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ELC-15-41Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-226240 Permit Number: ELC-1-15-41 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> Work Classification: Temp for Construction Phone Number (305)758-0539 Parcel Number 1122310430010 Contractor: MOODY ELECTRIC INC Phone: (305)758-2000 Building Department Comments CARNIVAL ------ TEMPORARY ----.TEMPORARY HOOK UP OF ELECTRIC FOR 26 INSPECTOR COMMENTS False CARNIVAL TENTS Inspector Comments Passed21 Failed�� . Correction Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. January 21, 2015 For Inspections please call: (305)762-4949 Page 14 of 29 A � 12 BUILDING PERMIT APPLICATION Miami Shores Village Building Department JAN opt 2015 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305)795-2204 Fax: (305) 756-.8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 ❑BUILDING X ELECTRIC ❑ ROOFING ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS FBC 20 Master Permit No. F-(--(-- Sub Permit No. ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 11%� //ZS 1424< S 7— City: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: _ OWNER: Name (Fee Simple Titleholder): S7 /2cjs& 0.0 Phone#: 36?5r Address: 66 .6— /vos 1406- -1— City: /yy.,o! w/ State: / G Zip: 331.3 Tenant/Lessee Name: Email: CONTRACTOR: Company Name: zwe- Phone#: ✓49"' Address: City:._ .rf�yJ / State: /cL Zip: .9 f' C2 Qualifier Name: .yri ' Phone#: 3®!i' 7_1W ref State Certification or Registration #: t-(— Onc 7 1 / Y11 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State Value of Work for this Permit: $ Square/Linear Footage of Work: — Zip: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work:�/,�,�✓,lj IlwL Sped :7color.., of color thiru #�iet, ". Submittal Fee$ _ Irrrit+ Scanning Fee $ Technology Fee $_ Structural Reviews $ (Revised02/24/2014) Radon Fee $ 14 4 ® mom ,, 60 CCF $... CO/CC $ Training/Education Fee $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ ® , �l J Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State �a 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. >eSignatur OWNER or AGENT The foregoing instrume was acknowledged before?mehis day of 20 , by Q: �r � ,d 66il is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: M &f�b Print: � ° a;,••. MARY PAT BRJF[orida, Seal: ' ° Notary Public -StatMy Comm. Expires MCommission # FF Signature CONTRACTOR :The foring instrume as acknowledged before me this day of 20 . by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign:_ Print: Seal: Notary Public- State of Florida My Comm. Expires May 11, 2011 Commission # FF 120746 APPROVED BY Q' vYiS��: Plans Examiner Zoning Structural Review (Revised02/24/2014) Clerk Local Business Tax Receipt -Miami-Dade County, Stateo Florida -THIS IS NOTA BILL - 00 NOT PAY 1499367 BUSINESS 1"EMOCATION. RECEIPT NO. : : M000.cti: c:;., E�PIRE� ' ::_� .:. :.. R •., � . RENEWAL S�EPTEMBE '.. 6G51 J' : ; ti.'• 1499367 . Must be di6p' to ed at place ofi puniness '. c. Pursuantto County£od; Chapter 8A - Art: 9 & 1:0.•; OWNER 'is: SEC, TYPR•`QF BUSINESS k96 ELE MOOp1G_Et KTRIC INC PAYMENT REC> 11 D M001ATLQAL CC1NTRACT`0R :;: 8Y TAX lxJLtE 1 . z? TkisLocaF§usiness7rpcfiaflr aceipta^c4fir>ns payoientoftfirffiicalBusQaessTax TheRecaiptlsaatafie :;',:'yrs: ;'y_! pe�arr`�'gr:e cert�catioiFgf Ike hold�,�•gilalificatiorils, to da kusiaess. Halder mast calaOlY.„I�aaY 9ovo"r'randtnai•`:�•.:z:z.�.; :.':. ani'"' .:rataneatak.�egiilatory lawsiauL_ _�e�uin�rents wkieh apply to tha huseiiess;,'::n;;',.:'.,t �?': .:� + �I�CEtAT AHF-.a'Sore masf�dtspfayad oa�etl corraneitiial relNcles�: JGlisna�-0adsCape Sec 8a-'Zj6.�. Lvv r�Wc"rriiaiuida sniP��s"y"' RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION FE FCTRICAL CC1'uTRACTORS LICENSING BOARD . 4 T61 -:L CONTRACTOR Naa�ecf below IS_.C.ER.T.IFIED-.: - ',U.rid6rth,-_-;rovls10ns,of chapter 4$9 FS. ,,.. �Xpir.�flo�i'.date:-..AUG�"'h-2Q;1:6...: ""... • L!j LM ko --�'•_ - '`�1A0002Y'ELECTC'ilC„1 �•��.� .';" � ��:.� , 4ti ,.:� ..-*3.7G0R0AN0XZ FJ 11 522 `D� ISSUED: 08/1012014 DISPLAY AS REQUIRED BY LAW SEQ # L1408100003121 MOODELE-01 MELBA A 10 ORD- ` 6...�' CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 12/8/2014 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 'PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. PORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements . PRODUCER Acrisure, LLC dilila InSource 9500 South Dadeland Boulevard CONTACT NAME: PHONE �t _(305 670-6111 �, (305 670-9699 c ADDRESS: 4th FloorE-MAIL Miami, FL 33156-2867 INSURER AFFORDING COVERAGE NAM # INSURER A: Monroe Guaranty Ins. CO. 12131/2014 INSURED INSURER B: FCCI Insurance Company 10178 Moody Electric, Inc. Mr. John Moody INSURER C : GEN'L AGGREGATE LIMIT APPLIES PER: POLICY Ea [X LOC OTHER: 669 NW 90 Street INSURER D! INSURER E: Miami, FL 33150 INSURER F: COVERAGES CERTIFICATE NUMBER: RE"VISInN NUMBER - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. INS LTR TYPE OF INSURANCE ADOL SUBR POLICY NUMBER POLICY EFF iMMIDDMDM POLICY EXP (MMIDDWnM 12/31/2015 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR CPPOODS69410 12131/2014 EACH OCCURRENCE $1,000,00 PREMISES & oaunence $ 100,00 MED EXP (Any one person) $ 5, PERSONAL 6 ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY Ea [X LOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGG $ 2,000,0 $ .. AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS- AUTOS NON -OWNED X HIRED AUTOSX AUTOS CA0006779 10 12/31/2014 12/31/2015 CEM BSED I 9INGLE LIMIT $ 1,000.00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ OPERTY AMAGE Peracckient $ B X UMBRELLA LIAB EXCESS LAS X OCCUR CLAIMS -MADE UMB0004787 9 12/31/2014 12/31/2x15 EACH OCCURRENCE $ 2,000,00 AGGREGATE $ 2,000.00 DED I X I RETENTION S 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTiVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes deambe under DESCRIPTION OF OPERATIONS below N I A PER TH• STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ '— E.L. DISEASE - POLICY LIMIT $ )CATIONS /VEHICLES (ACORD 101, Additional Ramada Schedule, may tw attached H mora apnea Is required) CERTIFICATE HOLDER CANCELLATION 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Z'd EEET--b9L-90E DLII Dt.a-4DaT3 RPDOW eBZ=OT TZ 60 Uer SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Villa of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd. Avenue Miami Shores, FL 33138 �,. AUTNORr.{ED REPRESENTATIVE 041 c�v--v-- 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Z'd EEET--b9L-90E DLII Dt.a-4DaT3 RPDOW eBZ=OT TZ 60 Uer MOODY -1 OP ID: TH '4� Ro- CERTIFICATE OF LIABILITY INSURANCE DA1211912014 ) 12/1912014 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 require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Workers Compensation Group P o sox at D Boca Raton, FL 33429-0410 NAME: Workers! Compensation Group PHONE , Ell: 561-392-3300 ac No : 561-361-1132 ArAL DDRESS: certs@workerscompgroup.com INSURER AFFORDING COVERAGE NA1C S 40—� INSURER A: Brid field Employers Ins 10701 INSURER e INSURED oody Electric, Inc -- _ 669 Northwest 90th Street INSURER C: Miami, FL 33150 INSURER D OCCURRENCE $ INSURER E MED EXP (Any one person) $ INSURER F: PERSONAL & ADV INJURY $ COVERAGES CFRTIFICATF Nt1MRFR- 0CAnQ1f%U 11,11I"Mon. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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. NSR LT TYPE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami Shores g 10050 NE 2nd Ave. POLICY POLICY NUMBER POLICY EFF MMID POLICY EXP IDD LIMITS 40—� COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR T::: OCCURRENCE $ PREMISES Ea oceurrece $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEML AGGREGATE LIMIT APPLIES PER: POLICY ❑ JELOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMPIOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTO COMB a IcntSlN LI $ BODILY INJURY (Per parson) $ BODILY INJURY Per aedda„t $ ( ) PROP —i Per accident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ A YORKERS COMPENSATION AND EMPLOYERSLIABILITYSTATE ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yee, describe under DESCRIPTION OF OPERATIONS below N I A 830-29673 01/01/2015 01/01/2016 X PFRTU - I OR E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE - POLICY LIMIT $ 1,000,00 LOCATIONS I VEHICLES (ACORD 101, Additional Remarka Schedule, may be attached If more,Pace is requ" CERTIFICATE HOLDER CANCELLATION MIAMIS3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami Shores g 10050 NE 2nd Ave. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE I 40—� C 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 6 -Cl EEE T-trSG-SOE Ou i 0',J40813 RPOOW egg :O T 13 60 Uer