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ELC-12-1918Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 179924 Permit Number: ELC -10 -12 -1918 Scheduled Inspection Date: October 16, 2012 Inspector: Devaney, Michael Owner: PROPERTIES LLC, SHORE SQUARE Job Address: 9031 -9069 BISCAYNE Boulevard 9045 Miami Shores, FL 33138 -0000 Project <NONE> Contractor: M ELLIS ELECTRICAL INC Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number (305)779 -8040 Parcel Number 1132060110051 Phone: (352)457 -5629 Building Department Comments CHANGE EXISTING GFCI OUTLET TO DISCONNECT FOR REDBOX KIOSK Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments /01.e-T -6v/z October 15, 2012 For Inspections please call: (305)762 -4949 Page 31 of 40 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: Electrical JOB ADDRESS: 90 31 �� 5 � e City: Miami S hores County: ? Folio/Parcel #: /1- J , ob -or/ / -0 '57 Is the Building Historically Designated: Yes NO OCT 152112 FBC 20t 2 Permit No. V l__C.i IL —19 I Y Master Permit No. ,JJJ i' !/P (UM / T 9oYs� Miami Dade Zip: Flood Zone: OWNER: Name (Fee Simple Titleholder): 5h'i2L° 9442 f 7' Phone #: 7.1'2 V(' 7 27 Address: t QG 4< 6• l g�f fi City: i v • ■4471. • Tenant/Less Email: / e lie y ✓ &c 4& Phone#: State: F L Zip: d f CONTRACTOR: Company Name: Address: t ,f)- 7 Y 5. 6 &L.E C % /2/C A L /it/C Phone #: ,)-f2 - 5 ?-,)4z9 City: i d ` SCO ' State: , T' C-- Zip: 73/7,5'. 3 Qualifier Name: 1/►4 . I ' * 4?) Phone#: . 2 - Y17- sz 09 State Certification or Registration #: &C- / 3'oo 3.5-5-7 •,, Certificate of Competency #: 1 Contact Phone#: �� 7 f )-3---i2., Email Address: 04, /� e OL LI S cu. �C Ia l t 4 (.. G 0-~1 DESIGNER: Architect/Engineer: Phone #: --- Value of Work for this Permit: $ D C.7 d d t Square/Linear Footage of Work: "...A. Type of Work: °Address °Alteration _ ONew 1 air/Replace °Demolition Description of Work: i ' •—� r;A�1 /Yea-MI -4-1;YA- C/71.4 14 £ 1.4th PGJ 0 *********+ xa: *** ************+x *******+xx *** Fees**: x****x: ***** ** ******** * *****:x+x***+x*m******* Submittal Fee $ So Permit Fee $ /' ®e''®® 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 FI.RCTRICAL 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 e notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to atta 'nt. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection wh • ._ , i ccurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be a i r >ed and a reinspection fee will be charged. Signature er or Agent The foregoing instru . =` t was acknowledged before me this day of of -- i ,2012- , by \-tt) YG� {`(� Z? hat _ , who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission E APPROVED BY Signature ' Contractor The foregoing instrument was acknowledged before me this l" day of U �� , 20 19, by l a i C, &— f l 'S who is personally known to me or who has produced T .__ ID as identification and 13rge, oath. NOTARY PUBLIC: Sign: Print: .... x..... a s ° °\' '0,,,, eJe 1 \S My Commission Expires: Zc® /Yo /1/t Plans Examiner Zoning Structural Review Clerk (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) C# STATE OF FLORIDA DEPAR LE RICAESCO S CTORSRLTCBNPIE AE TION saw L12081402461 LICENSE NBR 08/14/2012 128038557 EC13003559 The ELECTRICAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 Additional Business Qualification ELLIS, MICHAEL E M ELLIS ELECTRICAL INC 4234 8. BLUFF LAKE RD. MASCOTTE FL 34753 RICK SCOTT GOVERNOR BOB MsKEE LAKE COUNTY TAX COLLECTOR FACILITIES/ MACHINES ROOMS SEATS TYPE OF CONTRACTING BUSINESS BUSINESS M ELLIS ELECTRICAL INC 4234 S BLUFF LAKE RD MASCOTTE, FL 34753 MICHAEL E ELLIS 4234 S BLUFF LAKE RD MASCOTTE, FL 34753 DISPLAY AS REQUIRED BY LAW rj KEN LAWSON SECRETARY STATE OF FLORIDA I`ll it DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION EC13003559 08/14/12 128038557 CERTIFIED ELECTRICAL, CONTRACTOR ELLIS, MICBAM, E M ELLIS ELECTRICAL INC 8 CERTI9ZSD uuder the Provisions or eh.489 ae i mq)iiittan date. AUG 31, 2014 L120814024E1 2012 / 2013 LAKE COUNTY BUSINESS TAX RECEIPT STATE OF FLORIDA EMPLOYEES 1 ACCT NO. 90640 RECEIPT NO. 8760018676 EXPIRES SEPTEMBER 30, 2013 ORIGINAL TAX PENALTY TRANSFER FEE AMOUNT PAID TOTAL DUE NONEXEMPT Receipt #2012 - 9000468 Paid 08/28/2012 30.00 30.00 0.00 0.00 30.00 $0.00 '`' �® CERTIFICATE OF LIABILITY INSURANCE DA10/115/12� PRODUCER Great Florida Insurance 1326 West North Blvd #1 Leesburg, FL 34748 Phone (352) 365 -1222 Fax (352) 365 -6135 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT FICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED M ELLIS ELECTRICAL, INC MICHAEL E. ELLIS 4234 S BLUFF LAKE RD I MASCOTTE, FL 34753 INSURER A: CYPRESS PROPERTY & CASUALTY INSURER B: VICTORIA INSURANCE INSURER C: FIRST COMP INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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 LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A • GENERAL LIABILITY V COMMERCIAL GENERAL LIABILITY CLAIMS MADE V OCCUR • GFL 1018035 06/11 /12 06/11 /13 EACH OCCURRENCE 1,000,000 DAMAGE PREMISES TO RENTED 100,000 MED EXP (Any one person) 5,000 PERSONAL &ADVINJURY 1,000,000 GENERAL AGGREGATE 2,000,000 • PRODUCTS - COMP /OP AGG 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: 0 POLICY • PROJECT • LOC B ❑ AUTOMOBILE ❑ El V V n • LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON OWNED AUTOS 9582321 04/26/12 04/26/13 COMBINED SINGLE LIMIT (Ea accident) 1,000,000 BODILY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) • GARAGE UABILnY • ANY AUTO El AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG EXCESS/UMBRELLA LUU3ILITY II OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE • RETENTION $ EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below FCD0017530 -01 09/23/12 09/23/13 • WC STATU- • OTH- TORY LIMITS ER E.L EACH ACCIDENT 100,000 E.L DISEASE - EA EMPLOYEE 100,000 E.L DISEASE - POLICY LIMIT 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Dept. 10050 NE 2nd Ave Miami Shore, FL 33138 1email-silveraa@miamishoresvillage.com 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 LIABILnY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE BRAD BURLEY ACORD 25 (2001/08) OF © ACORD CORPORATION 1988 A jO IiP5 FA•wii(s 2o//,4,z z- x rtifm/ ID If Co $411e (14 20 "r Rckke o3/ FA-fri/lizy `Do I,fg 5Thie fi e.- 11)1 FC-1 5 EL &-c-r /a/ C4-c //t/ fifro r Ek. Pip 1P-)< eee. >2/ PiSCoMile-cY ce_ Aito Z- m! Shores Vd1qqfP., r - n'''T 0 CCIMPI.IANCE- wi I-I-1 ALL FEDERAL ' tsr_,UN 1 I.,t_FS AND REGULATIONS