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EL-13-2217N Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 202828 Scheduled Inspection Date: November 12, 2013 Inspector: Devaney, Michael Owner: , Job Address: 186 NE 109 Street Miami Shores, FL 33161- Project: <NONE> Permit Number: EL -10 -13 -2217 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel.Number 1121360090090 Contractor: EVOLUTION ELECTRICAL CONTRACTORS Phone: (786)351 -5784 euiiaing Department comments NEW GFI IN KITCHEN Passed Failed Correction Needed Re- Inspection Fee INSPECTOR COMMENTS False 0 C No Additional Inspections can be scheduled until re- inspection fee is paid. 12 IV l� November 08, 2013 For Inspections please call: (305)762 -4949 Page 36 of 37 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 202684 Scheduled Inspection Date: November 08, 2013 Inspector: Devaney, Michael Owner: , Job Address: 186 NE 109 Street Miami Shores, FL 33161- Project: <NONE> Contractor: EVOLUTION ELECTRICAL CONTRACTORS tiunamg uepanment comments NEW GFI IN KITCHEN Permit Number: EL -10 -13 -2217 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360090090 INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP- 200208. Failed Correction Needed ❑�`' Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Phone: (786)351 -5784 November 07, 2013 For Inspections please call: (305)762 -4949 Page 29 of 33 o�-�- 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: I X'6 Ale / (21 S70 FBC 20 o u o 12013 Permit No. _ I — I Master Permit No. k- 3 62d 11) City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: 111-7 3 j eb1 O8 10 Is the Building Historically Designated: Yes NO X Flood Zone: OWNER: Name (Fee Simple Titleholder): 'z)-f> Phone #: Address: "1��✓? pl01FI City: l d 1 Tenant/Lessee Name: Email: State: CONTRACTOR: Company Name: 7C i 1 b V7 PCB. n' Cep Phone #: 7�/ . �� Address: i > AAV 10. City: hi'l t o ° h State: Qualifier Name: 4 ky-t'b VP] 'b Q¢ Ga,��Jtt Phone #: State Certification or Registration #: 1(7 C Certificate of Competency #: _ Contact Phone #: ? �J) �I 5�� _Email ddress: DESIGNER: Architect/Engineer: / " 13L - Phone #: 4411-4 Value of Work for this Permit: $ ;'b to•o i> Square/Linear Footage of Work: Type of Work: ❑Address DAlteration ONew XRepair/Replace ❑Demolition Description of Work: )Nr— tr!�! Submittal Fee $ Permit Fee $ 1,4'0 -®P CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond Technology Fee $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State zip 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 INTO 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 Owner or Agent The foregoing instrument was acknowledged before me this day of —=� """,20%5 ,by P�yW791-7 who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: APPROVED JANICE AIMEE MATOS MY COMMISSION #FF011193 ?i'��04','' EXPIRES April 23, 2017 Signature Con etor , .The foregoing instrument as acknowledged before me this day'o , 20 by 4m-fV ri 6 4:. ,r os lX , who is personally known to me or who has produced % % Plans Examiner as identification and who did take an oath. .q NOTARY PUBLIC: Structural Review (Revised 3/12 /2012 )(Revised 07 /10 /07)(Revised 06/10 /2009 )(Revised 3/15/09) Si 1'tu r v ,, . M CommissionE,�'�'�.� Q�so, a e , Golding My ` sz: COMMISSION # EE 105391 EXPIRES:JUNE21,2015 www.AARONNoTARY.com zoning Clerk 4 cv� qr' r)Q 6e �v�I Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES 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) ',117 CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT 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 WORKERS 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: BUSINESS ADDRESS: //6' 31 AIcAI -5'012Z . CITY ,� g (q-,,A. STATE L ZIP CODE 32' D 12 BUSINESS PHONE: 528 q- FAX NUMBER (__) CELL PHONE QUALIFIER'S NAME: /15U74/4,119 14,c4dA QUALIFIER'S LIC NUMBER: /0 C 000 610 E -MAIL ADDRESS (IF APPLICABLE): ��� `t/��c� �lAc tc_m�CV F? b14 0 0 . c0,v1 . Created on 3119109 BY MLDV 1 RV 3126109 MLDV 1 RV 6127111 AS STATE OF FLORIDA DEPARTNMNT OF BUSINESS AND PROFESSI ELECTRICAL CONTRACTORS LICENSING BC 1940 NORTH MONROE STREET �'►� TALLAHASSEE FL 32399 -0783 ACOSTA, ANTONIO EVOLUTION ELECTRICAL CONTRACTORS, INC. 11631 NW 58TH PLACE HIALEAH FL 33012 to� EVOLUTION ELECTRICAL CONTRACTORS INC ANTONIO ACOSTA PRES 11651 NW 58 PL ' NIANI FL 33012 iIs III ►, III III Its IIfII1 131411111 Jh I #.III* I hill I If* III Im 11 AC1110 O" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 09/()2/13 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: tithe certificate holder Is an ADDITIONAL INSURED, the policAles) must he 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 Miami Insurance Agency 15670 S. Dude Hwy. Suite A Miami, FL 33157 Phone (305) 256 -7534 Fax (305) 255 -7544 W E!cT Anderson Gonz2lez PHON o , (305) 256-7534 A!C No): (305) 254 -1461 E-MAIL Jim—* IIsouth.net s AFFORDING CWERAGE NAIC s INSURER A, LLOYDS OF LONDON INSURED LCN Group, Inc. 201 S Biscayne Blvd. #2800 Miami, FL 33131 INSURER B: PROGRESSIVE EXPRESS INS 0612812013 INS R c : ILLOINOIS NATIONAL INSURANCE COMPANY EACH OCCURRENCE INSURER D: DAMAGE ENTED PREMISES a oocunence INSURER E : MED EXP (Any are person) INSURER F: PERSONAL &ADVINJURY COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 CLAM &R TYPE OF INSURANCE BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEREC IN ACCORDANCE WITH THE POLICY PROVISIONS. BR POLICY NUMBER POLICY EFF POLICY EXP uM� A GENERAL LIABILITY ® COMMERCIAL GENERAL LIABL.nY ❑ ❑ CLAIMS-MADE El OCCUR F-1 HUUT 131 0612812013 06/28/2014 EACH OCCURRENCE $ 1,000,W0.00 DAMAGE ENTED PREMISES a oocunence $ 10(),000.00 MED EXP (Any are person) $ 5,000.00 PERSONAL &ADVINJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LLNrrAPPLESPER: ❑ POLICY ❑ PRO- ❑ LOC PRODUCTS -COMPIOPAGG $ 1,000,000.00 $ B AUTOMOBILE LIABILITY ❑ ANYAUTO ❑ ALL ® AUTOS NON -O © HIRED AUTOS El ❑ 01875632-0 12/13/2012 12/13/2013 E MBIINEED� SINGLE LIMrr $ 5 ,000.00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ P sDPPEERY DAMAGE Uninsured ff*Wst 19 UMBRELLA UAB OCCUR EXCESS LIAB I CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE ❑ DIED ❑ RETENTION $ $ C 'WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRETORIPARTNERIEXECUIIVE OFFICERINEMBER EXCLUDED? (Mandatory in NH) ❑ If yes. describe under DESCRIPTION OF OPERATIONS below NIA A ❑ WC STATIII- ❑ 1- E.L. EACH ACCIDENT $110001OW -00 E.L. DISEASE - EA EMPLOYE $1,000,x.00 E.L. DISEASE - POLICY LIMIT $1,Oo,Q o.Im 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Romania Schalale, H more space is requhed) CERTIFICATE HOLDER CANCELLATION ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) QF The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED MIAMI SHORES VILLAGE BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEREC IN ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPT 10050 N.E. 2ND AVE - -� MIAMI SHORES, FL 33138 I� ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) QF The ACORD name and logo are registered marks of ACORD 11- 19-2012 JEFF, q,TUrtATER STATE OF FLORIDA CHIEF FINANCIAL OFRCER 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: 11/19/2012 PERSON: ACOSTA FEIN: 273616053 BUSINESS NAME AND ADDRESS: EVOLUTION ELECTRICAL. CONTRACTORS INC 11631 NW S TH PL. HIALEAH FL 33012, SCOPES OF BUSINESS OR TRADE. 1- ELECTRICAL WIRING WITHIN BOIL EXPIRATION DATE 11/19/2014 ANTONIO IMPORTAW: Pursuant to Chapter 340 . 0141, 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 440.11502), F.S., Certificates of election to he exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt Pursaaat to Cbapter 440.06113}, F.S., Notices of electioo to be exempt and certificates of election to be exempt shall be subject to revocation It, at any time after the firing of the notice or the issuance of the certificate. the person awed on the notice or 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 mated an the certificate to maet the requirements of this section. QUESTIONS? 1850} 413 - -1609 OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES D14i1 &ION OF WORKERS! COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW '° EFFECTIVE 11/19/2012 EXPIRATION DATE: 11/19/2014 PERSON: ANTONIO ACOSTA FEIN: 273618053 BUSINESS NAME AND ADDRESS: EVOLUTION ELECTRICAL CONTRACTORS 04C 11631 NW 58TH PL HIALEAH, FL 33012 SCOPE OF BUSINESS OR TRADE: 1- ELECTRICAL WIRING WITHIN SOIL IMPORTANT 0 Pursuant to Chapter 440.05114 }, F.&, 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 440,05(121, F.S., Certificates of election to be H exempt... apply only within the scope of the business or trade listed on E the notice of election to be exempt R E Pursuant to Chapter 441105(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 or 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 -1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11