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EL-13-1496Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 195827 Scheduled Inspection Date: July 29, 2013 Inspector: Devaney, Michael Owner: LLC, BAGON 3850 Job Address: 9839 NE 13 Avenue Miami Shores, FL Project: <NONE> Permit Number: EL -7 -13 -1496 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alarm Phone Number Parcel Number 1132050090500 Contractor: SAFE STREETS USA Phone: (813)514 -2693 Building Department Comments WIRELESS BURGLAR ALARM INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction��C� Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. July 26, 2013 For Inspections please call: (305)762 -4949 Page 23 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: 9839 NE 13 Ave FBC 201® Permit No. pp Master Permit No. I 14 II v City: Miami Shores County: Miami Dade gip; 33138 Folio/Parcel #: 11- 3205 - 009 -0500 Is the Building Historically Designated: Yes NO X Flood Zone: OWNER: Name (Fee Simple Titleholder): Bagon 3850 LLC Phone#: 305 - 733 -3428 Address: 20900 NE 30 Ave Suite 200 City: Aventura state: FL Zip: 33180 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: SafeStreets USA Phone#: 919- 861 -8521 Address: 5660 W Cypress St Suite G City: Tampa State: FL Qualifier Name: William Alan Peacock Phonek State Certification or Registration #: EG13000404 Certificate of Competency #: _ Contact Phonek 919- 861 -8521 Email Address: jadams @safestreets.com DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 99.00 Square/Linear Footage of Work: 33607 919- 861 -8521 Type of Work: ❑Addition DAlteration DNew DRepair/Replace DDemolition Description of Work: Wireless Burglar Alarm -1 Cell, 1 Panel, 1 Button Fob, 3 Door / Window, 1 Siren, 1 Motion Color thru tile: Submittal Fee $ Permit Fee $ 1P®1099 CCF Scanning Fee $ Radon Fee $ CO /CC $ 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 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. "WARMING 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 —# Owner or Agent Signature Contractor The foregoing instrument was acknowledged before me this 21 St The foregoing instrument was acknowledged before me this 21st day of May , 2013 , by Oscar Gonzalez , day of May , 20 13 , by William Alan Peacock , who is personally known to me or who has produced DL who is personally known to me or who has produced As identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: JARROD M. AD ,y., h�S kR ca{ fir; NOTARY PUBLIC igm NOTARY PUBLIC s A (f s Sign STATEOF FLORIDA DA Print Adams Coming EE160338 Print: • • Adams "Moo Weffle"— My Commission Expires: 3/18/2016 APPROVED BY Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) My Commission Expires: 3/18/2016 Zoning Clerk A� °® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 John T. Costa A enc Inc. 2025 Hamburgg TPKE quite J Wayne, NJ OT470 www.burglaralarminsurance.com CONTACT NAME: PHONE N A/C No -83 -3056 E-MAIL ADDRESS: in INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: S CO dale Insurance n INSURED SAFE STREETS USA,LLC 5305 RAYNOR ROAD SUITE 100 GARNER NC 27529 INSURER B : Hartford Underwriters 30104 INSURER C: OCCURRENCE INSURER O: -EACH PREMISES EaErrrDen� INSURER E: MED EXP (Any one person) INSURER F: PERSONAL &ADV INJURY CnVFRAr.FS CFRTIFICATF NIIMRFR- inmmao 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 SUBR POLICY NUMBER POLICY EFF iMmfDDrfYyYi POLICY EXP (mmmorYyyyj LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR CPS1720964 4/17/2013 4/1712014 OCCURRENCE $ 3,000,000 -EACH PREMISES EaErrrDen� $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 3,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP /OP AGG $ 3,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NON-OWNED HIREDAUTOS ✓ AUTOS 13UECUK0109 4117/2013 4117/2014 Ea a EDitSINGLE LIMIT $ 1,000,0 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) PP@O:EXRdT DAMAGE $ $ A / UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE UMS0027562 4117/2013 4/17/2014 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED RETENTION $1 0,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- TORY LIMITS E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A ERROR & OMISSIONS CPS1720964 4/1712013 4/17/2014 $3,000,000 EACH CLAIM $3,000,000 AGGREGATE DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Project Ref: CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NW 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 Ralph A. Costa ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD