EL-15-1402 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-237907 Permit Number: EL-6-15-1402
Scheduled Inspection Date: June 30, 2015 Permit Type: Electrical - Residential
Inspector: Devaney, Michael Inspection Type: Final
Owner: SUPREME, GERARD Work Classification: Alteration
Job Address:535 NW 112 Street
Miami Shores, FL 33168-3317 Phone Number
Parcel Number 1121360210900
Project: <NONE>
Contractor: JERUSALEM ELECTRICAL INC Phone: (305)206-5564
Building Department Comments
AC LINE POWER Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed
Failed
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
June 29, 2015 For Inspections please call: (305)762-4949 Page 35 of 39
y
Miami Shores Village 1> "N"TX
10050 N.E.2nd Avenue NW
0*00%
Miami Shores,FL 33138-0000 `
Y-hyo, Phone: (305)795-2204
#t eta
FNTEm,H
COR'lDp' �
` R6111/2615 Expiration: 12/08/2015
Project Address Parcel Number Applicant
535 NI
12 Street 11213so21osoo
GERARD SUPREME
Miamores, FL 33168-3317 Block: Lot:
Owner Information Address Phone Cell
GERARD SUPREME 535 NW 112 Street
MIAMI SHORES FL 33168-3317
Contractor(s) Phone Cell Phone FVauation:� $ 750.00
JERUSALEM ELECTRICAL INC (305)206-5564al Sq Feet: 0
Type of Work:AC LINE POWER Available Inspections:
Additional Info:
Inspection Type:
Classification:Residential
Review Electrical
Scanning: 1
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60 Invoice# EL-6-15-55907
DBPR Fee $2.00 06/09/2015 Cash $50.00 $58.60
DCA Fee $2.00
Education Surcharge $0.20 06/11/2015 Cash $58.60 $0.00
Permit Fee-Additions/Alterations $100.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $108.60
In consideration of the issuance to methis rmit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity ith t 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 that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhermore, I authorize the above-named contractor to do the work stated.
June 11, 2015
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
June 11, 2015 1
Miami Shores Village
Building Department JUN 09 2 15
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
BUILDING Master Permit No.Nc:, -1,5--IoZ-f5-/
PERMIT APPLICATION Sub Permit No. ��- y bZ
❑BUILDING 2ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
hCONTRACTOR DRAWINGS
JOB ADDRESS: I tl (,U //a S
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type:
Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder):�t eY CK s S d`'0 F'12 Phone#71A -411 =1150
Address: rJ' 3- N cij ja -S f /
City:P"1d4wi S60 &es State: L�}-/dydq Zip'U1Kj 9
Tenant/Lessee Name: Phone#:
Email: r/ `
CONTRACTOR:Company Name: J6 ZU�rBl-In /LGfK/C ,, Phone#: lam/j t7 66
Address: 5 o hV ' Y9..e,c_y
City:JJ d P--,4 M I Rt7 i / State: �"� Zip: 3 3 16 eZ
Qualifier Name: � rL(tJ'l � � Phone#: OJ) oct SS .
State Certification or Registration#: 0> 4b� Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
-.riJ
Value of Work for this Permit:$ 7J D - Square/Linear Footage of Work:
Type of Work: ❑ Addition [5 Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: 1i e / r/
Specify color
of color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning 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$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.
Signature (j ,� _ Signature '
OWNER or AGENT /ONTR�
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of �i�twC.Q 205 by day of ���— 20 by
whois personally known to/ US �� who is personally known to
me or who has produced 0eq �lJ /` ' as me or who has produced t�)01 as
identification d wh id tak an oath. identification and who did take an oath.
NOTARY P B NOTARY PUBLIC:
Sign Sign:
Print: Print: rn
Seal: ! ,; Seal:
� c �i � c2,• �•
4414 W
APPROVED BY ! -���� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
of _ STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
' ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1395
1940 NORTH MONROE STREET
COD W'E
TALLAHASSEE FL 32399-0783
DUBE, HUBERT
JERUSALEM ELECTRICAL, INC.
530 NE 178TH STREET
MIAMI FL 33162
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 STATE OF FLORIDA
from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND
and they keep Florida's economy strong. PROFESSIONAL REGULATION
__..
Every day we work to improve the way we do business in order to ER13014498 ISSUED: 06/08/2014
serve you better. For information about our services, please log onto
www.myfloridalicense.com. There you can find more information REG ELECTRICAL CONTRACTOR
about our divisions and the regulations that impact you, subscribe DUBE, HUBERT
to department newsletters and learn more about the Department's JERUSALEM ELECTRICAL, INC.
initiatives. (INDIVIDUAL MUST MEET ALL LOCAL
Our mission at the Department is: License Efficiently, Regulate Fairly. LICENSING REQUIREMENTS PRIOR
We constantly strive to serve you better so that you can serve your TO CONTRACTING IN ANY AREA)
customers. Thank you for doing business in Florida, HAS REGISTERED under the provisions of Ch.489 FS.
and congratulations on your new license!
Expiration date : AUG 31,2016 L1406080001815
DETACH HERE
RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD
ER13014498
The ELECTRICAL CONTRACTOR
Named below HAS REGISTERED -
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2016 '
(INDIVIDUAL MUST MEET ALL LOCAL LICENSING
REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) ❑ ❑
DUBE, HUBERT
JERUSALEM ELECTRICAL, INC.
530 NE 178TH STREET �• F;
MIAMI FL 33162
?'vcDt nv AQ RF(11 IIRFn RY I AW SEQ# L1406080001815
Jun, 9, 2015 3: 37PM No. 1494 P. 1
DATE CERTIFICATE OF LIABILITY INSURANCE 06/09/
_E 1I/Dp/YYYY)
`�• 06!08!15
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(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 thlc certificate does not confer rights to the
certificate holder In lieu of such endorsement(s), _
PRODUCERNAC NAME: -
Annette Willis Insurance PH E: -
18401 N.W.27 Ave E-MAIL riot,
ADDRESS:
Mlaml,FL 33056 PAODUCE-k " -
PUSIPMER ID N: _
Phone (305)625.2403 Fax (305)625.6472 INSURER(S) AFFORDING COVERAGE Nmo N
INSURED INSURERA: NATIONWIDE INSURANCE COMPANY
Jerusalem Electrical,Inc. INSURER B: DEPOSITERS INSURANCE COMPANY
530 NE 178th Street INSURERC:
Mlaml,FL 33162- INSURER 0:
FIL:"
SURER E;
_ SURER F r
COVERAGES CERTIFICATE_NUMBER, 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,
INSp
LTR TYPE OF INSURANCE ADD SUB •POLICY NUMBER MMlDD/YYYY• ( DD/TYYY LIMBS -
OENERAL LIABILITY EACH OCCURRENCE S_ 1,000,000
COMMERCIAL GENERAL LIABILITY DAMAGE-10 RENTED $ 100,000
❑ G. 1 CLAIMS-MADE U OCCUR . ).. -
ACP-59441350525 MED EXP Any ane person) $_ 5,000
A (J — Y 08/18/2014 09/18/2015 PERSONAL&ADV INJURY S 11000,000
❑ -•-- GENERAL AGGREGATE $ 2,000,000
GEN L AGGREGATE LIMITAPPLIF$PER PRODUCTS•COMP/OP AGG $ 2,000,000
❑ POLICY ❑ PRO- ❑ LOC
_ S
AUTOMOBILE LIABILITY COMOINED SINOLE LIMIT $ 300,000
ANY AUTO IEa accident)
❑ ALL OWNED AUTOS BODILY INJURY(Per Derson) S
ACP-5945497520 —
9
SCHEDULED AUTOS Y 08/18/2014 08118/2015 BODILY INJURY IPer socident $
❑
HIRED AUTOS PROPERTY DAMAGE
(Per eccldenl) $ �
❑ NON-OWNED AUTOS ... $ -• -•—�
❑ _. $
❑ UMBRELLA LIAR 1 1 OCCUR EACH OCCURRENCE $
EXCESS UAB ❑ CLAIMS-MADE
AGGREGATE $
❑ DEDUCTIBLE $ -
WORKERS COMPENSATIONSTATU- DTH• $AND EMPLOYERS'LIABILITY 8 ❑OT
ANY PROPRIETOR/PARTNER/EXECUTII/EY/N E.L.EJ�CHACCIDEN7 $
OFFICER/MEMBER EXCLUDED? NIA
If n descrIn un E,.L.,DISEASE-EA EMPLOYE S
If YYds deaaibe under .
DESL`RIPTION OF OPERATIONS wow EL..DISEASE-POLICY LIMIT i
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Allech ACORD 107,Addllrm l Remarks Schedule,(rmore space is required)
LICENSE#ER13014498
CERTIFICATE HOLDER CANCELLATION - -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
MIAMI SHORES THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING DEPARTMENT
10050 NE 2 AVE AUTHORIZED REPRE$ENTAYNE
MIAMI SHORES,FL 33138'
X305-756-8972 _
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 26(2009/09)QF The ACORD name and logo are reglstered marks of ACORD
011628
Local Business Tax Receipt
Miami—Dade County, State of Florida
—THIS IS NOTA BILL — DO NOT PAY
6695143
BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
JERUSALEM ELECTRICAL INC RENEWAL SEPTEMBER 30, 2015
530 NE 178 ST 6968151 Must be displayed at place of business
NORTH MIAMI BEACH FL 33162 Pursuant to County Code
Chapter 8A Art.9&10
OWNER SEC.TYPE OF BUSINESS
JERUSALEM ELECTRICAL INC 196 ELECTRICAL CONTRACTOR PAYMENT RECEIVED
1 OE000455 BY TAX COLLECTOR
Worker(s) 1 $45.00 07/17/2014
ECHECK-14-139991
This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license,
permit,or a certification of the holder'squalifications,to do business. Holder must comply with any governmental
or nongovernmental regulatory laws and requirements which apply to the business.
The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8a-276.
For more information,visit www miamidade aov/taxcollector
PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE
IMPORTANT
STATE OF FLORIDA Pursuant to Chapter 440 05(14),F.S.,an officer of a-corporation
DEPARTMENT OF FINANCIAL SERVICES t who elects exemption from this chapter by fiimg a cenifflwale of
election under this section may not recover benefits or
DIVISION OF WORKERS'COMPENSATION F corliper'sation unni tis chapter
CONSTRUCTION INDUSTRY EXEMPTION 0
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L Pursuant to Chapter 440 05(12;,F S. I"ertif icates of election,
WORKERS'COMPENSATION LAW D be exempt apply only within the scope of the business or trade
EFFECTIVE DATE- EXPIRATION DATE: listed on*,no-r,,o',;ce of eenon to be exempt.
PERSON: OUSE 'rLeER� H Pursuant to Chapte,440,35(1,3�,F.S..Notices of election to be
FEIN: E exempt anu,certificates of election to be exemp! shall be
BUSINESS NAME AND ADDRESS: R subject to revocation=,,a!any time after the filing of the notice
JERUSALEM ELECTRICAL INC E 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 certlicato.The department shall revoke
530 NE 178 ST a certificate at any tirne for failure of the person named on the
N MIAMI BEACG FL 33162 certificate to meet the requirements of thiF section
SCOPES OF BUSINESS OR TRA
LICENSED ELECTRICAL
CONTRACTOR L
DFS-F2-Dk,VC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?i850413-1609
r
SNoRFs G,
l,,, ,,,,,� Miami shores Village -
�� �� Building Department
ORiDp 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 and has acknowledge that he or she will not use
day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project. In these circumstances,Miami Shores Village does not require verification of
workers' compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this_ day of �Un ,201'SL.
By e lry9 irJ S Wire_rn {, who is personally known to me or has produced
as id
N�. ODAr1SlORI S
�} M't�,��htiSt�PdT� a•i3i0
Notary, �. = FXF R _..I,,n 4.,2,;16
00� ;,5 F�;'+ Bonder,'fNu No!ary PuNi;,Underwri!ers 1
SEAL:
Jerusalem Electrical, Inc.
530 NE 178 ST
N Miami Beach, FL 33162
Lic#: ER13014498
Cell: 305-206-5564
Date:
4
State of flU 1-�
County of
Before me this day personally appeared!�e7Z who, being dully sworn, deposes and
says:
That he or she will be the only person working on the project located at, iV
Sworn or affir )and subscribed before me this day of .20�, by
r7D
Personally know /
Or Produced Identification //
Type of Identification Produced AO Z
Print, Type or mp Name of Notary
YNotary Public State of Florida
Joanna M Feliciano
My Commission FF 082753
Expires 01/12/2018