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EL-14-2635Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-230364 Permit Number: EL -12-14-2635 Scheduled Inspection Date: March 25, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: MCHALE, EDWARD Work Classification: Addition/Alteration Job Address: Miami Shores, FL 33138-0000 Phone Number Parcel Number 1132060143640 Project: <NONE> Contractor: A & M ELECTRICAL, INC Phone: (561)251-2831 comments REPLACE WATER DAMAGED WIRING. INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-228476. CREATED AS REINSPECTION FOR INSP-224409. Need a smoke detector at the bottom of the staerway. 16 mar. 2915 Failed ❑ Smoke detectors on 2nd floor are not inter connected. The one at the top of the stairs didn't work at all. The detector at the bottom of the stairs is a battery one not hard wired. Correction Needed ❑/�-- Re -Inspection ❑ �' �� Fee No Additional Inspections can be scheduled until re -inspection fee is paid. March 24, 2015 For Inspections please call: (305)762-4949 Page 14 of 28 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) 762-4949 BUILDING PERMIT APPLICATION ❑BUILDING ❑■ ELECTRIC ❑ ROOFING °F�BC 20 � � Master Permit No. k220 V\A - 2— Sub Permit No. r q` ❑ REVISION ❑ EXTENSION ❑RENEWAL F-1 PLUMBING [:]MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9500 NE 12 Avenue City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3206-014-3640 Is the Building Historically Designated: Yes NO X Occupancy Type: Resid Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Edward McHale Phone#: 305-758-9823 Address: 9500 NE 12th Aenue City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: A & M Electrical, Inc. Phone#: 561-251-2831 Address: P.O. Box 1815 City: Pompano Beach State: FL Zip: 33061 Qualifier Name: Rafal Simonowsky Phone#: 561-251-2831 State Certification or Registration #: EC13005466 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 300.00 Square/Linear Footage of Work: _ /Do S Q Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: Replace water damaged wiring Specify color of color thru tile: Submittal Fee $ fPermit Fee $ /' 4-0 < U' CCF $ CO/CC $ Scanning Fee $ Technology Fee $ Structural Reviews $ (Revised02/24/2014) Radon Fee $ Training/Education Fee $ DBPR $ Notary $ Double Fee $ Bond $ 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 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 TO OBTAI//I YOUR NOl Notice to promise i whose pr for the fi Sign UR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND 'FINAN�IN NSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING CE OFC MENC ENT." ;fai 4je, ition to the issu ce of a building permit with an estimated value exceeding $2500, the applicant must opy of the notice commencement and construction lien law brochure will be delivered to the person is s ta t. Also, a tled copy of the recorded notice of commencement must be posted at the job site 2ectid,`Jich_,oec`u&4even (7) days after the building permit is issued. In the absence of such posted notice, the e appftled and a reitspection f f e will be charged. OWNER or AGENT The foregoing instrument was acknowledged before me this day of 1 y W}Q � 20 1 k , by C oc"Cd itv ck-tod"'— ,who is personally known to me r who has produced Signature CONTRACTOR The foregoing instrument was acknowledged before me this W • r day of k1 , 20, by who is personally known to as me or who has produced identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: as Sign: Sign. Print ® -�,M� ink;, Mary pole - $tab tR flakla Seal: �° •'' '• ° MY COMMMION t FF 061724 Y 0�• ft Z. 9017 * * EXPIRES: February 21, 2018 rr 1b�r�01Bwwft 9wge1 Notary Services �kNuB+kkkRil*N*R Mi �k � M� �k�k�k�k**�kk�R*bk*N*+kkiMW+9+kN+&&�k�#�k�kM�kM�B�ki�kk&�k&&�E�kU*�b*IeAe&9�+B�kK�B+kNk�bF+k&N�k4**�kffi+B*W APPROVED BY �, fit ! J'it� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) fr ,}' µ� fin. M } , �lW9�b + 6 "• Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: BUSINESS ADDRESS: CITY , li 4Ue ATE ZIP BUSINESS PHONE: ( ' 1 1 FAX NUMBER —7 - 5 f00 CELL PHONE O QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: —.s.— 1544tpCp 10 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORSLICENSINGBOARD 1940 NORTH MONROE SR TALLAHASSEE FL 32399-0783 SIMONOWSKY, RAFAL A& M ELECTRICAL. INC. P.O. BOX 1815 POMPANO BEACH FL 33061 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.myftorldalicense.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 stove 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 (850) 487-1395 44 .ate STATE OF FLORIDA DEPARTMENT PROFESSIONAL REGULAqF TION AND EC13005466 ISSUED: -08/31/2014 CERTIFIED ELECTRICAL CONTRACTOR SIMONOWSKY, RAFAL A& M ELECTRICAL, INC. IS CERTIFIED under the provisions of Ch.489 FS. ExphMw date : AUG 37, 201e 040831(XIM 8 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTELLECTRICAL CONTRACTORS T OF BUSESS AND PROFESSIONAL TION BOARD EC13005+466 The ELECTRIUAL UUN I "to I %Jr< Named below IS CERTIFIED Under, the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 SIMONOWSKY, RAFAL A& M ELECTRICAL, INC. P0Box 1815 - POMPANO BEACH FL 33061 icgi wn• nwm/917114 DISPLAY AS REQUIRED BY LAW SEQ # L1408310006808 • BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2014 THROUGH SEPTEMBER 30,201S DBA: Receipt #:ELECTRIaL/ALARMS/CoNTRAcT6R Business Name: A & M ELECTRICAL INC Business T pe: Y (ELECTRICAL CONTRACTOR) Owner Name: RAFAL SINONOwsKy Business Location: 180 SW 6 CT POMPANO BEACH Business Phone: 561-251-2831 Business Opened:01/05/2007 State/County/Cert/Reg:EC13 0 0 54 6 6 Exemption Code: Rooms seats Employees Machines Professionals 2 For Vending Business Only Numhar of Machines: Vendina TV= Tax Amount j Transfer Fee NSF Fee • Penalty Prior Years Collection Cost I TotalPaid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: A & M ELECTRICAL INC P O BOX 1815 POMPANO BEACH, FL 33061 2014 -2015 Receipt #30A-13-00012694 Paid 09/12/2014 27.00 Paychex, Inc. RF 11/19/2014 9:19:01 AM PAGE 3/003 Fax Server V CERTIFICATE OF LIABILITY INSURANCE 11/19/2014 ``"' 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 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 ce'tfficate does not confer rights to the certificate holder In lieu Of such endorsement(s). PRODUCER CONTACT Paychex Insurance Agency Inc PAYCHEX INSURANCE AGENCY, INC. 150 SAWGRASS DRIVE E • 877-266-6850 F X NO). 585-389-7426 E-MAILEN6 Certs@paychex.com ROCHESTER, NY 14620 INSURERS) AFFORDING COVERAGE MAIC# INSURED INSURER A: NorGUARD Insurance Company 31470 INSURER 8: A 8t M ELECTRICAL INC 180 SW 6TH COURT INSURER C: POMPANO BEACH, FL 33060 INSURER D: INSUR E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DL SR BR D POLICY NUMBER POLICY EFF (MWDD/YYYY) POLICY EXP (MAMIDDIYYYY) u(�S GENERAL LIABILITY EACHOCCURRENCE $ COMMERCIAL GENERAL LIABILITY =10LAIMSAMADEED:)CCUR DAMAGE TO RENTED $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERALAGGREGATE $ N1- AGGREGATE LIMIT APPLIES PER: POLICY O PROJECT=LOC PRODUCTS - COMP(OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED O SCHEDULED =AUT S nIED HIREDAUTOS AUTOS OS COMBINED SINGLE LIMIT (Ea accident) $ BODILY person) $ BODILY INJURY (Per acddenl) $ PROPERTY DAMAGE $ (Per acddent) UMBRELLA LIABOCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAR O CLAIMS,MADE $ DED RETENTION$ A WORKERS COMPENSATION AND EMPLOYERS LIABILITY AMWC572668 03!2512014 03/25/2015 X TO STAN• 0TH• E.L. EACH ACCIDENT $ 100,000.00 ANY PROPMETORIPARTNERIEXECUTNE OFF ICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ I00,000.00 E.L. DISEASE • POLICY LIMIT $ 500,000.00 (Mandatory In NN) N NIA d yee, describe under DESCRIPTION FOPERATIONS el DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Renmrks Schedule, H more space is required) LICENSE # EC13005468 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 10050 NORTH EAST DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY 2ND AVE PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALLIMPOSE NO OBUGA71ON OR MIAMI SHORES, FL 33138 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHO J ED (jEPRESENTATI ` I j AWKIJ ZO IZUlWUO) WIUWZYTU J4UVMU UUMrUKAl IUIN. All rlgmS reserve0. The ACORD name and logo are registered marks of ACORD 11/19/2014 8:31:17 AM 507-455-5200 Page 5 CERTIFICATE OF LIABILITY INSURANCE ��(�'' 11119=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 en s . PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 OWATONNA, MN 55060 PAFAX /CNR Exti: 888-333-4949 AIL me): SD7-446-4684 fin DRESS: CLIE TCON ACTCENTE DINS.0 M INSURER(S) AFFORDING COVERAGE RAIL # 05/11/2015 INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 CAMAGEB 6a ueaErrQnw $100,000 INSURED 272-529-9 INSURER B: INSURER C: A & M ELECTRICAL INC PO BOX 1815 POMPANO BEACH, FL 33061 INSURER D: INSURER E: INSURER F: MVCOAd%ca CERTIFICATE NUMBER: 31 KCV1C1IVN MUMOCK:Y 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. INBR LT TYPE OF INSURANCE L INSR SUER WVD Po NUMBER POLICY EFF M D POLICY EXP MMID LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR X BUSINESS OWNER'S LIABILITY N N 9863826 05/11/2014 05/11/2015 EACH OCCURRENCE $1,000,000 CAMAGEB 6a ueaErrQnw $100,000 MEDEXP(Any no perwh) PERSONAL & ADV INJURY $1,000,000 GENERALAGOREOATE $2,000,000 GEN'L X AGOREOATE UMIT APPLIES PER: POLICY JE� LOC PRODUCTS - COMPIOP ADO $2,000,000 AUTOMOBILE LIABILITYOMIN ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS EDE.SINGLE OMIT BODILY INJURY (Per person) BODILY INJURY (Por oxide!? ROPE AMAOE UMBRELLA UAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I ry ANY PROPRIETORIPARTNERIEXECUTNfi OFFICEWMEMBER EXCLUDED? (Mandatory in NMI It yes. describe undar DESCRIPTION OF OPERATIONS below N I A WC STATU• OTH- TORY LIMITSER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L DISEASE •POLICY OMIT DESCRIPTION OR OPERATION$ ( LOCATIONS I VEHICLES (Atlech ACORD 101, Additional Remarks Schodul% if more spew Is required! RE:LICENSE 9 EC13005466 CERTIFICATE HOLDER CANCELLATION 272-529-9 310 MIAMI SHORES VILLAGE BUILDING DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2ND AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES, FL 33138-2304 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0 1988-2("C ACORD CORPORATION. All rights reserved. ACORD 25 (2010!05) The ACORD name and logo are registered marks of ACORD