RC-14-2248 (2) Miami Shores Village
Building Department
artment
aC t 014
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 _N
Tel: (305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305)762.4949 113_—
FBC 20 LO
i BUILDING Permit No. K'Lx —[s3 -
PERMIT APPLICATION Master Permit No.
Permit Type: Electrical
JOB ADDRESS: yO NQS/
City: Miami Shores County: Miami Dade Zip: 3 3 l
Folio/Parcel#: �/�' 52.04-014— 3 3)0 /
Is the Building Historically Designated: Yes NO / Flood Zone:
OWNER:Name(Fee Simple Titleholder): /' I �/ L C Phone#: ,;�V�'_!?o ( O yS
Address: ( /
City: '?�T 0 �/� o_2/7 t�`e State. "A-M i )f Q C f S L Zip: 33/2 1'
Tenant/Lessee Namme: Phone#:
Email: 0 4A
CONTRACTOR: Company Name: deJ,2z Phone#: 30S'
Address: t u /03
City: State: k L Zip: -33 J
Qualifier Name: V f Phone#: 5 O— 341-5-1 q
State Certification or Registration#: GL 1300 19 70 Certificate of Competency#:
Contact Phone#: 3uS-"6 3u—ZLi / Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteratioon// ❑Nee�w WIG-pair/Replace ❑Demolition
Description of Work; `l e 7 .4 n F�S le C b?l C -P&1
Q C�4 �-,�e,ni 4 4 ex / 64 ,4 eK 'tom
,,L :De-�ec4eS
Submittal Fee$ Permit Fee$Z224,1 cel/ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$ 243, 16
i
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 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 iss --in-the- s�enc of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature -
O er or Agent Contractor
The foregoing instrument was acknowledged before
me this /� The foregoing instrLynent was acknowledged before me this-5—
day
hisday of�� ,20 M,byXr day of 20 A,by
—r•
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY BLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print:
4 � NFF084758
E& 21 201 D
MyI. My Commission d�( ice
RICARDOIRIARTE
MY COMMISSION#FF088736
(407)398-0153 Fioridah! rvice.com
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
S�ORFs
Miami shores Village
Building Department
ORiDp' 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. L/ COPY OF QUALIFIER'S STATE LICENCES
B. OPY OF LOCAL BUSINESS TAX RECEIPT
C. 2OPY 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: es'4 F/t&7 4 Pct S ...,/-/l C
BUSINESS ADDRESS: �°Z S .524--? 1d3 �CITY -STATE �L ZIP 33``S—
BUSINESS PHONE: ( 3d�) � 30 S FAX NUMBER ( )
CELL PHONE ( ) QUALIFIER'S NAME: /�—
QUALIFIER'S LIC NUMBER: Ec / 3 too /6 ?0
10/22/14 09:48AM Mesa Bros 3056302699 p. 01
RICK SCOTT, GOVERNOR
. .. .. . SI~ RETARY
STA`T'E QI~FLORIDA
i- DEPAR'TNIENT'OF BUSINESS'ANO PROFESSIONAL REGULATION
'ELECTftICA�C"NTMCTORS LICENSING BOARD
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ISSUED: 06/10/2014 DISPLAY A$ REQUIRED BY LAW SEQ4 L1406100001578
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ECEIPT bove i t �,: !d, +g?a
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For, k r ation ��+y "� ,' �¢ ,S•,r f,hj u,.; c
10/22/14 09: 48AM Mesa Bros 3056302699 p. 02
A4C4C>R" CERTIFICATE _OF LIABILITY INSURANCEOATk(MM001YYYY)
10/13/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPONTHE CERTIFICATE;HOLDER-THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPREBSe NTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an AbDITIONAL INSURED,the policy(les)must be endorsed. 11 SUBROGATION I$WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsomont. A statement on this certificate does not confer rights to the
certificate holder In lied of such endorsement(s),
NAME,: it3f)Sl�rri:'i)F)(i .Y.1.70B.i1
:4t OItr;ox'34, nSU!f,1n1:,3 SWU 1C�n5,.Ir1C. PHONE �; FAX
taxa.riox:344a �!;,.»fs�..o�,
(AIC,No,E>I) '-
7t:�;lue5{tT,FL 334G9 E-MAIL curls(��progrey-sivggmp+pyPr.gom
A!?�?fiarSS,
INSURERS)AFFORDING COVERAGE NAlC M
.........................._.__._....._....._.... -- ----- ... INsuxeR A:TochrotoyY Insurance Company.lno._............................................_:,......_4237f3
..........
ENSVREO
Progre65;ve Employer Management Co,Inc,and at its itiiiijil@s Arid Subsidiario r
For Co,OnlployAus of Mesa Brothers Inc INSURER C:
0407 Pyrkland C1r
S7ar:lSC{il,t=L 14343 INSURER 0
INSURER E:
tN3UR✓;,R F
COVERAGES CERTIFICATE NUMBER;6GxrS5Xv � REVISION NUMBER:
THICK IS TO CERTIFY THAT THE POLICIE$OF INSURANCE LIS I'I'0()J~L()W NfiVC-6FEnN ISSUEQ TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INOiCATEO. NOTWITHSTANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY f•C)NTRACI'QR QTH6:R 0()0UMI NT WITH 3tF:$PPUT•12)WHIQ'f THI:a
CERTIFICATE MAY BE ISSUED OR MAY Pl=.I't'rAIN,THE IN,^,,URANC13 ArFORDED aY 7hiE POIJCIES DESCRIBED HE'RE:IN IC SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF S0r,1H r�Ot,.l(:If�;.t-IMIT9$HOVJN MAY HAve p[EN REDUCED 6Y PAID CLAIMS.
Agtlf-:SUt1.R......... . . .
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TYPE OF fN4URANCE POLICY N4 MBt:q MM DD/YYYy M UO YY YY LIMITS
GENERAL LIASMITY
EACH OGCURYIENCE $
CUtAMG'RCIAI.GGNGRAL LIA£iil.Cr•/ DAMAGE TO RENTED
a.A1M5: u. r"PIMiSES;F.a ocevirtoros
MAf:' O!:•C::JR MFO FXfl-Any onI?Uargon; ,
F'QH ONAL 3 AOV INJUIJV
GENERAL AGGREGATE S
GGN'4.A(.;GIaE:GATB LIMIT APPLIES PER: PROMR7,TS,COMP!OP AGG 5
POLICY rT.. PRQ- LOC
AUTOMOSIL13 LIABILITY
ANY AUTO BO I .......
anWINED 7
...................... ..
ALL rMNED SCHEDULED OILY INJURY(Per person) S
AUTOS AUTOS RODIt-Y INJURY(Par zrridcnr) s
$ NON•OWNEO
HIRED AIJO �tiCjlsE yfY'ISAn9nC
AUTOS
IPu,rtcc¢ianq $
. . .__. . _._.._._..-__- ...r.�...,_.., ......,....,.,..........,..,........�....
VMBNF.66A LIAU CX CUR F.ACF Oi CkiRRENC6
a
EXCESS UAD CLAMS MADE AGC ECtATE' g
-DI=ED -RETENTIONS
A wof-efiscow wIciN TWQ3431,59',;��`� 09/15/2014 70i01/2045 x wf s"AT� 0.�4A.
AND EMPLOYERS'LIABILITY Y�N. 't.OfY t,IM.ITSGR ^TAT
ANY PR;jPRIETQRiPARTNFREXFCU7'!vF 1,000,000
OFFICGR/MRMBGR EXCLUDED? N/A E.L.EACH ACCIDENT 5
(Mandaloey to NH) r;L 0r„g.A54: G;A I,MPLOYFE $ 1.000,000
Ue:CfihE urt66r ...:...... .. .. .. .
DESCRIPTION OF OPERATIONS below F L.0IS13A$F•POLICY LIMIT $ 1,040,000
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DESCRIPTION Of OPERATIONS I LOCATIONS I VEHICLES iAUooh ACORD 10s,A01tionpl Romprks Schedvio,It mwe spn(:o IM 1'9r4oUoO)
COVOfai)(,is Oxlurldod to CL1•otnployoox!rut not sUUCorgraClrJrS of Mori)8rothot-Inc
License#EC1,1001070
CERTIFICATE HOLDER
CANCELLATION
SHOW-D ANY OF rHE:ABOVE DESCRIBED POLICIES LIE CANCELLED BEFORE
THE EXPIRATION DATSTHEREOF,NOTICE WILL OE DELIVERED IN
ACCORDANCE WIT14 tHE.POLICY PROVISIONS.
Mlarnl Shores V01tage AUTwbRlzLxa Rcaxcs!Nrarrve
10050 Northeast 2nd Avenue
mictnu,FL 3:3138 I'':�,•�!1' ji.y_:
P;Irk@ I UI I c40 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) The ACORD name and logo aro registered marks of ACORD
10/22/14 09: 48AM Mesa Bros 3056302699 p.03
MESAB-1 OP in: MY
CERTIFICATE OF LIABILITY INSURANCE x110110'1201 rr,
,__ _.... .,..... ,. ...�.. ._ _. _.,..... ,.., 10110/201 Q
rwS CERTIFICATE IS 15SUtiC3 A;i A AAAT7FR Of iNi'4RMATlON ONLY ANO CONFERS NO RIt3H1"$ UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AL,TCR THE COVERAGE- AFFORDED BY THE POLICII=S
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pokcy(ies> n'fust he et'1<fors(ic.1 If SUBROGATION IS WAIVED, SUbjer•.t to
the terms and conditions of the policy, certain policies may require an endorsolno t A stattnwr11 ori IMS rc,rtiflcatte (loos not Confer rights to the
certificate holder in lieu of such endorsements .
PNOuuC(4rt Phone; 305.364-7800 iiAMc�`"'
BROWN & BROWN OF FLORIDA INC r P
14900 NW 79th Court Suite#200 Fax:305.714-4401 IMHONE FAA C, ENo,eKtl. IA,C,Not
Miantl Lakes, FL 33016.5869 A-MAIt :
Ramon A Rodriguez
INSURER(S)AFFORDIN(I COYERAOF MAIC u
tNSWIFF1A FC:CIInsurance Company 10-178
t"skInet) Mesa Brothers Inc. INSURERa
5215 SW 1030 Avenue(Roar) 1N•y-IJ R1=R f;
Miami,FL,33165
IN,,UAC.k.�
INSURER E
COVERAGES _ CERTIFICATE NUMBER: REVISION NUMBER:
;'I-Q,; 1" T(1 CERTIFY YtlA1' '(HE POUCIE$ Ul, IN$URANCe 1,IS'rFp BF1.1,)W HAVE BEEN ISSUED Tp THE tNSIJREp NAMED AE30VE FOR YHE; Pl:)4iCY PERQD
INDICATED NOTWITHSTANDING ANY RF.QI_iREMENT, TERM OR, (,QNDITIC)N OF ANY (:CINTRACT OR UTHEi' pOCUMCNT VVITH I Ccf1C:CT TQ WHiC;j TI-{IS
(:EftTIr.ICATE MAY BE ISSUED OR YAY P`E'RTAIN, THE INSIjIjAro<jE; AFFORDgo 13't' THE POt.ICiln: HEFQEIN IS SU6JECT WO AL,L THE
EXCLUSIONS AND CONDITIONS OF SUCH PQLICIES LIMITS;SHOWN MAY HAVE 5F.EN RF..0t14:FD CY PAIL!(,L,AIM>
Ik1a TYPE OF I N$URANCLAD7l. SUeii POLICY EFr PULICYExP
GENe0l,LtA(•1lt.ITY JZ YA.._,—__ POLICY NUMBER `SdI��712!`.Y.YtJ.,.EMA91RRl)rKY.�.�------ (tMIrS ....�.__
- , ., •E,:te„.;tG':''i;�F.:v..r�.p
100,UUGl.44?A720'A X .�01
t;<,AtMy MAUI: X Ci(:CUIt Il F.q E:A-IAnf,,;ny por;onl S 5,00
P,'. 'KDNA.:.s A'W IW:IRY S 1,000.00
G;CWE IZaI.Ai;gkRGATF. ; 2,000,00
CIE-NIL AGGREGATE(AWT APPUF PER .Iz!d)t;`T5 CLOMP/QP Afj!j S 2,000,00
X ox
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AUTOMOBIL@LIABfL.11'Y .:(innfilNl?' .,t 1{;L LIMIT
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ANY Auto NVC.;1_<:`Ii4RY.;n61 pat90—
ALL OW NQG 'i CriL-:7Cq li i'
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UMpRF.CLA LIAi3 — OCCUR
BXG695LIAp CLAIMS,MADE AC<3REC,±ATF„ 5
Y- OED 8044,0 TION S
E
-WORKERSCOMPENSAVON �— Wc;TAT';.
ANO EMPLOYERS'LIABILITY Y N rue LI1AY'c: ER
ANYPRf;PRIET(}RlPARTNCR/EXECtlii,i: ;.A(;N.A'::! Nr c
:;Ft+>•+Il AN;rl.Y;va LIDF(3•+ N.A . ,.
(Mandatory in NN) '" ),3t SSE•cA EMPt,(1,:'!c 5
I!yae (loci nDa i�dnr l
OPr•WAtION',
Cl;ot)RIPTIUN OP OPERATIONS I LOCATiQNS,VCruCt e_S iAlWrI At`ORO 401.AddReonoi ItYrttrrl,\%% hvd,06.It-Ora 1paoD a{aqu!rddl
!s,ic;pt'tA6 no. EC130002E370
CERTIFICATE HOLDER _ _ CANCELLATION
SHDV1.0 ANY OF THE ABOVE aESCRISED POLICIES Be CANCELLED UEFORf:
Miami Shoras Villa a THE; EXPIRATION DATE THERt;OP, NOTICE WILL RR DELIVERED IN I
9
10050 NF. 2nd Ave ACCORDANCE WITH THE,POLICY PROVISIONS
Miami,FL 33138 Aul„nR'z(ns?kPkft`iCvtAIDE
0 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD