EL-14-536Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-209584 Permit Number: EL -3-14-536
Scheduled Inspection Date: March 25, 2014 Permit Type: Electrical - Residential
Inspector: Devaney, Michael
Owner: RODRIGUEZ, LUZ
Job Address: 1095 NE 95 Street
Miami Shores, FL
Project: <NONE>
Inspection Type: W. W.
Work Classification: Alteration
Phone Number
Parcel Number 1132060143630
Contractor: JAKE'S ELECTRIC, INC Phone: (305)796-6237
comments
REPLACE METER
INSPECTOR COMMENTS False
6,Inspector Comments
Passed �✓
Failed
Correction
Needed ❑
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
March 24, 2014 For Inspections please call: (305)762-4949 Page 30 of 36
Miami Shores Village ;BY. -
LA
®ll Building DepartmentR 1 o 2014 2
10050 N.E.2nd Avenue, Miami Shores, Flonda 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: BUILDING
FBC 20
Permit No.
L
Master Permit No. / v
UIM ,
JOB ADDRESS: Ci q /V1 9, 1 ) I �s
City: Miami Shores County: Miami Dade
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): �� 1�'U2cr-)'D-ifaj=2,e-z_ Phone#.- ,,5- 7?9 --,2Y�
Address:109S WG.
City: M 1 PsM% State: V= I Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: L� r� a c`7 � r, c` rJ C Phone#: �� S ? - SO �G
Addrn
City:
Quali
State Certification or Registration #: Certificate of Competency #: !q � e 0 0
Contact Phone# Email Address: ` I-YLo � y ss -c
DESIGNER: Architect/Engineer: Phone#.
Value of Work for this Permit: Square/Linear Footage of Work:
Type of Work:`,JUAddition ❑Alteration .. ONew ORepair/Replace ,
Description of Work:
Color thru tile:
Submittal Fee V ` 0 (� Permit Fee $ h�/ w V CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
ODemolitio1.n
DBPR $ Bond $
_ Technology Fee $
TOTAL FEE Nt54:
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 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 annroved and a reinsnection fee will be chareed.
Signature
Owner or Agent
The foregoing instrument was acknowledged bef re me thiBA
day of 17—, 20ff, by �Z �• il�
who is personally known to me or who has produced
—
D. L. As identification and who did take an oath.
Signature --:J
�� d2=
Contractor
The foregoing instrument was acknowledged before me this
day of94-IPA, ZOI, byr4 CEl �3 t^.hdh,.
who is personally �
known to me or who has produced,+ .' I�
Y P16cS—V nt�ification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
MAR/18/2014/TUE 01:56 PM FAX No, P,001/001
. c CERTIFICATE OF LIABILITY INSURANCE
�%✓'�
DATE(MMlDDIY
3/18/20144
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 pollcy(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
certlflcate holder in lieu of such endorsement(s).
PRODUCERNAME:
Jackson Insurance Agency
2075 West 76th St
Hialeah 5'L 33016
Maria Benitez
PHONE (305) 824-3464 FAC No: (305)822-8535
falp. No,
lt4WULAnDREss.mbenitez@jacksonagency.com
INSURERS AFFORDING COVERAGE NAIC
INSURERA-ASCOndant Colmmercial Insurance 13683
INSURED
Jake's Electric, Inc.
4410 Adams Ave
Miami Beach EZ 33140
INSURERB:Travelers Insurance Co.
INSURERC $rid efield casuality Insurance 10335
INSURERD:
INSURER E :
INSURERF:
vVV l Mn IIrll_/il r TVI IINI FSFK•l_.Lt K. 1. _S. I. LI II /tin OG\/IC1f kl All 1Rn=CO.
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,
LTR
TYPE OF INSURANCE
ALAUL
POLICY NUMBER
POLICY EFF
MMIDDNYYY)
POLICY EXP
IMMIDDIYYYYI
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
PREMISES Ea occurrence $ 100,000
MED EXP (Any one rson $ 5,000
A
CLAIMS -MADE 7 OCCUR
GL401621
/1/2013
6/1/2014
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATELIMIT APPLIES PER:
PRODUCTS -COMPIOPAGG $ 1,000,000
X POLICY PRO LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE CMT—
(Ea accident 300,000
BODILY INJURY (Per person) $
B
ANY AUTO
ALLX r;Wl AUTOSSCHEDULED470767A13SEL
/28/2013
/28/2014.
BODILY NJURY (Persocidert) $
X HIREDAUTOS X NON -OWNED
AUTOS
PR P TYD GE $
Peracddent
Uninsured motorist BI split limit $
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
EXCESS LIAR
CLAIMS -MADE
AGGREGATE $
DED I I RETENTION It
$
I
C
WORKERS COMPENSATION
VC STATU- -F0H-
AND EMPLOYERS' LIABILITY
YIN
TORY LIMITS I ER
E.L. EACH ACCIDENT $ 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
NIA
(Mandatory In NH)
30-31196
/24/2014
/24/2015
"-s, describe under
E.L. DISEASE - EA EMPLOY $ 1,000,000
E.L. DISEASE- POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addtdonal Remarks Schedule, Kmore space is required)
This certificate is solely for the use as 11 Evidence of Insurance"
1(305)756-8972
Miami Shores village
10050 HE 2nd Ave
Miami Shores, FL 33138
..��..r ry ��.v •v.vvl
INS025 (201005).01
R -wcu
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
Jackson/MARIAB-�
O 1989-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD