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ELC-15-93Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-226573 Permit Number: ELC-1-15-93 Scheduled Inspection Date: January 22, 2015 Permit Type: Electrical - Commercial Inspector: Devaney, Michael Inspection Type: Final Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Job Address: 415 NE 105 Street Miami Shores, FL Project: <NONE> Contractor: SUN POWER ELECTRIC CO Building Department Comments Work Classification: Addition/Alteration Phone Number (305)758-0539 Parcel Number 1122310430010 AMUSEMENT RIDES FOR TEMPORARY CHURCH CARNIVAL L JAN23-25, 2015 INSPECTOR COMMENTS False Inspector Comments Passed O n Failed "7 Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Phone: (305)297-6678 January 21, 2016 For Inspections please call: (305)762-4949 Page 16 of 29 BUILDING Miami Shores Village Building Department artment 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 PERMIT APPLICATION Permit Type: Electrical JAN 15 2014 FBC 2Ll 0°° Permit No. Master Permit No. JOB ADDRESS: 415 NE 105th t City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami Phone#: (305)757-6241 Address: 9401 Biscayne Blvd. City: Miami Shores State: FL 33138 Tenant/LesseeName: St. Rose of Lima Catholic Church Phone#: (305)758-9568 Email: CONTRACTOR: Company Name: Sun Power Electric Co. Inc. Phone#: (305)297'—'6678 Address: 1363 NE 182 Street City: North Miami Beach State: FL Zip: 33162 Qualifier Name: Silvio Medina Phone#: (305)297-6678 State Certification or Registration #: EC 1 3 0 0 2 8 9 7 Certificate of Competency #: Contact Phone#: (-4 0 5) 2 9 7— 6 6 7g Email Address: DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ $ 500.00 Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ONew ORepair/Replace ODemolition Description of Work: Amusement Rides for temporal Church Carnival Jan 23-25., 201 5 Submittal Fee $ Permit Fee $ %God d, 0e CCF $ CO/CC $ Scanning Fee $ Notary $ Radon Fee $ Training/Education Fee $ DBPR $ Bond $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ i '' 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 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 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 �� .,,kJ��� �/li�R.► Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this >45 day of NpjcA 1X, 20 LJ _, by &gtQrp =ge5 Z00is f �L€ dv , 20/ by , who is personally known to me or who has produced n L personally known tom or who has produced NOTARY PUBLIC Sign: Print: As identification and who did take an oath. lq CNi Ado My Commission Expires: -)f APPROVED BY�A-ZPlans Examiner Structural Review (Revised 3/12/2012XRevised 07/t0/07)(Revised 06/10/2009XRevised 3/15/09) as identification and who did take an oath. NOTARY PUBLIC: e� Sign: Print: of y4 a-tc,�j P My Commission E """""'"MARINO PASACHE MY COMMISSION # EE53299 �pFp�` EXPIRES: March 22, 2015 1900J-tJOTARY _ -_ . �: NWety Discount ANW, Co. Zoning Clerk ' STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD LICENSE NUMBER t►i i The ELECTRICAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 MEDINA, SILVIO J SUN POWER ELECTRIC CO INC 1363 NE 182ND ST NORTH MIAMI BEACH FL 33162 ISSUED: 08126/2014 DISPLAY AS REQUIRED BY LAW syss 7 SEQ # L1408260002262 Local Business Tax Receipt Miami -Dade County, State of Florida —THOS IS NOT ABILI -D4 NOT PAY LBTJ 6513403 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES SUN POWER ELECTRIC CO INC RENEWAL SEPTEMBER 30, 2015 1363 NE 182 ST 6783683 Must be displayed at place of business NORTH MIAMI BEACH, FC Pursuant to County Code 33162 Chapter 3A Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED SUN POWER ELECTRIC CO INC 196 ELECTRICAL BY TAX COLLECTOR CONTRACTOR 45.00 09/08/2014 Workegsj 1 EC13002897 0228-14-008479 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 arty governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles -Miami-Dade Code Sec 88-276. AN) For more information, visit www miamidade aovhaxcol1aW MOM JEFF ATWATER CHIEF FINANCIAL OFFICER �E L • ��oe we 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: 10/14/2013 PERSON: MEDINA FEIN: 943472315 BUSINESS NAME AND ADDRESS: SUN POWER ELECTRIC CO INC 1363 NE 182 ST NORTH MIAMI BEACH FL SCOPES OF BUSINESS OR TRADE: EXPIRATION DATE: 10/14/2015 SILVIO J 33162 LICENSED ELECTRICAL ELECTRICAL WRING CONTRACTOR -PROJECT BURGLAR AND FIRE CONTRACTOR WITHIN BUIL MANAGER, CO 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 listed 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 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. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 q 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 Contractor --, Q.., Y� l`Yp , Print Name: .' O D ►^ CL's Print Name: +�L % �'7Y a19�. � �f SignaOZZftA- Signature: �---� ¢--=---_. State of Florida ) County of Miami -Dade ) Sworn to and subscribed before me this IS' day of �„t,rc,...� 120 B� 1!! ��� Y (SEAL)� ° 4, Type of Identification proms cet?J' aondwd� °.Note u State of Florida ) County of Miami -Dade) 7 Sworn to and subscribed before me this day of 20 c By .. Type of Identificatio f-45.,C)"AtA l(' V �6tivWs / f M4,v MMY raft - ft* 4f Fleft n �{'NK�� � Asa •:. ;fit. Jan, 15. 2015 1:52PM No. 5584 P. ACOROCERTIFICATE OF LIABILITY INSURANCE DATE(MINbD1YYYY) 01/15/2015 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPOKTANT: If the certificate holder Is an ADDITIONAL INSURED, Lha p01iGy(ias) must be andorsed. Ir SUSROQATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an andomamant. A statement on this certificate does not confer rights to the _certificate holder In Ileu or such endorsalnent(s). PRODUCER CONTACT ' Allstar Direct Insurance PHONE`(305) 754-7414 F (305) 754-7416 16123 B1SC8yne Boulevard M IL - . AIJD Ess' Joe@allelardiredcom Aventura, FL 33160 Phone (305)754-7414 Fax (305) 754-7416 INsuRE9181 AFFORDING COVERAGE NAIL d INSURERA INSURED Sun Power Electric Co Inc INSURER 0: _ INSURER C : 1363 NE 182nd St INSURER D: IN URERE: INSURER North Miami Be FL 33162 COVERAGES CERTIFICATE NUMBER:_ REVISION NUMBER: THIS IS TO CERTIFY THAT THE G ANYES OF INSURANCE LISTED BELOW WIVE BEEN ISSUED INDICATED. NQTWITHSTANDINGANl REQUIREMENT. TERM OR CONDITION TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD OF ANY CONTRACTOR CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE OTHER DOCUMENT POLICIES DESCRIBED WITH 1158PEECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED HEREIN BY PAID CLAIMS. IS SUBJECT TO ALL THE TERMS, NSR ADD rB LTR TYPE OF INSURANCE gR .WYQ .•• -_ POLICYNUMBER LIMITS M�C_YjEF_ UiYYYlI) L OLICYEXP GENERAL LIABILITY CrlOCcuRRENCE1,000,000,00 �[] COMMERCIAL GENERAL LIABILITY DAMAGE70 RENTED PREMISES s 100,000.00 ❑ ❑ CLAIMS -MADE © OCCUR A ❑ 20F0071344-2 08/25/2014 09/25/2016 MED EXP (Any one person S 5,000.00 PERSONAL&AOVINJURY S 1,000,000,00 ❑ GENERAL AGGREGATE $ 2,00"')"oGENtAGGREGA7ELIM17APPLIESPER ❑ POLICY ElP 11 LOC FLRODUCTS-COMPrpPAGG $ 1,000,000.00 AUTOMOBILE LIABILITY MBINED SINGLE LIMIT $ ANYAUTO BODILY INJURY(Prrpersm) S 1❑ U AUTO QED ❑ SCHEDULED ❑ HIRED AUTOS NON -OWNED ❑ BODILY ]NJ,)R (Per accidrnlj S AUTOS ❑ PROPERTYOAMAGE Per3ccs 5 - ❑ UMBRELLALUUi El OCCUR OCCUR ❑ EXCESS LIAR ❑ CWMS-MADE EACH OCCURRENCE S ❑ DED ❑ E AGGREGATE g . WORKERS COMPENSATION s _ ❑ SY 7 T ❑ RH AND EMPLOYERS• LIABILITY YIN OFPICERRm�MBEA EXXCCLUDED 'En NIA E.L. EACH ACCIDENT 5 (Mdnd!(ory In NH) If Yes, de= be under E.L. DISEASE - EA EMPLOYE S DESCRIPTION OF OPERATIONS beloW E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (A(lach ACORD 101, Addl lluml Re rtwrks Schedule, If more space Is required) CERTIFICATE HOLDER Miami Shores Village Hall Building Dept 10050 NE 2nd Ave Miami Shores, FL 33138 ACORD 25 (2014/01) OF Electrical Contractor # EC13002697, CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED BEFORE THE: EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2014 ACORD CORPORATION. All Tights reserved. The ACORD name and logo are registered marks of ACORD