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EL-14-2496Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-225103 Scheduled Inspection Date: December 15, 2014 Inspector: Devaney, Michael Owner: BROWN, MORGAN Job Address: 29 NE 102 Street Miami Shores, FL 33138 - Project: <NONE> Contractor: XL ELECTRIC CORP Building Department Comments Permit Number: EL -11-14-2496 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1132060131650 Phone: (786)282-4449 REPLACE 1 DUPLEX RECEPTACLE GFCI, 2 SWITCHES Infractio Passed comments AND 3 RECESSED LIGHT IN TWO BATHROOMS. I INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. December 12, 2014 For Inspections please call: (305)762-4949 Page 19 of 25 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: (305) 762-4949 �.�� CEA NOV 1 0% nye FBC 20 !0 BUILDING Master Permit No. Iq ® 2. PERMIT APPLICATION Sub Permit No. IL4' 29g1 0 ❑BUILDING �LECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL [PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [—]CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9—q hJF,I D- 2 iL-J St City: Miami Shores County: Miami Dade Zio: 13 d the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: /ood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): PlA`rt.0 hi1 0��b Phone#:"�-90 af & Address: q 1 j E 10 a J . City: /=`'i a rn i Sh1pftj-:, State: I Di! ( Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: 94- 6�4:f— C'��� . Phone#• 266 - 2.b :j11 % Address: CC,7 15� ':;7 City: _ VIA -n r State: Zip: 33� � Qualifier Name: -,7V (-- ! D �41,,e .l��9;; Phone#: �2-300J^ State Certification or Registration #: � / 0O .3 7 CI Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: Address: City: State Zip: Value of Work for this Permit: $ 4?90®® Square/Unear Foo ge of Work: Type of Work: 11 Addition [I Alteration 1:1 New Repair/Replace ❑ Demolition Description of Work: AP -0 CeB74-CI&t ,SCE , 2 -SWI AC,640S Specify color of color thru the: Submittal Fee $50, •C)�) Permit Fee $ 1®0 CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ G Double Fee $ C� Structural Reviews $ Bond $ C Zi TOTAL FEE NOW DUE $ V 9 < l� (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address Zip 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 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 on 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. Signaturer • 1`///Signature —71A OWNER or AGENT The foregoing instrument was acknowledged before me this 1 day of `�. 20 ®' by who is personally known to me or who has produced -0 Identification and who did take an oath. CONTRACTOR The foregoing instrument was acknowledged before me this day"" of�f__ my" , 20 /4- by ;who is personally known to me or who has produced as Identification and who did take an oath. (V41 �2 --¢Z) - 0Z ,oa3d,p) NOTARY PUBLIC: NOTARY PUBLIC: Sign: �'' Sign: 4 Print: 1^f9tS I r��s��,� Print: Z �a S a� �!//� �r/� V� ao LiiiS FERMEZ v au Seal: MY COMMISti410N # EE 838180 Seal: o, ",, tus FERNANDEZ * EXPIRES: November 7,2016 +�' c MY COMMISSION # EE 838180 ��9TFOF �OP�P Bonded Thru Budget Notary Services *r EXPIRES: November 7, 2016 1 dol Bonded Thru Budget Notary Serviees sws*s**wwss**wwsss***sw*ws*wwwswwws****wwwws****wwwwswsw**********wwwwwwswwwwwsww*wwswwsss*ss**sssss*******w APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami shores Village Building Department CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) IF CONTRACTOR HAS A NBAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certicate Halder. MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MUM SHORES, FL 33138 Cerdilcate must specify the description of operatfons or contractor license number. BUSINESS NAME: X L cleo�P BUSINESS ADDRESS: (5-& 32 SX) 9�757_ Cr1Y o--( 07n ( STATE FL ZIP__3__ 3 3 BUSINESS PHONE: 02 �� �l FAX NUMBER r/00, 40w CELL PHONE (0) 2AZ WV -5 QUALIFIER'S NAME: Oly6) Al IAI 1�1�17�C 1 ft` Rf11fiAR4R• -EC1 3 0 6 5 3 "lel 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 . f: 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 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: An(°', fta TEO) l u� Signature: D YJ rt -D,\ -v% - ��, AAD�� State of Florida ) County of Miami -Dade ) Sworn to d bsc ' e day of LIM (SEAL) W L V Tvpe of Identification p10iARyp �' •G� �r CSS !RFs y s/off ZB �fth_ i «ILVPIFRZI —,w.-�._r�.� State of Florida) NOTARY County of Miami -Dade) `AG Sworn to and subscribed before me thig1 day of , 0 °`�oaie� /yF09' By �rr�2e`yo`o��F (SEAL)_./��sa2 Tvpe of Identification produced V462-421-662-30 -i JEFF ATWATER CHIEF 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: 8PJM13 EXPIRATION DATE: 8=015 PERSON: VALMASEDA JULIO A FEIN: 462954310 BUSINESS NAME AND ADDRESS: XL ELECTRIC CORP 15632 SW 59 STREET MIAMI FL 33193 SCOPES OF BUSINESS OR TRADE: ELECTRICAL WIRING ELECTRIC LIGHT OR BURGLAR AND FIRE WITHIN BUIL POWER LINE C ALARM INSTALL Pursuant to Chapter 440.05(14), 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 440.05(12), F.S., Certificates of election to be exempt- apply only within the scope of the business or trade Wed on the notice of election to be exempt Pursuant to Chapter 440.05(13), 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 cettificate. 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. DFS-F2-DwC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (8W)413.1609 CERTIFICATE OF LIABILITY INSURANCE D"E"'w"n 11/13114 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THUS 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT, If the cardfk ars holder ban ADDITIONAL INSURED, the po ft(les) must be endorsed. ff SUBROGATION 18 WAIVED, subJsctm — --- - - - - Oue terrrns and conditions of the Polity, remain policies may require an andorsement. A statement on Ods eer8tkate does not confer rights to the eer8ficste holder In Liu of such endorsement(s). PRODUCER Pandora Insurance 3520 West 18th Ave Sults 155 Hialeah, FL 33012 Phone (305j 23l-9898 Fax (305) 8754M INSURED XL EIaric Corp 15632 SW 58 ST MIAMI, FL 33193 (786} 2824449 COVERAGES CERTIFICATE NUMBER: Ane lamas 231-9898 Grarrsda htsurarwe Company NUMBER: C-tl'•�xrl 16870 'THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. — R TYPE OFINSURANCE AM "NM r umm EnCN Q u NCE _ S 1,000,000.00 4 Q6 - a 100,000.00 GENERAL LY BRM ® COMMERCIAL GENERAL UMUTY A ©❑ cwMS = ja OCCUR CJ 01815FL00054085 10129/2014 10129=15 MED MW am a 5.000.00 _. _.. PERSONAL&ADVINAW 8 1,000,000-00 -- — ❑ _ . _ — _-- .. _ GENERAL AGGREGATE - s 2,000,000.00 - ODA AGGREGATE LWT APPLIES PER PRODUCTS- COMP/OP AGG x_2,000,000.00 POuCY ❑ fELi ❑ LOG__-_ $._—•---_-- AUTOWBILE LIABILITY ❑ ANYAUTO •.- SINtaLE um BODILY Q+IJURY(Paperaan) S —..� _.. ❑ AMS ❑ BODILY INJURY MerwaWwX S p HIRED AUTOS ❑ UNBREIJA LIAB ❑ 0=UR — — ----- --- EACH OCCURRENCE s EXCESBUAB.-. ❑ CLAS04ME AGGREGATE a NIA V COWENSATgN AM EMPLOYERS' LIABILITY YIN ANY PRAPRETORMARTNERIE>IECLITAIE OFFICERIINE]MIBEREXCWDED? �in BESCRIFTgN OF OPERATIONS to. rr F -121w. CI• T RVTLAIM LJ ,,I E.L EACH ACOMENT d -------- E.L DISEASE - EA S E.L DISEASE - POUCY LIMIT S _ DESCRIPTION OF OPERATIONS I LOCATIONSI VEHICLES (AItwh ACORD 101, AddI1IwW IiwrwSdwdu"s, Nm m s=e IampAn d) - State License g EC 13005379 CERTIFICATE HOLDER Miami Shores Village 10080 NE 2 Ave FL, 33138 305-795-2204 ACORD 28 (2010/015) QF CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 09 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDRFYRESlfA 6INS-2010 ACORD CORPORAT)ON. AU rights reserved. The ACORD name and logo ars naglstered marks of ACORD TALLAHASSEE EL:3239M783 (850)-487-1'395 -.,_ ..: t;oti�tatufations!::VV�fti#his:i'i�rts�yau.fsac�rri�onet�%tt1e:1'�atiyy:_ ..:..::?:< ::::..; Dire rriiltiort:Floridiart's>Eitnsed:by;iile Repattrrteitt Qf. Bt�sEriess:and: Prof fonaE.Fdegaleti+afl :Dur professtwiats and bu'nesses::ratige:::. frorii:arctiit ts:to.ya ht: irokett ; irbM boxers to barbeq ire: restaurants; :...- and they:keep.Fiorida'secxtrrottty strung. Every iiay w** a v�orlc i6:inijiroire tlie:inray ave dey bwsii it s iit orifi r.ti►:::: : serve your better.. For.lr torrriar abouf-our services; plbase.tog:cHtio - :rtiytlorisialEci�rt>se:caotrr. 7'(itare.you sari find:more.infgr3rtatiora .. about our, divisions and the egulatidris.that.itrroict:you subscribe: to department newsletters and learn more. abw*-ths 6;;�al:;;eRi: initiatives. riot tYtiss!ori et the liepatrtrri�rie is: Li�rise �fttCieritiy; I;;egilEate Fairly. Nle constantly strive.to.serve you- better so that you can -serve your customers.: Thank.you ibrdoing.business in Flodda;,.. and gratu(ations-on.yournew.licon DETACH HERE ESSUEM OW7MI4 DISPLAY AS REQUI ED Y LAW sEQ # 04W70004333