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EL-14-2478Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-229399 Permit Number: EL -11-14-2478 Scheduled Inspection Date: March 06, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type.: Final Owner: , Work Classification: Service Change Job Address: 96 NW 92 Street Miami Shores, FL 33150 - Phone Number Parcel Number 1131010160070 Project: <NONE> Contractor: AD ELECTRIC SERVICES INC Phone: (305)896-3402 UU11U111V LJCFJ01L111C11L VV111111C11W Infractio Passed Comments SERVICE CHANGE INSPECTOR COMMENTS False Inspector Comments Passed 04� i� Failed ti Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. March 05, 2015 For Inspections please call: (305)762-4949 Page 15 of 19 AW-iami Shores Village . Building Department G� 2 2014 A 10050,N.E.2nd Avenue, Miami Shores, Florida 33138 Nw j 1 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 2010 BUILDING Master Permit No. n ry--//"f2• .Zl PERMIT A,PPPk LICATION Sub Permit No. 2� Z ❑ I I BUILDING LECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING [-1 MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS 30B ADDRESS:rJ'� a &a) —:;M _4_'C 7'� City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Occupancy Type: Load: Construction Type Is the Building Historically Designated: Yes NO X Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): /��,011-1 604VPhone#: c.5p Address: City: State: 7:;i`24 /mol Zip: �✓'JI2 ✓ Tenant/Lessee Name: Phone#:. G� Email: _ C� 3��j ONTRACTOR: Company Name: - "'� /' �'L" f `-+` � ISS e Phone#: v�'" �•9 "�� 2 �f�� ,�t C "` t Address: � � � � W .� ��., i V, L City: ���'in..tii '�- � State: "' �,-- Zip: J 0 to Qualifier Name: a �� l' ti �; n.i� (�' r Phone#­-�6" 3, q'i 0711 State Certification or Registration #: 115-` * .�U (; 1 • Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ - "• 0 C-' Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: -(( Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ ` • I (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 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: 1 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 $2500, the applicant must promise in good. faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. r-� VVVIVCR VI HVCIV I The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of �G 20 by ZZ day of l7 20� by who is personally known to who is personally known to _ ,e me or who has produced as--, me or who has produced as identifgc ion and who did take an oath. and who did take an oath. OTARY PUBLI NOTARYPILI .P IV I Sign: Sign: Print: g,'N' '�. LIDIA E. HERNANDEZPrint: C q, 6,Vim..\ t N Notary Public - State of Florida r Seal: My Comm. Expires Jan 19, 2018 SeaFqk* kotary Public State of Flori a'Commisslon # FF 81411'%SOF"•�Manuel Dominguez My Commital0fl EE129065 Expir" t t/t5/201b ********************************************************** ****************** APPROVED BY �,f/dt✓ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami shores V11age Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers$ 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 ou ma be personallyliable for the worker co m enation in'uries of an erson allowed to work under this ermit. 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:C1 Signature: State of Florida ) County of Miami -Dade ) Sworn to an b cribe day of�i M Contractor Print Name: el %, Signature: UOIA E. NEfINANDEZ Notary Puik - State of Fiof:idit My Com. ExOms Jan 19, 2018 1,r- 6emm slilw #► FF 81411 HERNANDEZ - State of Florida CommbNon #E FF 814 11 e of Florida ) my of Miami -Dade ) )m to and subscribed before me this _ © 5 of f/' )n o .J of 7. 108529 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department pf Business and Professional Regulation. Our professionals and b6sinesses 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 busjess 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 ILATION (850) 487-1395 STATE -OF FLORIDA DEPARY 'NESS AND PRO �. CULATI.O'N -E01 30051-57 p 7/24/2014 CERTI�,JED, AOR. DOMJNQIJE AbLEC71 ��t'S.C�,R1"IFt�ubTnnµ�-er.:€h w: �`ro.u,isrons cif Ch..4.B9��. x r ion date ,/4HJG 31 30Y�;, 11401240001771 KEN LAWSON, SECRETARY FESt-IbNAL REGULATION . hirl , Ad§& 0 p 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: 8/9/2013 EXPIRATION DATE: 8/9/2015 PERSON: DOMINGUEZ WILLIAM M FEIN: 263973253 BUSINESS NAME AND ADDRESS: AD ELECTRICAL SERVICES IN 8860 SW 171 ST PALMETTO BAY FL 33157 SCOPES OF BUSINESS OR TRADE: ELECTRICAL WIRING WITHIN BUIL 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 DATE A� CERTIFICATE OF LIABILITY INSURANCE 11/10114ro�W) 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 CONTACT NAME: Gil & Associates Insurance 9485 S.w 72 St Suite A-120 David Gil PHONE arc, No, Extl: (305) 279-7665- Fax ac, No): (305) 279-9705 Miami, FL 33173 E-MAIL ADDRESS: Phone (305)279-7665 dgil@gilinsurance.com PRODUCER CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # Fax (305)279-9705 INSURED NSURERA: The Travelers insurance Company AD Electrical Services, Inc. 9135 SW 182 St. Palmetto Bay, FL 33157- INSURER 8: NSURER C : INSURER D: INSURER E: INSURER F: 9 COVERAGES CERTIFICATE NUMBER: REVISION 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 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. ILTR TYPE OF INSURANCE ADOL SUB WVp POLICY NUMBER POLICY F M POLICY XP MMlDDJYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000,000 ® COMMERCIAL GENERAL LIABILITY PRMAISES (Ea oourrence) $ 100+000 MED EXP (Anyoneperson) $ 5000 A ❑ ❑ CLAIMS -MADE a OCCUR ❑ 1 -660 -182M4921 -TIL -14 09/25/2014 09/2512015 PERSONAL & ADV INJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY 1:1 PRIECTO❑ LOC $ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ SCHEDULED AUTOS ❑ HIRED AUTOS COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ PROPERTY DAMAGE $ (Per accident) ❑ NON -OWNED AUTOS $ ❑ $ ❑ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ _ AGGREGATE $ ❑ EXCESS LIAR ❑ CLAIMS -MADE ❑ DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATIONw9RY ElLAM S ❑ ETM AND EMPLOYERS' LIABILITY VIM OFFICERIMEM ER EXCLUDED? ECUTIVE N NIA N E.l. EACH ACCIDENT $ (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is requw) Electrical work -Services Electrical Contractor: EC 13005157 CERTIFICATE HOLDER CANCELLATION ©1988-2009 ACORD CORPORATION. All rights reserves. ACORD 25 (2009109) OF The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES VILLAGE BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 AVE MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserves. ACORD 25 (2009109) OF The ACORD name and logo are registered marks of ACORD