6897 Building Department Comments INSTALLATION OF ATM Passed Inspector Comments 9)2_ Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until For Inspections please call: (305)762 -4949 August 15, 2012 Page 1 of 1 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 No. CC— i l SO 3 Master Permit No. CC- 12 a 5 2- Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): u--1 St- 1i� -�'` 4� Phone #: AddresssO• —6(`)) ,Q65Ll City:TAY W 11 Yl Gj CU'Y I State: Zip: J q 0 Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: 9k q c1 ( c;- City: Miami Shores County: Miami Dade Zip: 33 1 3 Folio/Parcel #: l I — 3atkQ - d V.") 4?)(0O Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: ft Y Q L—i _ cC Ltc-- Y (�, I n L • Phone #: 45 q . 7&(D • SO UP Address: 30 1 I iv • T ')L► Q i v Lt • CityWCWY1 lo(A, irk) e>e C,'LGI'l n State: (_ , Zip: 330 CO 4 Qualifier Name JOSe f Imo\ rr\ Q A Phone #: State Certification or Registration #: EC-00 00 Li (ii Certificate of Competency #: Contact Phone #: 6(0 I • $ 0 --t & Email Address: DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑Address ciAlteration ONew ORepair/Replace ❑Demolition Description of Work: l i'1� _tl (SY\ or - 'r`(1 -1 • ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees**************** **+ x* * ********* ** * *** ******** Submittal Fee $ 50 .0 0 Permit Fee $ 44-0 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) NJ / Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) N/ P 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 AI MAVIT: 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. XSignature Owner or Age The forego; g trument was ac , 20 12-, by , day of o me or who has P roduce As identification and who did take an oath. NOTARY PUBLIC: day of who is Signature owledged before me this 2 The foregoi Sign: Print: �10Tl�TdY3LIG�TA'l DF 1RiDA lirlalt �arkctt My Commission Expii commission # 1)1)856683 ,;, Expires: FEB. 01, 2013 BONDED TURD ATLANTIC BONDING C0..1NC. **dsHa**AkBa******** APPROVED BY Contractor strument was acknowledged before me s ,2012. ,by� L 71 me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: NOTARY PTTRT.TC STATE nF �i.fRIDA Brian Barkett My Connive 1, o 'Mission #1)1)856683 Expires: FEB. 01, 2013 BONDED TURD ATLANTIC BONDING CO..1NG �N$ t�.... *ki$ ***K. **sk*** **+ k*8a**+ b*ikda*s k*** *N.K a*B+ k****k**k: A*** ****** ********jN**+h*+k*N=***oN*********** ** Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Zoning Clerk