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EL-13-2679I TA _ .W% Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shone Florida 33I38 Tel: (305) 795.2204 Fax: (305) 755.8972 INSPECTION'S PHONE NUMBER: (30S) 762.4949 BIJIL]€IING PERMIT APPLICATION Permit Ty: Elechiad Nov 2 s ft FBC 20 f-D Master Permit No. MC.zG — (o- JOB ADDRESS: 6 9q H Q ), sT -E CZ G City: wmmiamm couay: Miami Dade zw: 3 3-13 miomarcew.- 1 i - ,3 .Z ®r,, -043 _0 ;� 90 Is the Building HWorically Designaftd: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): AOef' E d-4 '-R0 SSA-N A C I s-n Phan#: City: !yaTi S1402 2 S State: C. zig: 3 313 Tenant/Ussee Name: Phone&. �K. A0 / 92 4 Email: CONTRACTOR: Company Name: Address- city.. Qualifier Name: ,�-9 4-7 &n 1 phones_ Lq7 642e f Z: 3 o S L � 2 �: 297 ''�O `� C � State certiliiradua or Regis an V a ®U 37 0 '—)' c1ert� of Competency * Contact Phone#: 16-m times- Y jt�_ cc\)_ �Q4k�u e ec DESIGNER: Architectffingineer: Phones: vas of Ww* fir t P rmit $ 4500 -` � dfWor: f f*0 s -• Type of Work: OAddrem oAlteration Ud W ORepaWlteplace ODemolition of Work: 04 C rWf.� 46y= A&37�'G� Submittal Fn Scanning Fee $ Permit Fee $ I Q' ',POP CCF $ COICC $ Ram Fee $ Notary $ Tr8hdUgWAb2Cafi= Fee $ Doable Fee $ Review $ DBPR $ Bod $ Tedumlegy Fee $ TOTAL FEE NOW DUE $ _ Company's Name (if applicable) • Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address zip city State zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no worker installation n has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws re¢ all ing construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOII ERS, 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. No 6 a t� � •�� As a conditdon to the issuance of a buiOng permit with an estimated value exceeding $2500, the applicant must ro-r --- promise in good faith that a copy of the notice of comrnencemet and construction lien law brochure wifl 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 f posted notice, the inspection wall &bevedand a reinspecdon fee will be charged 1 Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged // before me )this -Z® The foregoing instrument was ackns�wledged before me tbisd' day of -NOV 20a-by #A2J `Le C",S.4i day ofNpy .20 3 by y144iL 91ZI GOt , who is personally known to nee or who has prasduced &L - b L who is finally awn to me or who has reduced -6 --AL ? identificatim and who did take an oath. and who did take an oath. NOTARY NOTARY PUBLIC.- Structural Review (Revised 3/12r2012XRevised(711QW)Mevised 4WIM009)Mevised 3/15/09) Clerk 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. X COPY OF QUALIFIER'S STATE LIC CARD B. X COPY OF LOCAL BUSINESS TAX RECEIPT C. X COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPTI D. X 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 MM SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTON} YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 mammmammmamaammaflmmoaaaamaaammamammmaoaaammasammmoamm+ aaaaaaaaaamaaaaaaaaaaaamaaamammmmamQao COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: , & M Electrical Contractors, Inc BUSINESS ADDRESS. 1826 Monroe St CITY Hollywood STATE FI ZIP CODE 33020 BUSINESS PHONE: 305 ) 297 6428 FAX NUMBER ( 977 1 926 7466 CELL PHONE 3� 05 ) 2976428 QUAL11FIER'S NAME: Mihail Pricop QUALIFIER'S LIC NUMBER: EC13003702 EMAIL ADDRESS {IF APPLICABLE): mike@jandmelectric.org c��sY�vtRVe�w 115 S. Andrews Ave, Rm, A --100. Ft. tauderdaile, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2013 THROUGH SEPTEMBER 30, 2014 fteC6jpt*.182 08A.- ELEC- I thiftInAmm himita: J & M *ELECTRICAL CONTRACTORS, INC Bushuma Type: 13WnM OpOnOd:12/1612010 StatejCounWj0erVRe9:EC13Q-03702 Eximption Code: Tax Anlowt TmnSW Fee COWC&M Cola I Total Paw. 27.001 0 - 0 0 0.001 29.70 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE Of BUSINESS THIS WCOMES A TAX RECEIPT This tax is wvkw for tlne of doing Wsiness w" amwafd Coindy and is mmeplat" m nature. You owd most all Cm* mu ft Mwuc"* PWmmg WHEN VALIDATED and zoning m*mernerft. Thm &mkmm Tax Receipt nu* be transferred when the business, is said, business name has dmnged or v:W have moved the business location. This receipt does not kdcate that the Wsinew is legal or that it is in compliance with State or local laws and reguladotm.] Mailing Addrom: J & M ELECTRICAL CONTRACTORS,. INC PO BOX 545947 SURFSIDE, FL 33154 2013 -2014 Ihmeipt 0132-13-00006314 Paid 10/20/2411 29.70 Unknown J &MELEC -01 SKIRK CERTIFICATE OF LIABILITY INSURANCE 7111/20/2(MMM00113 JYYYY) GENERAL 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: N the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. H 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 CKP Insurance LLC 21845 Powerline Road CONTA NAME: CONE 561 807 -0900 3856 A/C N,: 561 826 -3782 Suite 205 Boca Raton, FL 33433 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC $ $ 100,00 INSURERA:Travelers Indemnity Company 25658 $ 5,00 INSURED INSURER B: Bridgefield Casualty Insurance Company 10335 INSURER C: J & M Electrical Contractors, Inc. P.O. BOX 545947 Suriside, FL 33154 INSURER D: PRODUCTS - COMP/op AGG INSURER E: INSURER F: AUTOMOBILE %'W V = AU=0 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 CONTRACTOR 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. L R T TYPE OF INSURANCE AD —DL UBR POLICY EFF POLICY EXP M= W POLICY NUMBER LIMBS A GENERAL LIABILITY COMMERCIAL GEN ERAL LIABILITY CLAIMS-MADE OCCUR ISSOIA80749ATIL12 12/12/2012 1211212013 EACH OCCURRENCE $ 1,000,00 X pREMIsE3 Eaoccurr 01 $ 100,00 MED EXP (Any one Persm) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY I I PRO- .IFCT F-1 LOC PRODUCTS - COMP/op AGG $ 2,000,00 AUTOMOBILE LIABILITY ANYAUTO TS ED ED AO AUTOS HIREDAUTOS NN��WNED L COMBINED SINGLE LIMIT aide t BOD ILY INJURY (Per person) $ H BODILY INJURY (Per accIdent) $ PROPER DAMAGE (Per accidem $ $ B UMBRELLALUIB EXCE8SLW8 HCLAIMS-MADE OCCUR NIA 19623974 12/1PJ2012 1211PJ2013 — EACH OCCURRENCE $ AGGREGATE $ DED RETENTION WORKERS COMPENSATION EMPLOYERS' LIABILITY ANY PROPRIETORfPARTNER /EXECUTIVEY/N OFFICER/MEMBER EXCLUDED? If In NH) If yyes describe under DESGhRIPTION OF OPERATIONS below WC 3TATU MEN, X TORY IMIT- S ER - $ E.LEACHACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYE $ 500,00 E.L. DISEASE -POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) r =0- r1C1/1ATG LlAl M-- Miami Shores Village - Building Department 10050 NE 2nd Avenue Miami Shores, FL 33138 AL:VKLJ 25 (201 U /05) IM\-I \I SHOULD ANY OFTHE 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 The ACORD name and logo are registered marks of ACORD An rinhta remarvrael ` , • (Al Uj Er x N tlbz� s �4 N Sr,.� � v 03 CO 6) �Cn I-K - 2 � ) 6 ak -f f 12/18/2013 12:34 r T0:13057558972 FRDK:8778240964 Page: 2 CERTIFICATE OF LIABILITY INSURANCE 12/18/20" 3 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER The Fairway insurance Group, LLC 5461 North Federal Highway Fort Lauderdale, Florida 33308 NAME: Jennifer Summerlott PHONE (954) 772 -9819 FAX (954)772 -8564 E-MAIL S:7en@tf1g1n8.cOm INSURERS) AFFORDING COVERAGE NAIC tt IN A :Old Dominion Insurance Co . INSURED Oft= FalEiCl..C.LGidi �.Vil Vi di.: W.Ce, 1AG•. PO Box 545947 Surfside, Florida 33154 INSURER B B: 2/12/2014 INSURER $ 1,000,000 INSURER D: $ 500,000 INSURERE• $ 10,000 INSURER F $ 1,000,000 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 POLICY NUMBER MMIDDY EFF P3LWD EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS &4AOE �X OCCUR X Residential Coverage 1686/0 2/12/2013 2/12/2014 EACH OCCURRENCE $ 1,000,000 Mal $ 500,000 MED EXP (Airy one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN1. AGGREGATE LIMIT APPLIES PER: POLICY X PRO LOC PRODUCTS -.COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON-OWNED D SINGLE LIMIT Ea eccrdent BODILY INJURY (Per person) $ BODILY INJURY (Peracck3erd) $ DAMAGE $ A A X UM13RELLALWB EXCESSLIIB X OCCUR CLAIMS -MADE NIA G1686M UCT1686M 2/17/2013 2/12/2013 2/12/2014 2/12/2014 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 DED X RETENTION 10,00 WORKERS COMPENSATION ANY EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER(EXECUTIVE OFRCEWMEMBEREXCLUDED, Q (Mandetcry In DESGIRIPTION OFF OPERATIONS bebwv WC STATU- 1711 X E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 EL DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION E VEHICLES AC1 Remarks Schedule, If more apsm Is QuCertcate3s subject to theterms C Adit ons,& exclusions O the policy. r_FRTIF'ICATC 41nt nets (305)756 -8972 Miami Shores village Building Department 10050 NL 2nd Avenue Miami Shores village, ACORD 25 (2010/05) twen .2t: .,. 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 Brown /iN 00 1988 -2010 ACORD CORPORATION. All rights reserved. ...A — -..wr \ noma ann te\nn ova rantefaraA morka nf.arnRr1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 205343 Scheduled Inspection Date: January 07, 2014 Inspector: Devaney, Michael Owner: GIUSTI, MARIELLA ROSSANA Job Address: 689 NE 92 Street 12-G Miami Shores, FL Project: <NONE> Contractor: J & M ELECTRICAL CONTRACTORS INC Building Department Comments ELECTRICAL FOR AC INSTALLATION Permit Number: EL -11 -13 -2679 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number (786)201 -5247 Parcel Number 1132060430280 Phone: (305)297 -6428 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. January 06, 2014 For Inspections please call: (305)762 -4949 Page 22 of 26