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EL-14-1842Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-234616 Permit Number: EL -8-14-1842 Scheduled Inspection Date: May 14, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: WILLIAM J. JURBERG, R. ANDREW DE Work Classification: Alarm oeee Job Address: 9350 NE 12 Avenue Miami Shores, FL 33138- Phone Number (305)609-3851 Parcel Number 1132050070150 Project: <NONE> Contractor: RELATED SYSTEMS INC Building Department Comments ALARM Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed lz� Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. May 13, 2015 For Inspections please call: (305)762-4949 Page 30 of 30 Miami Shores Village BuildingDepartment "VIr p 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 AUG 22 2014 Tel: (305) 795-2204 Fax: (305) 756-8972 BY_ INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION ❑BUILDING PELECTRIC ❑ ROOFING FBC 20;0 Master Permit No. , / 2!Z_ ZZ Sub Permit No. ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING [:]MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION [:] SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9350 NE 12th Avenue City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3205-007-0150 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE: OWNER: Name (Fee Simple Titleholder): R Andrew dePass Phone#: 305 502 6289 Address: 9350 NE 12th Avenue City: Miami Shores State: Florida Zip: 33138 Tenant/Lessee Name: Phone#: Email:randrewdepass@mac.com CONTRACTOR: Company Name: i� ��� rV� Phone#3V��&�--)766 Address: 7/57-- "Oi2eU, LA/iloc City: H;+ A % L'a kF..!S State: L_ < Zip: � I Qualifier Name: _ _ l'x\; j4(—*b c /a-y.L. A �)A Phone#: -30 State Certification or Registration #: 0&ot000/001 rtificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: 9 ®� Value of work for this Permit: $ �� �5� ware/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ ,- Dermit Fee $ Z& Oo PP CCF $ CO/CC $ SaMning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $. Bond $ TOTAL FEE NOW DUE,, (Revised02/24/2014) 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 $2504 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 %' Signature s OWNER or AGENT The foregoing instrument was acknowledged before a this A day of Q4& 2( /J/ , by QT6'1) who is personally known to me or who has produced Identification and who did take an oath. NOTARY PUBLIC: Sign: Print:Y. VILLARAN tQ .��►AJ Seal:* * W Cl INISSION # EE 050636 "OVA p EXPIRES: January 20, 2015 '�O B�dThruB�tNof�gSdvloea CONTRACTOR The fo^ ming instrument was acknowledged before a this day of 20 by who is personally known to as me or who has produced Identification and who did take an oath. NOTARY PUBLIC: Sign • I® Print: i �.L rig�ot9 �••t• o* W COMMISSION # EE 050538 EXPIRES: January 20, 2015 Y. vaijuva Seal: �"�� �o��O Babed'iiru Buda NataiY S�Ces as ssssssssssssssssssssssssesssssssssssssssasssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssss � ®fN APPROVED BY az GC&r Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) OWNER SEC. TYPE OF BUSINESS- RELATED SYSTEMS INC 196 SPEC ELECTRICAL CONTRACTOR � AX COLLECE oR Worker(s) 1 EG00M104 $45.00 09J27/2013 CREDITCARD-13-011507 Thi Local Business Tax Receipt only confirms�qme of the Loral Business Tax. Tho Receipt Is not a license, parmit or a certification of the holders gaalificetiarm =of do business. Holder must comply with any governmental or Paggoparomen al regulatory laws and requirements wbich apply,to the business. The RECEI TWO. above must be displayed an all commercial vehicles=fNiAits 4)--- s Curie sec oe-276. Farmers fnformatioe;visitwwwmiamidadeatau - w AC# 631192. . DFP: STATE OF FLORIDA:: SEW L12082803117 Expirati.on ADAMS,y. RELATE; AUG. 31,; 2 014 e �3 MS ING 7152 LAUREL LANE ZgW LAKES FL: 33014-2664. RI:CK.SCOTT KEN LAWSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW _ _ ACORO� CERTIFICATE OF LIABILITY INSURANCE D/21/ l2001Y 14 8/21/4 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 endomement(s). PRODUCER Premier Agents Group NAME: cT Tracy Brahm PHONE(AfjC- No -4350 F (964)382-2810 900 S. Pine Island Road #300 -MAIL INSU S AFFORDING COVERAGE MAIC 8 Plantation FL 33324 INSURERA:Western Heritage Insurance Co 37150 INSURED WSURER B Related Systems Inc INSURER C: 7152 Laurel Lane INSURER 0: INSURER E: INSURER F: Miami Lakes FL 33014 COVERAGES CERTIFICATE NUMBER_CL1312610534 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. INSR LTR TYPE OF INSURANCE ADDLSUBR AUTHORIZED REPRESENTATIVE POLICY NUMBER POLICY EFF D POLICY EXP M/D LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR SCP0953661 1/9/2013 11/9/2014 PREMDAMAGETO ES Ea NTED $ 100,000 MED EXP Any one $ 1,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acdderd BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Par acddant $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- TORY LIMITS AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A F -L EACH ACCIDENT $ E.L. DISEASE - EA EMPLO $ (Mandatory in NH) DESdescribe under CRIPTION OF OPERATIONS below F DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) Burglar Alarm Contractor State License Number EG0000104 CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010105) mQn-jr. n, ©1988-2010 ACORD CORPORATION. All rights reserved. TI-.. A^^Mn ---- -4 1--- -- -1-4-1 w.w-4.. -9 A^r%22 % SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village Bldg Dept ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores, FL 33138 /f Tracy Brahm/TLK ACORD 25 (2010105) mQn-jr. n, ©1988-2010 ACORD CORPORATION. All rights reserved. TI-.. A^^Mn ---- -4 1--- -- -1-4-1 w.w-4.. -9 A^r%22 % * * 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: 8/19/2014 EXPIRATION DATE: 8/18/2016 PERSON: ADAMS RONALD C FEIN: 800315949 BUSINESS NAME AND ADDRESS: RELATED SYSTEMS INC 7152 LAUREL LANE MIAMI LAKES FL 33014 SCOPES OF BUSINESS OR TRADE: BURGLAR AND FIRE 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 shalt 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 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 iniuries 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 /� �n Print Name: Signature: State of Florida ) County of Miami -Dade ) Sworn to and subscribed before me s J.,7 _ rk— dayof_QQ1,W.Lt_—, 20 YNIUARAN B * * MY COMMISSION#EE050636 By : January20, 2015 (SEAL Type of Identification produced I Contractor County of Miami -Dade ) Sworn t and �subs*bebeforeday of, 20 a of Identification this "P;L r. P4B Y. VMARAN �'.••,�tc* WCOMMISSIONHEOW EXPIRES: January 20 2015 �n