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EL-14-1477 (2)Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-223511 Scheduled Inspection Date: November 18, 2014 Inspector: Devaney, Michael Owner: IZOUIERDO, NICOLAS Job Address: 78 NE 101 Street Project: Contractor: Miami Shores, FL <NONE> ADAN ELECTRICAL SERVICES LLC Building Department Comments REWIRING 50% OF THE HOUSE AND KITCHEN RENOVATION Permit Number: EL -7-14-1477 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number (786)231-5339 Parcel Number 1132060131330 INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Phone: (786)285-3847 November 17, 2014 For Inspections please call: (305)762-4949 Page 43 of 45 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (30S) 762-4949 BUILDING PERMIT APPLICATION ❑BUILDING ELECTRIC ❑ ROOFING 1 'JUL 10 2014 FBC 20 LCD Master Permit No.1kc 14 p I�A Sub Permit No. E Ll, --A ' I --A4+ ❑ REVISION ❑ EXTENSION [—]RENEWAL ❑PLUMBING [—]MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 7? ✓V lo% 57 - City: Miami Shores County: Miami Dade Zip: 3313 Folio/Parcel#: Is the Building Historically Designated: Yes NO _ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): ZOR 060 C�fSl2G'b®r �b� Phone#: 71? " Address: j -Z �Z� s (ff.>4 e01f4 eLye 01�� City: /1/1m -m I State: /—� Zip: 3 31 O Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: /�'��� ����1 Phone#:2 Address: c-?tJ1)/ -S7f cJ e City: Qualifier Name: 542ri a Zip: .3, � ®® �3 _ State Certification or Registration #: �('�e ®CJ L��`� Certificate of Competency #: DESIGNER: Architect/Engineer: P.4 U- eG 0,V4 L e 9 }�� G o Phone#:-30,5-5�2 45-2?/71 2 e z Gv /' Address: � � % d'p� City: �Y��4 le..JQ h State: TL Zip: Value of Work for this Permit: $ � d Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New tepair/Replace 9-1 ❑ Demolition Specify color of color thru tile: Submittal Fee $ ' Permit Fee $ a - CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee Structural Reviews (Revised02/24/2014) Training/Education Fee $ 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 not be approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT C NTRACTOR The foregoing instrument was acknowledged before me this �a ,�'L day of , �J 20 _/ by /V Ir ,QXU 7� ql)/ who is personally known to me or who has produced l Aa 2?� as identification and who did take an oath. NOTARY PUBLIC: Sign: State of Flodde Joanna m rou-- My Commission FF 08V swpims 0111 21201 8 - %'A. The foregoing instrument was acknowledged before me this a.- day of ,Jc» 10 .20 6 by R Q1—q,0dQ la12• who is personally known to me or who has producedS identification and who did take an oath. NOTARY PUBLIC: Prtri� r ` - s State of Flotlda N01�3080118tA FeIICIano Seal: My Commission FF 082753 -Eyireso111212018 3 0 ry APPROVED BY �/� �/ �Lq �Z Plans Examiner Structural Review (Revised02/24/2014) Zoning Clerk A11%O'' CERTIFICATE OF LIABILITY INSURANCE DA o61MMID �"' 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(las) must he endorsed. N SU13ROGATION IS WANED, Subject to the terms and cond#fons of the Policy, certain policies may Inquire an andorsemert. A statement on this certificate doss not Confer rtghts to the certificate holder In Hou of such ondarsement(s). PRODUCER Qblk Inslaanos, Inc 5701 Sunset Drive Ste. 256 South Mod, FL 33143 Phone 868 320-7245 Fax 305) 964-7715 NTACT Alwds Del Vape WL ow (668) 320-7245 No 305) V64-7715 8delva98* bAdnsuralrca com AFFOROING COVERAGE MAIC # 6NURER A : At cldental h>SIranCe COmPany INSURED Adan Electrical Service 3001 SW 37Avenue Hollywood, FL 33023 INSURER s : INSURER C : INSURERD: INSURER E FR F COVERAGES GERTIFIGATE NUMBER: KCVICHUN Numac ; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE OSTEO BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OT14ER 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 SEEN REDUCED BY PAID CLAIMS. IWSR TYPE OF 94SMNM R �LiCY ER % LIMITS A GENERALLIABILITY ❑ COMMERCIALGENERALLwsLffY ❑ ❑ CLAIMS MADE [3 OCCUR E) CPP0002917-02 ObP21/2014 05/27/2015 MH S 1000.000.00 T $ 100,000.00 AHED EXP (My are person $ 5.000.00 PERSONAL&ADVINJURY $ 1,000,000.00 PERSONAL ❑ GENERALAGGREGATE $ 1000,000.00 GM AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ ❑ LOG PRODUCTS-COMPMPAGG S 1,000.000.00 $ AWOMOBILELIABILITY ❑ ANYAUTO ❑ �OOWNED ❑ SCHEDULED ❑ H�EDAUTOS ❑ AUT0.NED fd81� D. MOLE LIMIT BODILY INJIM(Per p ) S BODILY K)URY(Per �lc!84 S PROPERTY dE a $ ❑ UMBRELLA LIAR ❑ OCCUR El EXCESS LIAR ❑ CLAIMS MADE EACHOCCURRENCE $ AGGREGATE $ i El OED El RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER �ory EXCLUDED? (fyyBe8s�, stIn NH) DESGOT OPERATIONS below NIA I E] UWSTUW El Onl- E.L. EACH ACCIDENT $ L. DISEASE - EA EMPLOYE $ EL DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I I.00ATKINS I VEHICLES (Attar$+ ACORD 161. Addis Remarks Schedule, If more space Is requhV# Contactor License # EC13004453 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2 AVE Miami Shores, FL 33138 ACORD 25 (2010105) QF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988-2010 ACORD CORPORATION. AN rights reserved. The ACORD name and logo aro registered marks of ACORD JEFF ATWATER CHEF FINANCIAL OFFICER STATE OF FLORIDA 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: 6/1/2014 PERSON: ADAN FEIN: 272398773 BUSINESS NAME AND ADDRESS: ADAN ELECTRICAL. SERVICE 3001 SW 37 AVE EXPIRATION DATE: 5/3112D16 FL 33023 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR .._.��1\ r!� � =--z!.-_ r.C.�_..L_.d-i ftnd byfbwa MCIC41Wn Y1lYer UtlD � .r� • .j, ..r., w. w r _wrrw.,-w. w. U/NNIS\ V!� �i ww�@� not recover' 0 arampensefim, der dit dmpter. Pursuant to (iter 44 05(121, F S., Cei6firates of election to be exempt— apply wY within the ofdwhmkwnorbmbfidedm@wcmdmofdocrantobeeonVLPumumtfaChapter4aO5(14,F.S,NofimofebcOwtobeewmptoWeeffiRmAmof election to be ewmTV shaft be subject to revocation if; M arta fine aftrttx• tm of the no5ce or the issvwtce of the cwbl cote, fite per3on named on Ste notice or person named on the caNcate, to meat the requramerds of Otis suction, DFS-F2-1AW 252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (8W)413-1809 115 S. Andrews Ave., Rm. A-100. Ft Lauderdale, FL 33301-1895 — 954-831-4000 VAUD OCTOBER 1, 2013 THROUGH SEPTEMBER 30, 2014 013A.- Business BA:Business Name: ADAELECTRICAL SERVICES LLC Owner Name: ROLANDO ARAN BUSNJWS Lotion: 3001 SW 37 AVBNNIIS HOLLYWOOD Business Phone: 786-285-3847 Receipt 'ELECT.i�./i Business Type: (ELECTRICAL Business Opened:06/01/2010 StddCounty1CerUReg:EC13 004453 Exemption Code: Rooms Seats Employees I11ach6tes Professionals 2 ForveKnng ewhms order Number of Machines: Vendbg TYpn- Tax Amount Transrer Fee I NSF Fee Penaay Prior Years I CoUftn Cost Total Paid 27.00 0.00 0.00 0.00. 0.00 0.00 27.00 ]I THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the pnv fte of doing business within Broward County and is non4egulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. Ttus Business Tax Receipt must be transferred when the business is sold, business name has changed or you tmve moved the businm location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: ROLANDO ADAM 3001 SW 37 AVEMM HOLLYWOOD, FL 33023 2013 -2014 Receipt #022-12-00002264 Paid 09/25/2013 27.00 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: t y t3 P e46 Signature: State of Florida ) County of Miami -Dade) Sworn to and subscribed before day of 61TNotary Public State of Florida By . Joanna M Feliciano (SEAL) Print Nam Signature: State of County of Miami -Dade ) Contractor Joanna M Feliciano My Commission FF 082753