EL-14-1959Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-225903 Permit Number: EL -9-14-1.959
Scheduled Inspection Date: January 05, 2015
Inspector: Devaney, Michael
Owner: VEJDANI, RAMIN & BETHANEY
Job Address: 665 NE 97 Street
Miami Shores, FL
Project: <NONE>
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Alteration
Phone Number 305/758-9375
Parcel Number 1132060171910
Contractor: CUSI ELECTRICAL SOLUTIONS INC Phone: (786)390-4962
Isuuamg uepartment comments
KITCHEN REMODEL
INSPECTOR COMMENTS False
Inspector Comments
Passed
Failed ✓��%�'`� /�
Correction ❑
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
January 05, 2015 For Inspections please call: (305)762-4949 Page 19 of 21
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) 362-4949
Fill
a
SEP 69 2014
FBC20'`
BUILDING Master Permit No' V_C 1 `t .
PERMIT APPLICATION Sub Permit No. 6_1i1.4 ' 111
❑BUILDING
ELECTRIC
❑ ROOFING
❑ REVISION ❑ EXTENSION
❑RENEWAL
❑PLUMBING
MECHANICAL
❑PUBUC WORKS
❑ CHANGE OF ❑ CANCELLATION
❑ SHOP
DRAWINGS
,rCONTRACTOR
7;E
JJU f`
JOB ADDRESS:
City:
Miami Shores
County:
Miami Dade Zn:
Folio/Parcel#:
1 w J�� `O� 7
Q O
Is the Building Historically Designated: Yes
NO �+
Occupancy Type:
��"Nf -Load:
Construction Type:
Flood Zone: BFE:
FFE:
OWNER: Name (Fee Simple Titleholder): Q --TMA MA u Q_
an
State:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: _ _y 9 -9 S W
_S01171iolts _T_1e
(190310 -- q 17 &2
City St te• Zip:
Qualifier Name: �_(� Sy S S Phone#:
State Certification or Registration #: �Z-� 30 11 -4 I -9A Certificate of Competency #: O E 2 Z
DESIGNER: Architect/Engineer: Phone#:
Address: City: State:
halos of Werk tw II» !� e� Square/Linear Footage of Work:
Type of Wa& 0 Addition Alteration New ❑ Repair/Replace
Description of Work:
Specify color of color thru the:
Zip:
❑ Demolition
Submittal Fee $� Permit Fee $ ®� �® CCF $ ®_ CO/CC $r
Scanning Fee $C Radon Fee $ c - DBPR $ Notary $
Technology Fee $— Training/Education Fee $ Double Fee $
Structural Reviews $}' Bond $ q
TOTAL FEE NOW DUE $ r"S
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State Zip
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 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 $1500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien low 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 CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
_day of -'0 t 20 I Zi
byy,�B day of i 20 4 , by
who is personally known to who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY
Sign:_
Print:
as me or who has produced
1►t►"""1//// identification and who did take an oath
`�•(tAN Cq q
GHQ •O*TARY PUBLI .
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s*s#�•*•*��s�r***+ras*rr*• s*a>r4:r�r*s*«sir«�*�:*r*:��::*�lsT*�sy�:*J+iar�s��*�*:*��*�re� �*:*s+�xress�::*:
APPROVED BY / Pians Examiner Zoning
Structural Review __ ____ _____ _ Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION FORM
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS
SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A :330.00 FEE PER YEAR.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. COPY OF QUALIFIER'S STATE LIC CARD
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT)
D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. _X COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER
B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT
C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT)
D. c --' COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION)
YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
r■rrrrrrrrrrr�rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr�rrrrrrrrrrrrr�
COMPLETE CONTRACTOR'S INFORMATION
BUSINESS NAME: G'JS ( L c;C G_f2%(Arr S06vt I'dw (l c ,
BUSINESS ADDRESS: Sw CIS! ) c� _ CITY u l
STATE FtO 60A ZIP CODE 33 L. °1(/
BUSINESS PHONE:( -)141 3 ,j0- y °j% , FAX NUMBER
CELL PHONE ( QUALIFIER'S NAME: 164 uS M - SA L LrDn
QUALIFIER'S LIC NUMBER:
pcoco I2Z
E-MAIL ADDRESS (IF APPLICABLE):
Created an 3MO9 BY NUN t RV 3126f09 MMV
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CLAW E • Any ^o^'co vepisN *a a OVWR Mos Mor, 26,M bs: - SM RV
RNLAWAINT LICEM E ANK4M VA MIN le DAYS OF ADORM OR NMt CMAMOE.
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QUALIFYING TRADE(S)
0001 ELECTRICAL
Charles Daaper P.E. Jk -,
Secretary of the Board '" 1 www.a��.I
tl
ELECTRICAL CONTRACTORS LICENSING BOARD
w
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
SALCEDO, JESUS MISAEL
CUSI ELECTRICAL SOLUTIONS INC
889 SW 149TH CT
MIAMI FL 33194
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 learn 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
RICK SCOTT, GOVERNOR
ISSUED: 08/13/2014 DISPLAY AS REQUIRED
(850) 487-1395
KEN LAWSON, SECRETARY
SEO # L1408130002099
OWNER SEC. TYPE 01V8
CUSi ELECTRICAL SOLUTIONS INC 196 ELECTF
Worker(s) 1 10E000122
This Local Business Tax Receipt only confirms paymae
permit or a certification of the holders qualifications,I
or nongovernmental regulatory laws and requirements
� The RECEIPT N0. above must be displayed on all c
Mi,t%D For more information, visit
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: 41712414 EXPIRATION DATE: 41612016
PERSON: SALCEDO JESUS M
FEIN: 263937158
BUSINESS NAME AND ADDRESS:
CUSI ELECTRICAL SOLUTION
889 SW 149TH COURT
MIAMI FL 33194
SCOPES OF BUSINESS OR TRADE:
LICENSED ELECTRICAL
CONTRACTOR
Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by riling a certificate of election under this section mey
not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt ••• apply arty within the scope
of the business or trade fisted 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 it, 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 lime 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? (850)413-1609
09/05/2014 13:37 17866012998 FLORIDA CITY INS:. PAGE 02
e , s
CERTIFICATE OF LIABILITY INSURANCE F
bAM(MMIDDNYYY)
Dsro5/2014
FERTIFICATE
RTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
HIS
DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
ENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLLER.
MPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(tes) must be endorsed- If SUBROGATION IS WAIVED, subject to
[85
terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate doss not confer rights to the
tiflcate holder In lieu of such endorsement(s).
PCER N racr $onla Toruno
a City Insurance OBA Inter continental insur PHO" ;(788 601-2654 n/c Ne ; (7E6) 601-2898
NE 1st AVE Suite 103 ADDR fforlda Ins meiLc=
ADDREssI _ �Y� �9
I'liarrij FL 33034- INSURER A: Wesco InsuranceCampany 25011
IVERAGES
ED INSURER S:
COSI Electrical Solutions Inc INSURER C:
889 SW 149th Ct, INSURER D :
INSURER I,:
Miami FL 33194 INSURER F;
CERTIFICOTIM NIIMRER! REVISION NUMBER:
HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. N07WITHSTANDING 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.
L R
TYPE Op INSURANCE
I �
a wya
POLICY NUMBER
OIJCY EFF
POLICY EKP
MM
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE S 1,000,D00
X COMMERCIAL GENERAL LIABILITY
CLMMS-MADE OCCUR
PREMISE venae S 100,D00
MED EXP (An one ersm) S 51000
_
PERSONAL, a ADV INJURY s 1,000,000
1NPP1055044 01
03118!2014
03/162015
GENERAL AGGREGATE S 2,000,000
PRODUCTS -COMPIOPAGG $ 2,000,000IL
XAGGREGATELIMITAPPLIESPER,,
POLICY PRO .JECT F7 LOC
s
AUTOMOOLE
LIABILITY
a WaWMM91NGLE LIMIT S
BODILY INJURY (Per woon) 5
ANY AUTO
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BODILY INJURY (-went) went) $
HIRED AUTOS NON-0WNED
AUTOS(Perecd(IND
DAMAOB $
S
UMBRMIA UAD
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AGGREGATE S
EXCESS UAB
CLAIM$ -MADE
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_
$
WORKERS COMPENSATIONYYC
STA U- I Tww-
AND EMPLOYERS LIASILITY YIN
ANY PROPRIETORrPARTNER/EXECUTNE M
O1andat M In BERNH) EXCLUDED?
(Orantlalory In NH)
H Yes tleeame sada
O>=^q(,`RIPTION OF OPERATI S below
MIA
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EL DISEASE - EA EMPLOYE S
E.L DISEASE - POLICY UMiT-T ;
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RIPTION OF OPERATIONS! LACATIONS I VEHICLES tAWAII ACORI) 901, Additional Remarks Soeadule, M mac wpm Is r;;IMd)
lectriaal Work Contractor `
USI ELECTRICIAL SOLUTION
!CENSE NUMBER: ER13014419
CITY Off MIAMI SHORES VILLAGE
SHOULD ANY OF THE ABOVE DESCIRM IED 12OUCIES BE CANCELLED BEFORE
714E EXPIRATION DATE THEREOF, NOTICE WILL 8E DELIVERED IN
10050 NE 2ND AVENUE
ACCORDANCE WITH THE POLICY PROVISIONS.
MIAMI, FL, 33138
AUrHOIvtFb f1EPRESENTA
" „"-" �"" •"•""/ 7 A1.Cilydifrp UKA I IUN. An ngnm reserves.
The ACflRD name and logo are registered m ACORD
♦ SRs
smogdares MiamishorVillagees
Building Department
OR1Dp 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 ormembersof 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 apermit 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 maybe
personally liable for the worker compensation iniuries of anLperson 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 Contractor
Print N, .ne: t Print Nam4',67DSignatu kt C4
Signature
State of Florida) State of Florida )
County of Miami-Dade County of Miami-Dade
���utuuau n' ) �iuua�,y�
Sworn to and subscribed before me this -C iiq���, Sworn to d sub cribed before me this %0N
day of , —LA-- :0 OP ....... 'T,9Oi��i' _day of 20 �� Q�C,qs i�
Sq-611
Cj 05,
By �� s• j> : * B 05, S
(SEAL) * • #M14799 % p(SEAL)__0�
T e of Identification produced 1s •' o�.� ` #14799 Q
��'°�'�^ � �� Type of Identification roduced � -9 •.IC S1, �'•
'I.-.114►Iilllli ````` �Bl/c, STA