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EL-15-1265Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 nspection Number: INSP-235631 Permit Number: EL -5-15-1265 Inspection Date: June 01, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: KELLY, JANET Work Classification: Alteration Job Address: 112 NE 110 Street Miami Shores, FL 33161-7046 Phone Number Parcel Number 1121360040410 Project: <NONE> Contractor: DJ ELECTRICAL SERVICES OF S FLORIDA Buildinn Donartmont Cnmmpnts RE -OPEN PERMIT IN ORDER TO CLOSET IT. TO REPLACE PERMIT EL 08-1158 UNDERGROUND Infractio Passed Comments INSPECTOR COMMENTS False SERVICE AND FEEDER Passed ED Inspector Comments Failed El Correction Needed l Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. For Inspections please call: (305)762-4949 May 29, 2015 Page 1 of 1 Miami Shores Village rfi 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Parcel Number Applicant 112 NE 110 Street 1121360040410 JANET KELLY Miami Shores, FL 33161-7046 Block: Lot: Owner Information Address Phone Cell JANET KELLY 112 NE 110 ST MIAMI SHORES FL 33161-7046 Contractor(s) Phone Cell Phone DJ ELECTRICAL SERVICES OF S FLC of Work: RE -OPEN PERMIT IN ORDER TO CLOSET I ional Info: kation: Residential nine: 1 Fees Due Amount CCF $0.60 DBPR Fee $2.25 DCA Fee $2.25 Education Surcharge $0.20 Permit Fee - Additions/Alterations $150.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $159.10 Valuation: $ 500.00 Total Sq Feet: 0 Pav Date Pav Tvoe Amt Paid Amt Due Invoice # EL -5-15-55723 05/28/2015 Check #: 7137 $ 159.10 $ 0.00 Available Inspections: Inspection Type: Final Review Electrical In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify th9A all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construetie�ning. Fut)1err, I authorize the above-named contractor to do the work stated. May 28, 2015 AWonzea Signal _ ner cant / Contractor / Agent Date Building Department Copy May 28, 2015 1 BUILDING 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 FBC 20 t k Master Permit No.f L 1`T--1•� PERMIT APPLICATION Sub Permit No. ❑BUILDING �ECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION E?ENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: _ 1/z Mf I l Q' th SL z 2 City: Miami Shores / County L q Miami Dade zip: 331 Folio/Parcel#:_f ' zi � -QQ 4 - 94 IQ/ L� W IO is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Phone#: `M5 .75"/ • c Address: Samr as ahm- City: State Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Address: City: rlyr Qualifier Name: u ,(rll q54 44.111 I RL Zip: _3532 dt' State Certification or Registration #: Ca Q Q 9 Certificate of Competency M 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: it=2 8 r-7(�,ez— Specify color of color thru tile:. Submittal Fee Scanning Fee $ Permit Fee $ CCF Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ (ReAsed02/24/2014) DBPR $ CO/CC $ 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 Zi 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. Si ature OWNER or AGENT The foregoing instrument was acknowledged before me this day of 20 V5 by who is personally known to me or who has produced Pnve—m as identification and who did take an oath. NOTARY PUBLIC: Sign: Print4A6�0211 Seal: APPROVED BY (Revised02/24/2014) Signature CONTRACTOR The foregoing instrument was acknowledged before me this �.) day of UA 20 15 by who' personally kno n to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: A Print: W ----•-••- w..,....... Seal: COMMISM 0 FF=W ►�. WM AM 1, 2018 ►���`'� WWWAAMONARY.001A L Plans Examiner Structural Review COWAWM ;i FRIM 0 WM' A 1, 2018 WWW Zoning Clerk 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 CONT CTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. � COPY OF LOCAL BUSINESS TAX RECEIPT C. PY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE 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 form and Contractor 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: �J L �('4jq e d JfVVI LYS OF SO .til T Lb6H& BUSINESS ADDRESS: low4QGjY1 C( 10q CITI( STATE_ZIP X� BUSINESS PHONE:65-4-)A3q 3111 FAX NUMBER (u 1 M7 Z. 511 CELLPHONE( QUALIFIER'S NAME:L��Se—FlymaS QUALIFIER'S LIC NUMBER: Fro O)no 2 A0 NAM 4.40, ROAD, 04 COOPER a they keep HoMars -+sc:' r ztl q: a Every d8Y We Work to inVrove ft way we do In order to f.a etE:: � : • q,r B t V71777 -A 11 till F-Tt!-. M I q'e its -s t r:.e at /z t RICK SCOTT, GOVERNOR KEN LAWSON. SECRETARY a 9, IOU,, \� � � � � \ \� q \\�. / 2 og o A� op CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD/YYYY) 10512712015 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 pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns 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 C & CInsurance 1921 NW 150 Ave. Ste. 101 Pembroke Pines FL 33028 CONTACT PHONEX1.2008 FAX(AIC N, r9 )4 704 Q507 ADDRESS, info0carldeinsurance.com PRODUCERCUSTOMER 13 #- 8019 INsu S AFFORDING COVERAGE NAIC # INSURED DJ Electrical Serivices of South Florida Inc dba IBC Construction 4301 South Flamingo Road, Stuite 106-210 Davie, Florida 33330 INSURERA: Scottsdale INSURER 8: United States Liability Policy INSURER C: INSURER 0: INSURER E: INSURER F Vv V GIVi\7r-0 GCK I II-IGA 1100 NUMMI-R, . 17FVICIf1N NI IMQCD. 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. MLTR SR I TYPE OF INSURANCE DL BR POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $1000000 A X COMMERCIAL GENERAL LIABILITY X X GPS1859944 06/16/2014 06/1612015 DAMAGE TO RENTED occtirrenaW $100000 CLAIMS -MADE XX OCCUR X Blanket Additional Insured MED EXP oneperson) $ 5000 PERSONAL & ADV INJURY $1000000 GENERAL AGGREGATE $2000000 PRODUCTS - COMP/OP AGG $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY AFrTPRO LOC $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE (Per accident) $ HIRED AUTOS $ NON -OWNED AUTOS $ UMBRELLA LIAROCCUR HCLAIMS-MADE EACH OCCURRENCE $ 2000000 B X EXCESS uae XL1560912 07/16/2014 07/16/2015 AGGREGATE s 2000000 DEDUCTIBLE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE[—YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under NIA WC STATU-OTH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L DISEASE - POLICY LIMIT $ D SCRIPTION OF OPERATI NS below -71 1 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) Blanket waiver of subrogation with written contract, Blanket primary/non contributoryAll Coverage is for Florida operations only MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O ACORD CORPORATION. All dahta rasarvad ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE 5/2015 Producer: Plymouth Insurance Agency 2739 U.S. Highway 19 N. This Certificate is Issued as a matter of Information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend Holiday, FL 34691 or alter the coverage afforded by the policies below. Insurers Affording Coverage NAIL # (727) 938-5562 insured: South East Personnel Leasing, Inc. & Subsidiaries Insurer A: Lion Insurance Company 11075 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer B: Insurer c: Insurer D: Insurer E: Coverages The policies of insurance listed below have been Issued to the Insured named above for the policy period indicatedNotwithstanding any requirement, tens 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. Aggregate limits shown may have been reduced by paid claims. INSR LTR DL INSRD Type of Insurance Policy Number Policy � Effective Policy p e� Expiration Limits (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence Commercial General Liability Claims Made Occur Damage to rented premises (EA occurrence) Med Exp Personal Adv Injury General aggregate limit applies per: General Aggregate Policy ❑Project 1:1 LOC Products - CompfOp Agg AUTOMOBILE LIABILITY Combined Single Limit Any Auto (EA Ardent) Bodily Injury All Owned Autos Scheduled Autos (Per Person) Bodily Injury Hired Autos Non -Owned Autos (Per Accident) Property Damage (Per Accident) EXCESS/UMBRELLA LIABILITY Each Occurrence Occur ❑ Claims Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2015 01/01/2016 X WC Statu OTH- Employers' Liability to Limits ER E.L. Each Accident $1,000,000 Any proprietor/partner/executive officer/member excluded? NO If Yes, describe under special provisions below. E.L. Disease - Ea Employee $1,000,000 E.L. Disease - Policy Limits $1,000,000 Other Lion Insurance Company is A.M. Best Company rated A- (Excellent). AMB # 12616 Descriptions of Operations/LocationsNehicles/Exclusions added by Endomement/Special Provisions: Client ID: 24-65-305 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following "Client Company": D7 Electrical Services of South Florida, Inc. dba IBC Construction & dba McClure Electric Coverage only applies to injuries incurred by South East personnel Leasing, Inc. & Subsidiaries active employee(s), while working in: FL. Coverage does not apply t0 statutory employee(s) or independent contractors) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562. Project Name. ISSUE 05-27-15 (TD) Beffln Date 12/25/2011 CERTIFICATE HOLDER CANCELLATION VILLAGE OF MIAMI SHORES BUILDING DEPARTMENT Should any of the above described policies be cancelled before the expiration date thereof, the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named to the left, but failure to do so shall impose no obligation or liability of any Idnd upon the insurer, Its agents or representatives. 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 L