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RC-12-698
Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 193749 Permit Number: RC -4 -12 -698 Scheduled Inspection Date: June 19, 2013 Inspector: Rodriguez, Jorge Owner: CLARK, SCOTT Job Address: 62 NE 108 Street Miami Shores, FL 33161 -7036 Project: <NONE> Contractor: HMF CONSTRUCTION CO Permit Type: Residential Construction Inspection Type: Final Building Work Classification: Alteration Phone Number Parcel Number 1121360110030 Phone: (954)931 -9886 Building Department Comments BATHROOM REMODEL Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. June 19, 2013 For Inspections please call: (305)762 -4949 Page 33 of 38 Mi ,Ei► , hores Village Bui g Department 10050 N.E. /`venue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 I ^ q, s INSPECTION'S PHONE NUMBER: (305) 762.4949 Lidt BUILD Permit No. Master Permit No. a > Ct RECEIVED APR 19 20 BY: PERMIT APPLICATION FBC 2001 Permit Ty UILDING T ROOFING OWNER: Name (Fee Simple Titleholder): SCOTT CLARK Address: 62 NE 108TH STREET City: MIAMI SHORES Tenant/Lessee Name: NIA Email: NIA Phone#: (305)610 -7156 State: FL Zip: 331614036 Phone#: N/A JOB ADDRESS: 62 NE 108TH STREET City: Miami Shores County: Miami Dade zip: 33161-7036 Folio/Parcel #: 11- 2136- 011 -0030 Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: STATE CERTIFIED CONTRACTORS INC Address: 3389 SHERIDAN STREET, #522 City: HOLLYWOOD State: FL Qualifier Name: SALVATORE MIRABELLA Phone#: (954)467 -0651 ci-ktio 59115 Zip: 33021 Phone#: (954)467 -0651 State Certification or Registration #: CGC 035940 Certificate of Competency #: NIA Contact Phone#: (954)4674651 Email Address: INFO @STATECERTIFIEDCONTRACTORS.COM DESIGNER: Architect/Engineer: NIA Phone#: WA 1.O ' e %' Value of Work for this Permit: $ 7,60100 Square/14par Footage of Work: Type of Work: DAddition Alteration New G Repair/Replace Demolition Description of Work: REMODEL BATHROOM Building: Replace Vanity Cabinet, Replace Cement Boards In Tub (same for same) Electrical: Replace outlets, lights and switches (same for same) Plumbing: Replace Lav Sink, Replace Water Closet and Replace Tub (same for same) e*******+ ************ a************ *e*** Fees*ee e*ee ********* *e n eewas+xeewe****e*ee******** Submittal Fee $ ✓ ..' Permit Fee $ Al 0 CCF $ CO /CC $ ,7 IP 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) N/A Bonding Company's Address NIA City N/A State NIA Mortgage Lender's Name (if applicable) NIA Mortgage Lender's Address N/A Zip N/A City N/A State NIA Zip N/A 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 s Rosted notice, the inspection will not be approved and a reinspection fee will be charged. � Signatl e //AAA . Signature effir Owner or Agent The foregoing instrument was acknowledged before me this I. day ofd, 20 , by .0 O `* ':s- who is personally known to me or who has produced"- As identification and who did take an oath. NOTARY PUBL - y Sign: / WITARY PUBLIC-STATE OF FLORIDA �� . '' Jordan Kohn Print: A ms' ': Cammiscinn #DD919494 My Commi ion Expires: ' %,,,',,.•O` Expires: AUG. 24, 2013 BONDED THRU ATLANTIC BONDING CO. , LNC Contractor The foregoing instrument was acknowledged before me this I day of , 20 '; by cWP /f(# who is ► rsonally . o me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: 1 orsan Print: ' �Iiriy Commission #DD919494 M Commission Ex ire .�„� Expires: AUG. 24, 2013 y P �ONDID MK ATLANTIC BONDING CO., INC. OTARY PLBLIC -STATE OF FLORIDA ** * * **ib*N+**sR*** 9k+ kiR 9lsga******M tl%1479--a-- s A�4t+ k+ k4+ �AKs�k+ k�kdrasAe N�+ k�k**** d�+ k�b* H��P�NB�B �kob�kd�N�spd��b *�1+sR *�kd�N+�h�k�h�7 * �k ****�k h+ R�kd��k�i +�8�k�k�k *�H�kK�N�iNNi• *** APPROVED BY Plans Examiner Zoning.. Structural Review Clerk (Revised 07 /10/07)(Revised 06/10/2009)(Revised 3/15/09) TE C CGC 035940 www .StateCertifiedContractors.com 3389 Sheridan Street Suite #522 Hollywood, FL 33021 phone : (954 964 -2400 fax : (954)989-6668 info©StateCertified Contractors.com Miami Shores Village Building Department 10050 NE 2nd Avenue Miami Shores, FL 33138 AUTHORIZATION LETTER To whom it may concern: Date: 03/05/2012 Please allow our permit runner, MATTHEW FITZGERALD, to perform all duties required with your building department including registering, applying for permits, picking up permits, paying for fees and scheduling inspections. Should you have any questions with this request, you may reach me at (954)854 -3332. Thank you for your assistance. S'n ce ly, atore Mirabella C 035940 STATE OF FLORIDA COUNTY OF BROWARD Sworn and subscribed before me, did personally appear S. (} - V 4 ` 0e ►46 - On this q' day of k �°4 , 20 L �. SEAL: NOTARY PLBLIC.STATE OF FLORIDA Jordan Kohn Tr4 Commission #DD919494 �,,,,, ,,/ Expires: AUG. 24, 2013 BONDED M: MAIM:. BONDING CO., INC. Miami Shores Viiiage 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. N COPY OF LOCAL BUSINESS TAX RECEIPT C. OPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. - -/1 COPY OF WORKERS COMPENSATION EITHER CERTIFICATE OR EXEMPT N ( C 10 ) 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: STATE CERTIFIED CONTRACTORS INC BUSINESS ADDRESS: 3389 SHERIDAN STREET CITY FT LAUDERDALE STATE FL ZIP CODE 33304 BUSINESS PHONE: (954 ) 467 -0651 FAX NUMBER (954 ) 467 -0655 CELL PHONE (954 ) 854-3332 QUALIFIER'S NAME: SALVATORE MIRABELLA QUALIFIER'S LIC NUMBER: CGC 035940 E -MAIL ADDRESS (IF APPLICABLE): INFO @STATECERTIFIEDCONTRACTORS.COM Created on 3119109 BY MLDV 1 RV 3126109 MLDV STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487 -1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 MIRABELLA SALVATORE STATE CERTIFIED CONTRACTORS INC 33899 SHERIDAN STREET HOLLYWOOD FL 33021 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.myflorldaticense.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 stove 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 STATE OF FLORIDA STATE FLORIDA tom; 5 5 8 E DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CGC035940 04/20/11 100423099 CERTIFIED C:.. RACTOR MIRABELLA, SALVATORE STATE CERTIEIED CONTRACTORS INC CERTIFIED under the lerevisiCate o! cdt.409 `Y s+ pisstiom ®atst AUG 31, 2012 . L11O42000636 DEPAR c ®NSO t usiN 88 INDUSTRY PROFESSIONAL REGULATION LICENSING SE 1111042000636 BATCH NUMBER 100423099 C00036 -940 The GENERAL CONTRACTOR Named below IS CERTIFIED Dhder the provisions of ChsPter 4 iration date: AUG 31, 2012 MIRABELLA SALVATORE STATE CERTIFIED CONTRACTORS INC 3389 8= E =RIDAQ STREET HOLLYWOOD RICK SCOTT GOVERNOR DISPLAY AS REQUIRED BY LAW ACORD CERTIFICATE OF LIABILITY INSURANCE PRODUCER COVER ALL INSURANCE 6800W.ATLANTIC BLVD. MARGATE FL 33083 PALM 9664006 FX1954) 9664386 MOM STATE CERTIFSD CONTRACTORS, INC. 3368 SHERIDAN STREET SUITE 822 HOLLYWOOD FL 33021 m t9tat2111 _ THIS ERTIFICATE IS YCA COi NO DRX AE A MATTER OF CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT EXTEND OR ALTER THE C EAweFORDRD SY THE BELOW_ INSURERS AFFORDING COVERAGE 1 NAIL IIuleE& AOCIOCANMEXE NNW= CO Newt INCPPER MISER P: M UNE COVERA POLK,1ES OF INSURANCE LISTED snow HAVE BEEN ISSUED TO THE INSURED NAMED MOVE FOR THE POLICY PEN= INDICATRG, NO1WITHSTAIEIN0 ANY REQUIREMENT, . TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MICH THIS CERTIFICATE' MAY BE IBSUMD OR MAY PERTAIN, THE INSURANCE AFFORDS) Ili THE POLICIES DESCRIBED HERON IS SUBJECT TO ALL THE TERM$, EXCLUSIONS AND COMMONS OP SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAYS BEEN REDUCED SY PAID MAIMS. , �- i1�N. A• r !i 1 1111M07,11111MINI IRSCRW1IDN OP OPERATION i LOCATION/ MENUS IOW/MO ADDEOSY ENOORUMI$I1 EPROM PROVISION LEMODELING .ER,TIFtCAT! IR VILLAGE OF MIAMI SHORES 10050 NE 2ND AVE MIAMI SHORES FL 33138 FAXY38 CORD 361 2001108) ACORD CORPORATION 12111 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: STATE CERTIFIED CONTRACTORS INC Receipt yte:GEN�ER2i�,i1CONNTRACTOR () Business Name: Business Type: Owner Name: SALVATORE MIRABELLA Business Location: 3389 SHERIDAN ST #522 HOLLYWOOD Business Phone: 954 - 989 -6666 Rooms Seats Employees 10 Business Opened:o5 /23/2011 StatelCounty /Cert/Reg :CGC03 5 9 4 0 Exemption Code :NONEXEMPT Machines Professionals For Vending Business Only Number of Machines: Vendine Tvoe: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 2.70 0.00 0.00 29.70 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: STATE CERTIFIED CONTRACTORS INC 3389 SHERIDAN ST #522 HOLLYWOOD, FL 33021 ill 2011 - 2012 .. Receipt *01C- 11- 00000051 Paid 10/03/2011 29.70 ta. ACORD CERTIFICATE OF LIABILITY INSURANCE ta......--"- DATE efflexeryyro 12/12/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA'TE 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 pallcy(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 Mark van Wert C./0 VVIllis of Florida. inc . 3000 Bayport Drive; Suite 300 Tampa, FL 33607 C.ONTACT NAME: P (866) 293-3660 Ext. 623 1 foot Nok (888)228-4049 ADDRESS. 1NSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A : American Zurich Insurance Company 40142 INSURED Workforce Business Setvices, Inc. Alt. Emp: State Certified Contractors Inc 1401 Manatee Ave. West Ste 600 Bradenton, FL 34205-6708 INSURER B: INSURER D: $ INSURER E : $ INSURER F : $ CERTIFICATE NUMBER: 11FLO79818931 — - —REVISION_N MBER:-- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN' ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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, EXCLUSIONSAND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR TYPE OF INSURANCE ADM INSR - . YAM POLICY NUMBER POLICY EFF IMMIXDPITYY) POLICY EXP (MMIDDANYY) LINTS GENERAL _ LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PRIMISES (Ea occurrence) $ MED EXP (My one person) $ I CLAIMS-MADE OCCUR PERSONAL & ADV INJURY GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ GERI AGGREGATE LIMIT APPLIES PER 7 POLICY El swi Fl LOC $ AUTOMOBILE — , _ LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS — SCHEDULED AUTOS NON-OWNED AUTOS MIT COMBINED L LIMIT Me accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ ,(P10.0SIASka) $ UMBRELLA UAB EXCESS UAB . OCCUR CLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ DED 1 I RETENTION $ . .P1 WORKERS COMPENSATION AND EMPLOYF-RW UABIUTY Y N ANY PROPRIETOFUPARTNER/EXECUTNE °FACER/MEMBER EXCLUDED? (Mandatory In NH)-- - If ), describe under DESCRIPTION OF OPERATIONS betow NIA WC 90-00-818-01 _ _ . — 12/31/2011 — 12/31/2012 - - -- ir I WC STATU- I 10TH. ^ I TORY Mimi I ER E.L EACH ACCIDENT $ 1,000,000 El. oisEAsE,BA EMPLOYF.E $ - 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 Location Coverage Period: 12/31/2011 12/31/2012 Client# 053720 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD UN. Additional Remarks Schedule, If more space le required) Mate Contractors Inc Coverage is provided for Certified only those employees leased to but not • subcontractors of: CERTIFICATE HOLDER CANCELLATIO Miami Shores Village Bldg Dept 10050 NE 2nd Avenue Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS AUTHORIZED REPRESENTA11VE /77MJ. 1.A.)27.56 1988-2010 ACOPD CORPORATION. All rights reserved. 8' -0" LC; r • • • • • • • 2'-6° G� ?", / _ Miami Shores Village APPROVED BY DATE ZONING DEPT BLDG DEPT SUBJECT TO COMPLIANCE WITH ALL FEDERAL ,1 Alf AND COUNTY RULES AND REGULATIONS Pte- * , -- +r - - -4 1 a +r \t 111 II t ! all \ \\ / /8t b \ �. / tl a J� cc cc c W cc 5 W d m W CC W IC m ® p .- CID CO • Za 0 CC 4C C U t/3 OWNER BATRIROOM REMODEL: Demo Plan SC LE: %" = 1' -0" CONTRACTOR Scott Clark 62 NE 108th Street Miami Shores, FL 33161 SCOPE OF DEMO: SCOPE OF DEMO: State Certified Contractors 3389 Sheridan St, #522 Hollywood, FL 33021 (984) 964 -2400 CGC 035940 -Structural • Remove Vanity Cabinets - Electrical • Rem � • • Remove Lights FBC 2007 NEC 2008 - Plumbing • Remove Tub • Remove Toilet • Remove Vanity Sink -Mechanical • NO MECHANICAL • Existing Exhaust to Remain FPC 2007 FMC 2007 11 EC , g NOTARY Z '•,., DATE 02/28/2012 PUBLIC -STATE OF Ken Jordan Kohn Commission #DD9194 . ' Expire AUG. 24, 20 TIM ATLANTIC BON]MNG CO., r N ; tary BONDED 8'-O" 2'-6" OWNER BATHROOM REMODEL: Proposed Plan SCALE: 1/2" = 1' -0" CONTRACTOR Scott Clark SCOPE OF WORK: SCOPE OF WORK: State Certified Contractors 62 NE 108th Street - Structural - Plumbing 3389 Sheridan St, 5522 Miami Shores, FL 33161 • Replace/Relocate • Replace/Relocate Tub Hollywood, FL 33021 Vanity Cabinets • Replace Toilet (954) 9642400 • Replace/Relocate � EC 1 ,�; q g CGC 035940 DATE 02/28/2012 i Replace Outlets Vanity Sink NCTARY PUBLIC-STATE OF PUB: • Replace Switches - Mechanical Jordan Kohn • Replace Lights • NO MECHANICAL ='. Com #DD914 • Light over Tub to be WP • Existing Exhaust to Remain ,fin ,:` Expires: AUG. 24, 2 j 'ryu`� BO CJ&D TIM ATLANTIC $QNDL1 G CO. FBC 2007 NEC 2008 FPC 2007 FMC 2007 94 )13 Dm. 1 BUILDING PERMIT APPLICAT Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305)756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permit Type: BUILDING JOB ADDRESS: a 1 O gr'$T FBC20 CO Permit No. / Master Permit No... 12 -� �P1 cb ROOFING City: Miami Shores County: Miami Dade Zip: 3 316 1 Folio/Parcel #: f / / &, 6 I / L) 1 Is the Building Historically Designated: Yes NO Flood Zone: 644_ 3 0 , 5 —W - 7 6 OWNER: Name (Fee Simple Titleholder): ,_ 5eeT • 744'6_ Phone #: 35- 767-'41 %) Address: Ali 10 8 City:L> 1/ Tenant/Lessee Name: Email: State: zip: 33 CC 1 Phone #: p(CONTRACTOR: Company Name: i/ /'" a 4 41/Alf; Phone #: Address: a/ 6 0 4►�n dq 7e4 %2. City: State: /44' Zip: Qualifier Name: LL" / ' f e Phone#: 141 r0.7/2..k4 i‘-.1()A CO Q Caw% C a i . 4 -.)- State Certification or Registration #: Cer C 0 77P.? Certificate of Conj►petenct, #: Contact Phone#: if 1.1 97 1 X226 Email Address: DESIGNER: Architect/Engineer: Phone#: -V Value of Work for this Permit: $ CS 017 Square/Linear Footage of Work: Type of Work: Addition .{` ltera 'on ONew ORepair/Replace Demoli * on K. Description of Work: how114, kf-r) ((J' Color thru tile: ***************************************F w * * * * *.x***** *s• * * ******* ** •+x *****x•.x ******** ** Submittal Fee $ Permit Fee $ ...-6 °lam CCF $ CO /CC $ Scanning Fee $ 3 . olk,) Radon Fee $ 1 acD - (� ) DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ l en 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 p> -d at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the ab e of su ' po, ted notice, the inspection will not be approved and a reinspection fee will be charged. Signature wner or 2 The foregoing instrument was acknowledged before me this 3 day of jOi'le , 20 /3, by Le-3 he Tediei who is personally known to me or who has produced P/'ive r5 1)e-As identification and who did take an oath. Or NOTARY PUBLIC: /Q-1 Sign: � c� Print: My Commission Expires, APPROVED BY Notary Public, State of Florida My Comm. Expires Nov. 7, 2016 No. EE849959 Bonded thru Arthur J Gallagher & Co. ************************ x*m***************** ** ***** ** **** * ** ******w** ****** Signature J /HZ ontractiv The foregoing instrument was acknowledgedpefore me this � / day of 7-LA e- , 20 13, by Lei 1i Te /`el c who is personally known to me or who has produced R. 'Vi ved Lied as identification and who did take an oath. ,NOTARY PUBLIC: Sign: ,P5 `C" Print: My Commissior DA hatary Public, die u Ffiaride My Comm Expires No 7, 2016 No. EE849959 Bonded thru Arthur J Gallagher A, Co. ‘-/eri Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Zoning Clerk Miami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit I R� -f-- I Lgi/ Owner's Name (Fee 8imple Title Holder): .er r (�q Phone #: 3 - 75 7 -'-r/ 1? Owner's Address: a A1 g /Or -5 City: /ice ' SAP r State : -�L- Job Address (Of where work is being done): City: Miami Shores SA de /Or--r- Zip Code: 33I i State: Florida Contractor's Company Name: Address: /0 Co City: Qualifier's Name : State: c,, Zip Code: J3/4/ Phone# 9?) Jai Zip Code: 3.Jy`M'6 Lic. Number: 0773 Architect/ Engineer of Record Name: Phone #: Address: City: State: Zip Code: Describe Work: did / &c)r -,, I hereby certify that the work has been abandoned andlor the contractor /architect is unable or unwilling to complete the contract. I hold the Buildin • • fficial the Miami Shores harmless for all legal involve Signature ent The foregoi - i strument was aknowledged before me this 3 day of 3-- .20i3,by LeJ6/C r e/ Who is personally known to me or who has produced 7Z afn/7s t . as indentillcation. 4 Ndtary Sign: Seal: Signat �i,11 ._` i ' ld l @3t *der The foregoing instrument was aknowledged before me -t this 3( day of -SU'lr' ,20 by Ie /e /leg who is personally known to me or who has produced .L. Dri os Lie as indentiflcation. Notary Sign: GRACIELA TABLADA Seal: _ °' Notary Public, State of Florida My Comm. Expires Nov. 7, 2016 No. EE849959 Bonded thru Arthur J Gallagher & Co. SCOTT B. CLARK 62 N.E. 108TH STREET MIAMI SHORES, FLORIDA 33161 CERTIFIED MAIL State Certified Contractors 3389 Sheridan Street, Suite 522 Hollywood, Florida 33021 Attention: Itzick Kohn Dear Mr. Kohn: It has come to my attention that State Certified Contractors, Inc. (CGC# 035940) is apparently no longer in business. Please accept this letter to inform you that the permit number RC -4 -12 -698 for bathroom renovation located at 62 N.E. 108th Street, Miami Shores, Florida 33161 was never closed out and requires a contractor to close out this job. Being that State Certified Contractors, Inc. is no longer in business, please accept this letter than State Certified Contractors is no longer the contractor of record and will be replaced for purposes of closing out this permit. This letter is being sent certified and retum receipt requested to assure notification of this action. Should this information be in error, or if you need to contact me, you may do so by calling me at 305 - 995 -7155. Since, ely, "dr*/ ' = . Clark SBC:gt Cc: Mr. Sam Danziger, Esquire Mr. Peter J. Olde Mr. Paul Kaess Miami Shores Village Building Department 1 SENDER: COMPLETE THIS SECTION Oomptete items 1,, 2, and 3. Alsq complete lterrr4 if Restrlcted Delivery Is desired. P Print your name and address on the reverse so that we can return the card to you. 1 Attach.;thls oard to the baok of. the mallplece, or-drl the front if space' permits. Article Addressed to: COMPLETE THIS SECT ON ON DELIVERY t] Agent Addressee 8. Received •°`(Pen a Name) !very D. Is deltyery.atldress .dlfferent.from Item 1? -t] Yes "r if YES, enter delivery address below ll1 No Arflole Ntu iber�i ritans(eMmm Ali Service Type' t] Cettifed Mall ii Empress Mail o Registered p Return Receipt for Merchandise t 0 Insured Man o C.O.D. 4. Restricted Delivery? (Extre.Fee) C]yes 7012 1010 0000 0720 7448 PS F o r m 38:11, Februaly 21)04 omestio Ret lm U.S. Postal Service,. CERTIFIED MAIL RECEIPT (Domestic Mail Only;: No Insurance Coverage Provided) For delivery information visit our'_website at www.usps.come 102595.02 -M -1540 Postage Certified Fee Return Receipt Fee (Endorsement Requires Restricted Delivery Fee (Endorsement Required) Total Postage & Fees Sent street Apt No. or PO Bax No,O I //t aI4 Cl ty State, 4P+4 PS Form 3800. August 2006 . See Reverse for Instructions 22 2 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 174894 Permit Number: PL -4 -12 -700 Scheduled Inspection Date: June 18, 2012 Inspector: Hernandez, Rafael Owner: CLARK, SCOTT Job Address: 62 NE 108 Street Miami Shores, FL 33161 -7036 Project: <NONE> Contractor: SMN PLUIMBING CONTRACTOR LLC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360110030 Building Department Comments PLUMBING WORK FOR KITCHEN REMODEL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FO SP- 172605. no access 12:05 June 15, 2012 For Inspections please call: (305)762 -4949 Page 26 of 27 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 cv \2.- 66 Inspection Number: INSP- 172605 Permit Number: PL -4 -12 -700 Scheduled Inspection Date: June 11, 2012 Inspector: Hernandez, Rafael Owner: CLARK, SCOTT Job Address: 62 NE 108 Street Miami Shores, FL 33161 -7036 Project <NONE> Contractor: SMN PLUIMBING CONTRACTOR LLC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360110030 Building Department Comments PLUMBING WORK FOR KITCHEN REMODEL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments June 08, 2012 For Inspections please call: (305)762 -4949 Page 6 of 28 Miami Shores Village Building Department LNIt APR 1? cu'a �Y: - - - - -- - - 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 No Pt t Z4 1CO PERMIT APPLICATION Master Permit No. FBC 20 jQ Permit Type: PLUMBING OWNER: Name (Fee Simple Titleholder): SCOTT CLARK Phone#: (305)610 -7158 Address: 62 NE 108TH STREET City: MIAMI SHORES Tenant/Lessee Name: NIA Email: NIA State: FL zip: 33161 Phone#: N/A JOB ADDRESS: 62 NE 108Th STREET City: Miami Shores Folio/Parcel #: 11- 2136 -011 -0030 ounty: Miami Dade zip: 33161 Is the Building Historically Designated: Yes NO Flood Zone: SMN PLUMBING CONTRACTOR LLC CONTRACTOR: Company Name: Phone#: Address: 7444 SW 128TH COURT City: MIAMI State: FL Zip: 33183 Qualifier Name: SEENAUTH NARAIN Phone#: State Certification or Registration #: CFC 1428106 Certificate of Competency #: N/A Contact Phone#: Email Address: N/A DESIGNER: Architect /Engineer: NIA Phone#: NIA { Value of Work for this Permit: $ /) WV'r Square/Linear Footage of Work: Type of Work: OAddress XA,lteration DNew ORepair/Replace ❑Demolition Description of Work: REMQDEL BATHROOM PLUMBING - replace tub, replace toilet and replace Iav sink (same for same...existing,sanitary and water) **************************************F *+n**** * *a ************* * *** x** * * * * * ** n****a ** Permit Fee $ /53 CCF $ CO /CC $ Radon Fee $ DBPR $ Bond $ Submittal Fee $ Scanning Fee $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ I d U ■ V Bonding Company's Name (if applicable) NIA Bonding Company's Address N/A City NIA State NIA Mortgage Lender's Name (if applicable) NIA Mortgage Lender's Address N/A City NIA Zip N/A State N/A Zip N/A 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 ET.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 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 ap pry d and a r� ec ; ee will be charged. Apt, d.7 id& Signature / Signature er or ent The foregoing instrument was acknowledged before me this l day of f I,20/a--,by . >CYfJ who is personally known to me or who has produced YL �" As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission TAR?' PUBLIC•STATE OF FLORIDA Jordan Kohn Contractor The foregoing instrument was acknowledged before me this 3 day of ApQlL , 20 i1- , by 4- who is personally known to me or who has produced fLOL FLDt- as identification and who did take an oath. NOTARY PUBLIC -STATE OF FLORIDA My Commission xpires: BONDED THRti AT..AYTIC BONDING CO.,INC. **** �+ �r�x: s�xa�x�*+ z'**** �na�****+ s************************ �x *�a�x�xx�s+�a****a��x�x** ** **** �** **�x�ra�** **a�x�:r * * ** * *** x *a�m:><�x�:**** *** APPROVED BY (Revised 07 /10/07)(Revised 06 /10/2009)(Revised 3/15/09) Plans Examiner Structural Review Zoning Clerk o STATE OF FLORIDA AC# 5 8 0,556 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CPC1428106 10/06/11 110132217 CERTIFIED PLUMBING: CONTRACTOR 3MN PLUMBIN CONTRRACTOR LIMITED IS CERTIFIED under t:ao peovieione of 1111.489 as aaeia'aeiaas daces AUG 31, 2012 L11100802289 STATE Of FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OP WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO 8E EXEMPT PROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 10/14/2011 EXPIRATION DATE: 10/13/2013 PERSON SEENAUTH NARAIN FEIN 787228707 BUSINESS NAME AND ADDRESS: SMN niumeiNa CONTRACTOR LIMITED LIABILITY COMPANY 7444 SW 128Th CT MIAMI, FL 33183 SCOPE OF BUSINESS OR TRADE CERTIPIO PLU8818O CONTRACTOR IMPORTANT F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.051121, F.S., Certificates of election to be r;.; exempt_ apply only within the scope of there business or trade listed on the notice of election to be exempt. E Pursuant so Chapter 440.05)13). F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice ar certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1809 THIS DOCI.7MCNt HAS 11 COLORED BACKGROUND, MICROCRINTING • LINE,t4ARK•F. PATENT-CO PAPCFf --:'� AC# 5814556 STATE OF FLORIDA DPAR NSHUMON N2SRYRLIg er , B O TION SEQ# L11100602289 DATE BATCH NUMBER CENSE NBR 10/06/2011 110132217 CFC1428106 The PLUMBING CONTRACTOR Named below I3 CERTIFIED Under the provisions of Chapter. 489 FS. Expiration date: AUG 31, 2012 NARAIN SEENAUTH M SMN PLUMBING CONTRACTOR LIMITED`LI 7444 SW 128TH CT MIAMI FL 33183 TY COMPANY RICK SCOTT GOVERNOR DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY +cwild.v 1d 11:15 MORGAN INSURANCE '+ 19544670655 CERTIFICATE OF LIABILITY INSURANCE NO.345 9001 DATESSUDDmnrY) 04103/12 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY 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. IMPORT ANT: lithe certifoate holder is an ADDfONAL INSURED the poUcy(les) must be endorsed i<SUBROGATION IE WAIVEO, subject to the terms and conditions of the policy, certain policies new 'volts an endorsement A strdernent on this mink et* does not confer dgM$ to the certificate holder In lieu of such endoi ement(a), PRODUUaR Morgan Insurance Group 13168 SW 42nd Street, Suite 0107 Miami, FL 33178 Phone (306) 2229001 INSURED SMN PLUMBING CONTRACTOR LLC 7444 SW 128 Ct MiRmi,•FL 33183• (306) 322-2642 Fax (305) 222 -9008 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 POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITWN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT,TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PALS CLAIMS. A wee OF MIDRANGE 1111059 11/10/2011 11/10/2012 UNITS 1.10 .'.rJI -,- CE 1000,000 Wr fc7 1 1 #- d.(tdr ma or L a+e PERSONAL & AIM INJURY e 100 000 9,000 1,000000 2,000,000 1.000000 1 EACH OCCURRENCE AGGREGATE t DESCRIPTION OF OPERATIONS I LOCATI0N81 VEHICLES (Attach ACORD 101, Additional Ranenla Schedule, ifmere spas k reqarodl PLUMBING CONTRACTOR` CERTIFICATE HOLDER l +l• lf: I. J� EL EACH ACCIDENT . EL OIUASE- FAemu , $ E.L. DI$BA9E- POLICY Miami NS E res Village Miami Shores, FL 33138 CANCELLATION [SHOULD ANY OP ME MOVE DESCRIBED POUCIES 6E CANCELLED BEFORE THE EXPWATION DATE THEREOF, NOTICE WIL,I, BE DELIVERED ACCORDANCE WITH THE POLICY PROVISION&. AMINO= RENESIBITATNE ACORD 26 (2009109) QF 1988'2008 ACORD CORPORATION. All Nights reserved. The ACORD name and logo are raglstered merits of ACORD ustoreter:Scott Clark Attn: Scott Clark 62 NE 108th Street Miami, Ft. 33161 Mobile: (305) 610-7156 Nome: (305) 757-4191 Li= te: Primary., . Scott Clark 62 NE 1 08th Street FL 33161 MobileiA305) 610-7156., Homo: (305)757-41l1 , r . ) r-- r--.45°.• • ..,.■ -n. -or- PRA? 1. 4 ■ VIA c\M . , 4 . . 447' 6 .,t.... ,.7:f., .,,,..4...... .-, -.. .,' ,. ' 4;-4,,;,• i'i-'4,17' "...I f;.... rr ,FAV 7::'‘ ''''' '''''''''''4'''' 444.0..",t ...,....,.., . . '1,7:•'.4,,-;‘,C.111,.."4.'''...re :::','::•X'1"-e , U r f rr. i500k-Depositf2MiLiiif egUport,Co viravw4-070.241w.N,4,,,,i phetorhotWortc my noi kft, f14410,4t tp,r wlthbi30 oto_nottwovontie, OF propaprad bX■11.041,aladarit *spank a Srel party . , Potr:A49411,84, "1Y rights uYidar fit 171,w0,ovvnare Raaavry.Fund ,themkeni *und4t5le depo* in Credit Card # Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 174924 Permit Number: EL -4 -12 -699 Scheduled Inspection Date: June 20, 2012 Inspector: Devaney, Michael Owner: CLARK, SCOTT Job Address: 62 NE 108 Street Miami Shores, FL 33161 -7036 Project: <NONE> Contractor: SUNCOAST POWER AND FIRE INC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360110030 Phone: (954)452 -9805 Building Department Comments ELECTRICAL WORK FOR NEW BATHROOM REMODEL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 174893. CREATED AS REINSPECTION FOR INSP- 172602. Need smoke / carbon monoxide detectors. No access at 3:20 p. m.. June 19, 2012 For Inspections please call: (305)762 -4949 Page 12 of 14 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 FBC2010 Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): SCOTT CLARK Address: 62 NE 108TH STREET Permit No.'' Master Permit No MOMIWIlit APR 1 9 zui2 tip BY: 2- PSI Phone#: (305)610 -7156 City: MIAMI SHORES Tenant/Lessee Name: NIA Email: NIA State: FL Zip: 33161 Phone#: N/A JOB ADDRESS: 62 NE 108TH STREET City: Miami Shores Folio/Parcei #: 11-2136-011-0030 County: Miami Dade Zip: 33161 Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: SUNCOAST POWER AND FIRE INC Address: 15041 SW 13TH PLACE Phone#: (954)452 -9805 City: SUNRISE Qualifier Name: JOHN ANNIS State: FL Zip: 33326 Phone#: (954)452 -9805 State Certification or Registration #: EC 13002067 Contact Phone*. (95(954)452-9805 DESIGNER: Architect/Engineer: WA Certificate of Competency #: NIA Email Address: Phone#: NIA Value of Work for this Permit: $ err •00 Square/Linear Footage of Work: XAlteration New ORepair/Replace Type of Work: ❑Address ODemolition Description of Work: ELECTRIC - replace outlets, lights and switches (same for same...no new circuits) ******** ** * *** *** * **** *** ** * * **a**** *w* Fees * * *** * * * * ************ *** * *** * * * ** *** ** * *** Submittal Fee $ Permit Fee $ /ts—a' Ca v CCF $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ CO /CC $ Bond $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) NIA Bonding Company's Address N/A City N/A State N/A Mortgage Lender's Name (if applicable) N/A Mortgage Lender's Address NIA Zip N/A City N/A State NIA Zip N/A 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 FLRCTRICAL 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 b , #proved and einspe tion fee will be charged. Signature A (A . 'vairow w- Agent The foregoing instrument was acknowledged before me this ' day of MO(k ,20h —,by 5 La -.- CIA(' who is personally known to me or who has produced J,mv As identification and who did take an oath. My Commis • on Expires: * * * * * * * * * * * * * * * * * * ** ** APPROVED BY NOTARY PUBLIC4TATR OF FLORIDA Jordan Kuhn Eammissivva , `-,.,,..••' Expires: AUG. 2 . 2013_ ATLANTIC BONDING CO., INC. ..g Signature Contractor The foregoing instrument was acknowledged before me this 1 day of / 4k0G► i , 20 , by J r 5 who is personally known to me or who has produced as identification and who did take an oath. /9 `t ' Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) NOTARY P Sign: Print: My Co Y PUBLIC 4TATE OF FLORIDA Jordan Kohn ssion Expires: iras: AU ATLANTIC ®ONDL'iG CO., INC. Zoning Clerk 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: Business Name: SUNCOAST POWER AND FIRE, INC Owner Name: JOHN R ANNIE Business Location: 15041 SW 13 PL FT LAUDERDALE Business Phone: 954-423-1321 Rooms Seats Employees 1 Receipt #: 181-2422 Business T ype ELECTRICAL /ALARMS /CONTRACTQ: '(ELECTRICAL CONTRACTOR) Business Opened:oi /29/2004 State/County /Cert/Reg :EC13 0 02 0 6 7 Exemption Code:NONEXEMPT Machines Professionals For Vending Business Only Number of Machines: Vendinra TYD0: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT WHEN VAUDATED Mailing Address: JOHN R ANNIS 15041 SW 13 PL FORT LAUDERDALE, FL 33326 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 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. 2011 - 2012 Receipt #108 -10- 00006795 Paid 08/24/2011 27.00 DBPR - ANNIS, JOHN R; Doing Business As: SUNCOAST POWER A... hrips: / /www.myfloridalic ense.comTLicenseDetail .asp ?SID= &id= 51668B... 2:40:05 PM 4142012 Licensee Details Licensee Information Name: Main Address: County: License Mailing: County: UcenseLocation: License Information License Type: Rank: License Number: Status: Ucensure Date: Expires: Special Qualifications ANNIS, 3OHN R (Primary Name) SUNCOAST POWER AND FIRE, INC. (DBA Name) 15041 SW 13TH PLACE SUNRISE Florida 33326 BROWARD 15041 SW 13 PLACE SUNRISE FL 33326 BROWARD Electrical Contractor Cart Electrical EC13002067 Current,Active 08/19/2004 08/31/2012 Qualification Effective View Related License Information View License Complaint 1940 North Monroe Street, Tallahassee FL 32399 :: Email: Customer Contact Center :: Customer Contact Center: 850.487.1395 The State of Florida Is an AA/EEO employer. Convdaht 2007 -2010 State of Florida. Privacy Statement Under Florida law, a -mall addresses are public records. If you do not want your e-mail address released In response to a public- records request, do not send electronic nail to this entity. Instead, contact the office by phone or by traditional mail. If you have any questions, please contact 850.487.1395, 1 of 1 4/4/2012 2:40 PM A�..Rni CERTIFICATE OF LIABILITY INSURANCE 4/11/2012 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 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 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 Bruening Insurance 2700 S. Commerce Parkway Suite 309 Weston FL 33331 COOMNTTACT Commercial Lines N Esq. (954) 473 -1406 1 talc. Nol: (954) 659 -2338 EADMM,AA.� L INSURERS) AFFORDING GOVERAGE NAICS INSURERANOVa Casualty Company 42552 INSURED Suncoast Power and Fire, Inc. DBA: SteadSafe Fire & Security 15041 SW 13 Place Sunrise FL 33326 INSURER B : INSURER C: 09AL071852 INSURERD: 1/8/2013 INSURER E : $ 1,000,000 INSURER F: PRaENTED PREEMIMI ESES S (RENTED occurrence) COVERAGES CERTIFICATE NUMBER:CL1211703105 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 taw_ POUCY NUMBER I D)YYEYYY) ( CDDIYYYY) LIMITS A GENERAL LIABIUTY COMMERCIAL GENERAL LIABILITY OCCUR 09AL071852 1/8/2012 1/8/2013 EACH OCCURRENCE $ 1,000,000 X PRaENTED PREEMIMI ESES S (RENTED occurrence) $ 100 r 000 I CLAIMS -MADE X MED EXP Any one person) $ 5 , 000 PERSONAL 8, ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY n PE a Ti LOC PRODUCTS - COMP /OP AGG $ 2,000,000 31 $ AUTOMOBILE LIABILITY ANY AUTO ALLOYSNED HIRED AUTOS SCHEDULED NON -OWNED AUTOS COMBINED SINGLE LIMIT BI $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LtAB EXCESS UAB — OCCUR CLAIMS -MADE _ EACH OCCURRENCE $ AGGREGATE $ DED 1 'RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N yes describe under DESCRIPTION OF OPERATIONS Y / N N t A I TORY I I ER E.L. EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ glow E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, U more space M required) Please refer to policy for terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION (305)762 -5253 Miami Shores Village 10050 NE 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 J Bradley Bruening /IP .^ ACORD 25 (2010105) INS025 rnlnrun n1 ©1988 -2010 ACORD CORPORATION. All rights reserved. Thu A(:ARrt namu anti Innn aru runintururl marina of Annan 01 -19 -2012 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: PERSON: FEIN: 01/19/2012 EXPIRATION DATE: 01/18/2014 ANNIS JOHN R 650696374 BUSINESS NAME AND ADDRESS: SUNCOAST POWER AND FIRE INC 15041 SW 13TH PLACE SUNRISE FL 33328 SCOPES OF BUSINESS OR TRADE: 1- Electricaki Wiring IMPORTANT: Pursuant to Chapter 440. 05114), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.06112), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05413), F.S., Notices of election to be exempt and certif!cotes of election to be exempt shall he subject to revocation if, at any time after the filing of the notice or the issuance of the certitieate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certiftcate. The department shall revoke a certificate at any time for failure of the person named on the certiftcate to meet the requirements of this section. QUESTIONS? {850) 413-1609 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11