EL-13-285011-1
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Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-204900
Scheduled Inspection Date: October 01, 2014
Inspector: Devaney, Michael
Owner: ,
Job Address: 102 NE 106 Street
Miami Shores, FL 33138-2037
Project:
Contractor:
<NONE>
AP POWER ELECTRIC CORP
eunaing Department comments
INTERIOR REMODEL
Permit Number: EL -12-13-2850
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Addition/Alteration
Phone Number (786)371-8479
Parcel Number 1121360050080
INSPECTOR COMMENTS False
Phone: (954)822-4496
Inspector Comments
Passed
Failed //;P�
Correction ❑
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
September 30, 2014 For Inspections please call: (305)762-4949 Page 2 of 41
Miami Shores Village
Building Department
10050 N.E2nd 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: Electrical
FBC 20
Permit No. �I `3 -► .2$Se
Master Permit No. aL l ,!.� "19 w
^T
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip;
Foho/ParceW.
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): i T®0-o'sr p�`the.,-.11 . —I*?- x")-7 Q,
Tenantliessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: , -T 41,,e a
Contact Phone#• Email Address:
of Competency #.
DESIGNER ArchitectlEngineer:
Phone#•
Value of Work for this Permit: $ SquareAUnear Footage of WorL-
7y7 of Work: OAddress DAlteration UNew 13Repair/Replace ODemolition
Description of Work: -r 119,v., f e --16
Submittal Fee $- e �Q Permit Fee $_XZ ��® CCF $ CO/CC $ .
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
Bdnding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
zip
stateP
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 jiirisdiction. 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
1WROVEMENTS 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 thesence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged
Signature_
Owner or Agent
The foregoing instrument was acka ledged before met
day of ie 20 � by /
who is personally known to me who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Contractor
The foregoing instrument was acknowledged before me this
day o 20,(, by
is ersonally known tom who;lzas Produced •
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Sign: '
J
Print:p
g
My Commission Expires:
s
,t Fartda
pupt`c State My CommiSS
tea
Pu�c gta
Notary
i4ew, l n EE 188011
a MY `812018
,,9K �r4�,
Notal
µ2r881 AZEE 198011
My Cites 0098
— W Ob t ,- - - - - - ki,
APPROVED BY
Plans Examiner
Zoning
Structural Review Clerk
(Revised 3/1212012XReviW 07/10/07XRevised 06/10/2009XRmised 3/15/09)
06109/2014 23:56
7865734486
INSURANCE NOW AGENCY
PAGE 01101
CADIOR CERTIFICATE OF LIABILITY INSURANCEDATEJN=DNYYY)
06/10/2014
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 roquiro an vndwsement. A statement on this certificate does not confor rights to the
certificate holder In lieu of such endomemen .
PRODUCER 786-573-4485 786-573-4486
Insurance NOW Agency
12915 SW 132 Street suite 4-B
Miami, FL 33186
NAME: DT Ma leen Blandon
PHONNo. Ejdh E 786,573-44$5 Fj0'� Ne: 786573-44$6
A', : mayleen a@insurancenowa enc .com
DD
VIER Io a:
INSUR$ S AFFORDING COVERAGE MAIC S
INSURED
AP Power Electric Corp.
3758 SW 16 Street
Fort Lauderdale, FL 33312
INSURERA:Wastem Heritage Insurance Co.
INSURER a:-
INSURER c
INSURER D:
INSURERE:
INSURER F t
00VERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CFRTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTIMTHSTANDING 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 CWMS.
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
EFF
rAmmo ryyT
Y
POU AdMU
LIMITS
GENERAL UABIUTY
EACH OCCURRENCE $
A
COMMERCIAL GENERAL LIABILITY
.1-000,000
PREMISESO RENTED $100,900
CLAIMS -MADE 71
OCCUR
MED EXP (Any one person) $5,000
SCP0929397
03/115/2014
03/16/2016
PERSONAL& ADV INJURY $ 1 000 00
_..__
GENERAL AGGREGATE 42-000,000
GERL AGGREGATE LIMY( APPLIES PER;
PRODUCTS - COMPIOP AGG $1,000,000
POLICY PRO -_CT F7 LOC
8
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
(es 61caftno
8ODILYINJURY (Per pe(M) S
ALL OvvNEO AUTOS
i
BODILY INJURY (Per accent) S
SOMWULED AUTOS
i
PROPERTY DAMAGE- $
HIRED AUTOS
(Peraceiderd)
NON -OWNED AUTOSLl
$
UMBR91. UAB
OCCUR
EACH OCCURRENCE $
EXCE33 UAB
CLAIMS MADE
AGGREGATE $
DEDUCriBLE
$
$
RCTCNTION $
WORKERS COMPENSATION
WC 3TATU- DTH-
AND @MPLOVERS' LIABILITY
R
E•L. EACH ACCIDENT $
OFrICEWMEMBEREEXCLUOE �ECUTIVE
NIA
C.L. DISCASE - G EMPLOYE $
(Manaatcry In NH)
Mee ,G
F.L. DISEASE - POLICY LIMIT S
PTIONOERATIONS Wow
DESCRIPTION OF OPERAYIONS I LOCATIONS I VEHICLES (Atteeh ACORD 101, AndManal Remarks Schedule, if more apace Is mqui-dl
Hector Arzola ##ER13014434
Miami Shores Village
Building Department Department
10050 N.E. 2nd Avc
Miami Shores, FI 33138
Fax: 305 -
.....+..v � 1Avva1rsf
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEIN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
Mayleen
01988-2009 ACORD
Tne ACOFtD name and logo are registered marks of ACORD
All rights reserved,
JEFFATWATER
CHIEF FI ILIAL OFFICER
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVIC
111,14 111111 11 117111111 111111:11111111 iiiiiiiiiijili�llilli'llill
I HE It
'fo, M*Til M.
EFFECTIVE DATE: 4/13/2014
PERSON-. ARZOLA
FEIN: 2716359M
BUSINESS NAME AND ADDRESS:
AP POWER ELECTRIC CORP
Itelff*10
FORT LAUDERDALE FL 33312
EMIJ, 01� -11 1-j 17 1 AM
lelrl TITX14
Pursuant tD Chapter 440,05(14), F.8, an ofd cerof a =poraflon who elect exempthafromthis chaptarbylling a cer0ficateofelaction tender this salon may
not recoverben efits orcompensatiDn under this chapter. Pumuentio, CChapter "O.W121 F.S,, Certificates ofelectiontobeexempt— appty only within the scope
ofthe business ortrade listed an the notice ofelaction to be exompt. Pursuantlo Cfiap*r440,0S(13), F,&, Notices of election io boaxemptand cartificates of
election to be exempt shall be subjDct to revocation if, at any time after the fling of lho Police or ft issuame of the certifloate, the person Pawed an the notice or
co to no Janger meets ft requirements of this sedan for Issuance of a caffmats. The deWment shalt revoke a certificate at any time for fe of the
person named on tie cerNikate to meet the requirements of this section.
DFS.F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (860)413-1609
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 any 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 Name:
SiIf �..
State of Florida)
County of Miami -Dade)
Sworn to Ad subscribed before m
day of , 20� eto�
LIM
(SEAL)
Tvne of
Contractor
Print Name:
_9f&-_ 4r� if
Signature:
State of Florida)
County oAM
iami-Dade) D
Sworn t9 qnd subscribed before me�hja
day o , 20 ,J
Dov
;1 By