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ELC-12-2109141 B I I G PERMIT APP FBC 20 t, Permit Type ELEC) Owner's Name (Fee Simple I Owner's Address Tenant/Lessee I Email Job Address (m City FOLIO / PAR( Is Building His Contractor's C Contractor's Ad City Qualifier Name State Certificate Contact Phone Miami Shores Village Building Department' 10050 N.E.2nd Avenue, Miami Shores, Florida 3313 Tel: (305) 795.2204 Fax: (305) 756.8972 TNS ECTION'S PHONE NUMBER: (305). 762.494 Per _CATION Master Per RJCAL leholder) rJ -i g o / i' <-- —Phone # State Zip III _ Phone # the world is 1Z done)I, U 7r NE County —Miami. -1 1 / (0D YES NO 't � � �� � �-�� •L � an hone # n►�A _ nState Zip_ L�Gc J IIS, 4' L Phone # Certificate of Competent I� I� E-mail V �I `J OZ2012 i j�''' � ® � No. j lit � 0 _anat j t No.CC- /O - a— (0 �I Architect/Engin per's Name ( f applicable) Phone # I II Value of Work or this Perc�it Square / Linear Footage OI Work: Type of Work: ElAdditio"n EP16teration []New ❑ Repi ir/Repla Describe Work a I II Sd15116tal Fee i� Notary $ Scanning $_ Double Fee $_ Structural Re, Radon':. Flood Zone I to ❑ Demolition Les CCF $ CO/CC $ II/Education Fee $ Technology Fee $ DPBR $ Bond $ Violation date: Total Fee Now Due $ -59 ,(0,0 See Reverse side 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. "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 re -inspection fee will be charged. s Signature —JA Signature Owner or Agent /�j Contrac The foregoing instrument was acknowledged before me this:. The foreg ing instrument was acknowledged before me this ,'fes day of , by �� ( c .�/� day of �i , 20 �1�b �� 5 �A4 d IJ 1-9 who is Crsonally me or who has produced who is wn to me or who has producedlet/ As identification and who did take an oa as id �ftftwnd who did take an oath. Engineer (Revised 07/10/07)(Revised 06/10/2009) Clerk checked y Aryry��-� a�'I'vI WHVAU[ r '. �r-��� s r ';'ai�a - 1TaarlAs� >jA a � ?22���Rcissi .,.�� vx i 10 t yht "�" T"ransie Fee NSF Fee Prrorr `;,Cai�.ecijbn CoSt'�+ Tgtal,Paid a T>yX�flrn t; , , $Penallya Years, , ti_ 0 00 - 0 00 0 00 0 00 =150 00' Y. , 20 THK©U.GH SLPTLM, E3LK 3U, LY13 r 12 DBA= RecetpL # i1 ` 3425° MILLER ELECTRIC COMPAN' ` Busilnass Name: Y Btistntass yp � cAL/mss/ ' xcxAc'mR X' 4fi (ELCTRI 1 O.,ner Name: THomAs ml m LONa Businass Opened•z 0` 03/2006 lsiness Locaton:18;81 W STATE RD 84 104State/County/Cert%Reg $C oo03�2 FP LAUDERDALE EXeltnption Code' Business Phone: 954-761-2110 Rooms Santa Employees Machines Professlonals Signature Number of Mi Tax Amount Transfer Fee 150.00 0.0 127 NSF Fee I Penalty I Prior Years I Coflection Cost I otal Paid 0.001 0.001 0.001 0.001 150. Receipt •032-11-00003463 Paid 07/20/2012 150.00 ACORIZ CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDIYYYY) 06/13/2012 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: 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). PRODUCERk;OT Cr Paula C. Beers, CIC, CRIS, CWCS, RWCS NAME: Cecil W. Powell & Co. PHONE 904.3S3.3181 x257 904.353.5722 AIC No Ext AIC No P.O. Drawer 41490 ADDRESS: pbeers@cwpowelIins.com 219 Newnan St. INSURER(S)AFFORDING COVERAGE NAICS Jacksonville, FL 32203-1490 INSURERA: Hartford Fire Insurance INSURED Miller Electric Company INSURER B: National Union Fire Insurance of PA P 0 Box 1799 INSURERC: Midwest Employers Casualty Co Jacksonville, FL 32201-1799 INSURERD: Hartford Companies INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER-- 2012 Permittina 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 AUDL INSR WOR WVO POLICY NUMBER POLICY EFF MMIDD1YYYY) PC (MMfOONYM LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 21UENOH164 07/0112012 07/01/2013 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ 300,0001 MED EXP (Any one person) $ 10,0001 PERSONAL & ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: POLICY FXIJPERCOT [XI LOC PRODUCTS - COMPIOP AGG $ 2,000,00( $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS 21UENOH1644 07/01/2012 07/01/2013 (Ea accident)$ 1,000,00( BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ AMAUL $(Per acddenl B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE BE158055 07/01/2012 07/01/2013 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ S , OOO , OO F-TDED I X I RETENTIONS 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTI Y / N OFFICERIMEMBER EXCLUDED? (Mandatory In NMI If es, describe under DESCRIPTION OF OPERATIONS below N / A EW008 S 1 CESS WORKERS COMP-FLE.L. SEE ATTACHED FL SEL INSURANCE CERTIFICAT 07/01 /2012 07/01/2013 X TORY LIMITS ER EACH ACCIDENT $ 1,000,00 E.LDISEASE -EAEMPLOYEE $ 1,000,00 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DCompensation Other States —Workers Employers Liab 21 WE OH16407/01/2012 WC STATUTORY LIMIT BY STAT 07101/2013 EL Ea Accident $1,000,000 EL Disease Ea Emp $1,000,000 EL Dis. Pol Limit $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) e: All work performed by Miller Electric Company on behalf of the certificate holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Miami Shores Village Occupational Licensing & Registration AUTHORIZED REPRESENTATIVE 100SO N.E. 2nd Avenue Miami, FL 33138 Fitzhu h K. Powell Jr AAI CRIS/PCB ACORD 25 (2010/05) ©1988-2010 ACORD The ACORD name and logo are registered marks of ACORD All rights reserved. STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 LONG, THOMAS DAVID MILLER ELECTRIC COMPANY 4156 RAINTREE DRIVE MACCLENNY FL 32063 Congratulationsl With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. (850) 487-1395 STATE OF FLORIDA: ACS/ 111,39t.97 DEPARTMENT.OF BUSINESS AND t PROFESSIONAL_REGULATION' _` EC0003112 '' _0.5 41%12 118189551 'CERTIFIED. ..E:LECTRICAL,,: CONTRACTOR LONG, ' THOMA$;'DAVID';;'::::'r MILLER ELECTRII-0.COMPANY Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. IS CERTIFIED under .the provieione of Ch.489 FS Thank you for doing business in Florida, and congratulations on your new license! ( exviratscn dere: AUG 31,, 2014. 1:12 0 529 0 117 1 i . DETACH HERE yr,4w. I �_ ...�. ... ._ ... -;— —"5 '- .. ._. i 7 cl."`Y �. �. . jib _- �K.. �..•..�5'��pBEtK�I;oflNq .rnl3aPRll jiSENtAI#tEftt> .yf. l • 94 STATE OF FLORIDA DEPARTMENT • PROFESSIONAL • ELECTRICAL • e• c• •D T.he ELECTRICAL CONTRALTO Named below IS CERTIFIED Under the provisions of Expiration date: AUG 31, R Chapter; 48'9:;FS.. 2014 LONG, THOMAS DAVID MILLER ELECTRIC COMPANY 2251 ROSSELLE STREET JACKSONVILLE FL 32204 RICK SCOTT GOVERNOR DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY