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ELC-12-1928Inspection Worksheet n }� Miami Shores Village Z_-0 /1 -V 10050 N.E. 2nd Avenue Miami Shores, FL � Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 185534 Scheduled Inspection Date: September 17, 2013 Inspector: Devaney, Michael Owner: INC, PUBLIX SUPERMARKETS, Job Address: 9050 BISCAYNE Boulevard Miami Shores, FL 33138- Project: <NONE> Permit Number: ELC- 2- 13-257 Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number (863)688 -747_ Parcel Number 1132060100010 Contractor: SUMMIT ELECTRICAL CORP Phone: (305)251 -3501 tiuuamg uepartment comments ALL ELECTRICAL WORK INSPECTOR COMMENTS False Inspector Comments Passed ��A' Failed 2 1 Correction Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. September 17, 2013 For Inspections please call: (305)762 -4949 Page 2 of 39 U.S. POffrAGE PAID PERW NO x'31 57511 —1 THM IS NOT A 8!U_ — CO NOT 12AY RENEWAL CORPORATION 599712 -8 • Supt�lT'r EL�CT�z� sl'ATE��13fS0 • 12333 SW 131 AdE ' 33186 UNIN BADE COUNTY "191MIT.'EIECTRIC CORPORATION ! E CAL CONTRACTOR WORK30 /S 9�. 4 i m m v • DO NOT F40MAW SUMNIT ELECTRIC CORPORATION is JUDI-TH 33SW WILLIS MIMI FL 33166 pAlA1fYTAlI 08/13/2012 60000000207 �� 000175.00 ! 1114 dha��tt 1��1��11 ���11���t��l +I1•• =I�l���ll���ll �d1 OTHER ME TO 39Vd cfdOD DI8103-13 IIWWIIS 08OZEEZ50E OT :5T ETOZ/50 /EO d '► Miami Shores Village Building Department 11050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 7952204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER. (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: Electrical FBC 20 V\2 FEB 0 8 2013 Permit No.� -°�� Master Permit No. CQ a — 10124— JOBADDRESS: 11Q50 13;.IcaV,,,e SSo%fer- -otJ City: Miami Shores County: Miami Dade Zip: 3 3/3 e Folio/Parcel#: Is the Building Historically Ieignated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): P14 b P 'Ar Skj2ar '"W406 06 _TW'c Phone#: 1W s 6O F m 1/99 Address: F0 &k *!t0_7 city: i w ke lawd State: R Tenandl.essee Name: Phone#: Email: VONTRAC'TOR!('.mmmanvName- 150MM,T U,F-r C-0 4P Phone*- 30 9- 'Zip /- 3fO/ Address: f2,333 SI J /34 NC city: M / Awl1 State: FL Zip: 331 8'6 Qualifier Name: K l d a/ A±, W A-tA*A1 E 1 Phone* ZS/ " / State Certification or Registration # PG C / 300/36 D Certificate of competency #: Contact Phone#: 3OC- LD- 39-01 Email Address: 9 o GK 6P SUN% o t T r-C,E C. ij uT DESIGNER: Architect/Engineer. Phone#. Value of Work for this Permit: $ 13s, 3 S o 2` Square/Linear Footage of Work: Type of Work: DAddress #Alteration ONew ORepair/Replace ODemolition Description of work: O a lsd f,ca 1 we r k 015 eer elaxs d- fp Submittal Fee $ Permit Fee $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE Ld i- 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, BORERS, 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 approved and a reinspectdon fee will be charged 4 Signature — Owner or Agent The foregoing instrument was acknowledged before me this day o 20 Qom, by y0 rri who is y o to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: W• Contractor w The foregoing instrument was acknowledged before me this-LS:7N day of 20 jam, by R t c-mrtl n o W . M A Lo AJ E y, who isjjrsonally known tom who has produced as identification and who did take an oath. APPROVED BY !rA /,-7 7 f 0? Plans Examiner Structural Review (Revised 3 /1212012)Mevised 07 /10/MXRevised 06/10/2009)Wevised 3/15/09) NOTARY PUBLIC: *,yt Yq LISSETTE R. MILLER VOTARY PUBLIC a _ o STATE OF FLORIDA ? Comm# EE133152 Sign: rs _ ° Expires 92572015 Print: 9, - iVfi < <e( My Commission Expires: Zoning Clerk SUMMELE -01 RGOMEZ ACQRO� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 1112/2012 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 cart flcate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns 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 Collinsworth, Alter, Fowler & French, LLC 8000 Governors Square Blvd Suite 301 Miami Lakes, FL 33016 CONTACT NAME: PHONE 305 822 -7800 , No : 305 362 -2443 Alc No MM: t ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: FCCI Advantage 12842 $ 1,000,000 INSURED INSURER 0: FCCI Insurance Company 10178 INSURER C: PERSONAL & ADV INJURY Summit Electric Corp. INSURER 0: 12333 S.W. 131st Avenue INSURER E GEML AGGREGATE LIMIT APPLIES PER: POLICY X PRO LOC Miami, FL 33186 INSURER F: $ 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 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. ILTR TYPE OF INSURANCE IN SR WVD POLICY NUMBER MMND EFF MMIUDD EXP LIMITS • GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx-1 OCCUR GL00093994 11/112012 1111/2013 EACH OCCURRENCE $ 1,000,000 PREMISES Eaoccurrenoa $ 300,000 MED EXP (Arty one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE 1$ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: POLICY X PRO LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ • AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON-OWNED HIRED AUTOS AUTOS CA00081117 11/1/2012 11/1/2013 (Ea a enmSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ A X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE UMBOOOIS4310 1111/2012 11/1/2013 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I X I RETENTION $ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS YIN LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) B yes, describe under DESCRIPTION OF OPERATIONS below NIA 001 WC13A21483 1/112013 1/1/2014 X WC STATU- 0TH - TORY LIMITS ER E.L. EACH ACCIDENT $ 500,000 E.L DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS l VEHICLES (Attach ACORD 101, Addidonal Remarks Schedule, K more space is required) Operations: Electrical Contractor CERTIFICATE HOLDER CANCELLATION ACORD 26 (2010105) ©1988 -2010 ACORD CORPORATION. All rights reserves. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores, City of Building & Zoning 10060 NE 2nd Avenue THE EXPIRTION DATE THOF, ACCORDANCE WITH THE PO CYYPPROVISIONS. NOTICE WILL BE DELIVERED IN Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE ACORD 26 (2010105) ©1988 -2010 ACORD CORPORATION. All rights reserves. The ACORD name and logo are registered marks of ACORD ,A # b 14 U 3 9 ST E Of FLORIDA jid 4V RPARTg BCTICkL�ONTRi�CTORSL3CEN8g1 80 �►RD TIONC 11 a l...' .` :`':' v: .Y .5 >' .; L•l>+TA' `s.>`.1,. 9 y. 1. YEWL12052501062 • ' fiCE R ` 5,..2 201-211-10401-057f: gC130�d,56;. /, _ the3LECTRICAIF CONTRACTOR .. ,�► k:Idamed.: b�slova! IS CLR'4'IF ` t IInder "the:.ravisioaa o£ .<Clap Expiration date: ATJG 31, 2014 4A RI / @ STJL�IIT' ELECTRIC CQiRFO1tA'ION � 14531 HICKORY CT,.;..: DAVIE FL 33325_ RICK SCOTT i 5 /d >s KEN LAWSON GOVERNOR v .:.; w , a t... SECRETARY _` z "D1SOLAY``AS REQUIRED •BY-LAW bl� Petc 4e IV -14* Pl� A 111401