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EL-13-130(Y' I Icd , Miami Shores Village 19a� r i u C , Building Department 112T / y 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fag: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 t�L, B LIING PERMIT APPLICATION Permit Type: Electrical JOB ADDRESS: 5 c/ 5 NCI f& A .S j— FBC 20 /0 Permit No. Master Permit No. City: Miami Shores County: Miami Dade Zip: 33)'39 Folio/Parcel#: Is the Building Historically Designated: Yes OWNER: Name (Fee Simple Titleholder):, Address: P E '7 k .o^ NO Flood Zone: City: /Vi 1.4m t S H®State: F— - Zip: 33 d 3 ff TenanVLessee Name: Phone#: Email: u Sv2 a CONTRACTOR: Company Name: r7 S+ -+z- Phone# 51S- iS 1 Address: I / 2, Y City: 4Jc;: 1'1-,. ;�V`ca'4-)l State Qualifier Name: S 6 #1k(&Ad Phone#: 30._ - 8 9% Z SI)0 State Certification or Registration #: 4' z0ay Certificate of Competency #: Contact Phone#: _'bS7 - J 25 -jSS Email Address: DESIGNER: Architect/Engineer: Value of Work for this Permit: $ LIZ • cu Square/Linear Footage of Work. 1D Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: v'i" Submittal Fee Scanning Fee $ Permit Fee $_/00 / '01**9 CCF $ CO/CC $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 u r or Agent The foregoin nstrume was acknowledged before me this day of , 20 l3 by JAY�07 Ya wh_ o is personally known to me of-wh ,4--,,-4 c ide tifcation and who did take an oath. NOTARY PUBLIC: Print: My C LORRAINE LA ROSA My Signature Contractor The foregoing instrument was acknowledged before me this. Z of 20 �, by s� rsonallv brown to m r w enfifi aftm and who did take an oath. ..vicar ruenc . State of FIWWa - - Mr Comm. Expires Aup 10, 2014 abn FREE 4.19 I Plans Examiner y `Structural Review (Revised 3/12J2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) NOTARY PUBLIC: Print: ,e.. a ��;r My C `"`�''••• LORRAINE LA ROSA . wry Pubk - State of Fbft Mfr Comm. b0ea Avg 10, 2014 Comndeebn # EE Ism zoning Clerk AC # 6 2 5 3 0 9 1 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD SEQ# L12080702778 08/07/201211280155.47 1EF20000707 Additional Business Qualification The ALARM SYSTEM CONTRACTOR I Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 RENTERIA, STEPHEN 50 STATE SECURITY SERVICE INC 915 NE 125TH ST, SUITE 200 NORTH MIAMI FL 33161 RICK SCOTT KEN LAWSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW i MIAMI-DADE COUNTY ' 2012 LOCAL BUSINESS TAX RECEIPT 2013 FIRST-CLASS TAX COLLECTOR MIAMI-DADE COUNTY - STATE OF FLORIDA U.S. POSTAGE 140 W. FLAGLER ST. EXPIRES SEPT. 30, 2013 PAID 1st FLOOR MUST BE DISPLAYED AT PLACE OF BUSINESS MIAMI, FL MIAMI, FL 33130 PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 PERMIT NO. 231 620372-3 RENEWAL BU%VSS NA / LO ATI N RECEIPT No. 634053-3 5U STA SCU�ITY SERVICE INC STATE# EF20000707 915 NE 125 ST 200 33161 NORTH MIAMI OWNER 50 STATE SECURITY SERVICE INC SeC.T eofBusiness WORKER/S 1466 SPEC ELECTRICAL CONTRACTOR 5 THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY OR ZONINGG LAWSLAOFR THE DO NOT FORWARD COUNTY OR CITIES, NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. THIS IS 50 STATE SECURITY SERVICE INC NOT A CERTTHE OLDER'ISICATQ AILOIFICA- STEPHEN RENTERIA PRES '. TIONS. 915 NE 125 ST 200 PAYMENT RECEIVED NORTH MIAMI FL 33161 MIAMI-DADE COUNTY TAX COLLECTOR: 09/20/2012 60070000217 000045.00 �3S1�SIt13Sti�i��k3friitkFil4�Si}}iliS�S�i:iti�iiiiS�ii93 � I SEE OTHER SIDE ---NON% 5000ST1 OP ID: KD ACOIssL�eDATE `�. CERTIFICATE OF LIABILITY INSURANCE (MWDDNWY) 10/17/12 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 OELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED '31RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 954-883-2900 Tanenbaum Harbor of FloridaPHONE 2900 SW 149th Avenue 954-517-7400 Miramar, FL 33027-6605 Alina Larraz, CPCU, AAI, CRIS ACT CONNAME: FAX Arc No Ext : A/c No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA:Brldgefield Employers Ins. Co. 10701 10/15/13 INSURED 50 State Security Service, Inc INSURERS: Philadelphia Indemnity Ins.Co. 18058 915 N.E. 125th Street, Ste 200 North Miami, FL 33161 INSURER C: Gemini Insurance Co. 10833 INSURER D : U.S. Fire Insurance Company 21113 INSURER E: GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC INSURER F: Emp Ben. $ 1,000,000 CAVFROGFS CFRTIFICeTF NI IMRFR! 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. ?NSR LTR TYPE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Miami Shores POLICY NUMBER MMADDLSUBRO/uDD EFF MNOI/uDU EXP LIMITS C GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR a _1.0:;'b LSG000126002 10/15/12 10/15/13 EACH OCCURRENCE $ 1,000,000 GE DAMA PREMISESS (RENTED 100,000 Ea occurrence $ MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 5,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 5,000,00 Emp Ben. $ 1,000,000 ( B 1UTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PHPK921077 09/16/12 09/16/13 Ea aBINEDtSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per ac ldent D X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE 5821009209 10/15/12 10/15/13 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,00 DED I X I RETENTION $ $ A WORKERS COMPENSATIONX AND EMPLOYERS'LIABILITY N ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICER/MEMBER EXCLUDED? El (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 083039048 04/01/12 04/01/13 WC STATU- OTH- TORY LIMITS E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more space Is required) CERTIFICATE HOLDER CANCELLATION CITY138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Miami Shores THE ACCORDANCE EXPIRATIONDATEE WILL BE DELIVERED IN HE POLICY PROVISIONS. 10050 NE 2nd Avenue Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVES a _1.0:;'b © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD CANCt ��