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EL-14-1286Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-220739 Scheduled Inspection Date: October 15, 2014 Inspector: Devaney, Michael Owner: , Job Address: 11225 NW 5 Avenue Miami Shores, FL 33168-3329 Project: <NONE> Contractor: JERUSALEM ELECTRICAL INC Building Department Comments KITCHEN RENOVATION UPGRADE GFI'S Permit Number: EL -6-14-1286 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number (305)759-1111 Parcel Number 1121360010170 INSPECTOR COMMENTS False Phone: (305)206-5564 Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-220647. Bathroom receptacles not to code. Garage receptacles not G F I protected. Outside panel vandelised. Failed ,r Correction Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. October 14, 2014 For Inspections please call: (305)762-4949 Page 20 of 40 Miami Shores Village Building Department I JUN 182014 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 by Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20/6 BUILDING Master Permit No.& PERMIT APPLICATION Sub Permit No.2f-j ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: �l �oZs r'`J 6-p- City: Miami Shores County: Miami Dade Zip: 3346g Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): I /�Ue e-1f�®7f d �� 6 e Phone# �a�,) ��'91111 Address: Sri! :5 ky �P� City: &/_ K,4"2QR_ State: Zip: !� 3' a - Tenant/Lessee Name: Email: one#: CONTRACTOR: Company Name: a����[�%��('E'� G► L Phone#: f/3 e6% �dJ� Address: 5r ® AJ % �__ /__d� r� City: �%® I'll ice/, 6= State: JZ Zip: ✓3 / 02 Qualifier Name: State Certification or Registration M 1:-� l 3 19 IV 9-'!F Certificate of Competency #: IF1 r a97eA09W�' DESIGNER: Architect/Engineer: Phone#: Address: City: State: t� Value of Work for this Permit: $ 7 �r,� Square/Linear Footage of Work: Type of Work: ❑ Addition Description of Work: ❑ Alteration ❑ New � & „ &--4�' Zc Z Specify color of color thru tile: Submittal Fee $ Scanning Fee $ ®' Repair/Replace Zip: ❑ Demolition �► /4ire Permit F ... . � ee $ '�'®� a -� CCF $ CO/CC $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ (Revised02/24/2014) DBPR $ Notary Double Fee $ Bond $ 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 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, 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 n�ot�be approved and a reAspection fee will be charged. Signature OWNER The foregoing instrument was k'® day of 20 . by o is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign:_ Print: Seal:SILLIEN A DERIUS MY COMMISSION 9 EE177498Q-91 EXPIRES March 30.2616 Signature ® CONT CTOR The foregoing instrument was acknowledged before me this M day ofl�'-X�, 20 IS6 by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Print: 81LUEN A DERIU3 Seal: _� My COMMISSION # EE177498 ..,...s. ___ EXPIRES Mardi 30.2816 APPROVED BY ✓�I'LO Plans Examiner Structural Review (Revised02/24/2014) Zoning Clerk STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 DUBE, HUBERT JERUSALEM ELECTRICAL, INC. 530 NE 178TH STREET MIAMI FL 33162 Congratulations! 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 leam more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE l • , STATE OF • (850) 487-1395 . STATE OF FLOPIDA DEPARTMENT OF , PROFESSIONAL AC# r.139545 BUSINESS AND REGULATION ER13014498 05/24/12 117058272 REG.ELECTRICAL'CONTRACTOR DUBE, HUBERT` JERUSALEM ELECTRICAL, INC. (INDIVIDUAL MUST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) HAS REGISTERED under the provisions of ch.489 8apiration date: AUG 31, 2014 L12 0 5 24 012 2 1 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD SEQ# L12052401221 .• - LICENSE NBR 05/24/2012 117058272 ER13014498 The ELECTRICAL CONTRACTOR, Named below HAS REGISTERED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 (INDIVIDUAL MOST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) DUBE, HUBERT JERUSALEM ELECTRICAL,INC. 530 NE 178TH STREET MIAMI FL 33162 RICK SCOTT. REN LA';+riSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY ! CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 06/13/14 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: H the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WANED, 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 Annette Willis Insurance 18401 N.W. 27 Ave Miami, FL 33056 CONTACT E PHONE FAX VC. No: E-MAIL PRODUCER CUSTOMER ID #9 Phone (305) 625-2403 Fax (305) 625-6472 INSURE S AFFORDING COVERAGE NAIC # INSURED INSURER A: NATIONWIDE INSURANCE COMPANY Jerusalem Electrical, Inc. INSURER B: DEPOSITERS INSURANCE COMPANY INSURER C: 530 NE 178th Street INSURER D: Miami, FL 33162- INSURER E: ACP -5934650525 INSURER F: 08/18/2014 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, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ggEXCLUSIONS ILTRR TYPE OF INSURANCE ADD S B POLICY NUMBEfl WDD/POLICEFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A ©COMMERCIAL GENERAL LIABLnY F-10 CLAIMS -MADE Q OCCUR ❑ Y ACP -5934650525 08/18/2013 08/18/2014 GE TO RENTED 100,000 PREMISES a occurrence $ MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 ❑ POLICY El PRO ❑ LOC $ BSCHEDULED AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS D AUTOS ❑ HIRED AUTOS Y ACP -5935497520 08/18/2013 08/18/2014 COMBINED SINGLE LIMIT $ 300,000 (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ ❑ NON -OWNED AUTOS $ ❑ $ ❑ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ AGGREGATE $ ❑ EXCESS UAB ❑ CLAIMS -MADE ❑ DEDUCTIBLE $ $ ❑ RETENTION $ WORKERS COMPENSATION W C STATU- TH- TORY EMPLOYERS' LIABILITYhM ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N OFFICERIMEMBEREXCLUDED? N/A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yyes describe under DESM11PTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) LICENSE #ER13014498 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES BUILDING DEPARTMENT 10050 NE 2 AVE MIAMI SHORES, FL33138' 305-756-8972 ACORD 25 (2009/09) OF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR® REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 07-30-2012 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 09/21/2012 PERSON: DUBE FEIN: 300636589 BUSINESS NAME AND ADDRESS: JERUSALEM ELECTRICAL INC 530 NE 178TH ST N MIAMI BEACH FL 33162 SCOPES OF . BUSINESS OR TRADE: 1- ELECTRICAL WIRING WITHIN BUILD EXPIRATION DATE: 09/21/2014 HUBERT IMPORTANT. Pursuant to Chapter 440 . 051141, F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.051121, F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05/131, F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 09/21/2012 EXPIRATION DATE: 09/21/2014 PERSON: HUBERT DUBE FEIN: 300636589 BUSINESS NAME AND ADDRESS: JERUSALEM ELECTRICAL INC 530 NE 178TH ST N MIAMI BEACH, FL 33162 SCOPE OF BUSINESS OR TRADE: 1- ELECTRICAL WIRING WITHIN BUILD IMPORTANT 0 Pursuant to Chapter 440.0504), F.S., an officer of a corporation w elects exemption from this chapter by filing a certificate of electi L under this section may not recover benefits or compensation under D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade list) E the notice of election to be exempt R E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exe and certificates of election to be exempt shall be subject to revoc if, at any time after the filing of the notice or the issuance of ti certificate, the person named on the notice or certificate no longer the requirements of this section for issuance of a certificate. Th department shall revoke a certificate at any time for failure of th1 person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner -Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be personally liable for the worker compensation injuries of anv person allowed to work under this permit Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Print State of Florida ) County of Miami -Dade) Sworn tn"d subscribed befc day of CLAND , Bye (SEAL) MY Contractor Print Name: Signature: A DERIUg RSION 6 EE1774 30.2®16 Site of Florida ) nty of Miami -Dade ) or to and subscribed before me this of _)C)(1. -!e _,2014. By My commission Expires 0111212015 A CTQB Construction Trades Qualifying Board '-BUSINESS CERTIFICATE OF COMPETENCY I OE000455 JERUSALEM -ELECTRICAL, INC D.B.A.: DUB�RT Is certified under the provisions of Chapter 10 of Miami -Dade County 003414 Local Business Tax Receipt Miami -Dade County_, State of FloridaLBT -THIS-IS NOT A BILL- DO NOT PAY-, 6695143 BUSINESS NAME/LOCATION RECEIPT NO. EXPI RES JERUSALEM ELECTRICAL INC RENEWAL SEPTEMBER 30, 2014 530 NE 178 ST 696$161 Must be displayed at place of business NORTH MIAMI BEACH FL 33162 Pursuant to County Code Chapter 8A — Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED JERUSALEM ELECTRICAL INC 196 ELECTRICAL CONTRACTOR BY TAX COLLECTOR Worker(s) 1 10E000456 $45.00 07/10/2013 TXHS1-13-020406 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0. above must be displayed on all commercial vehicles Miami—Dade Code Sec 88-276. For more information, visit www.miamidade.gov/taxcollector