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ELC-15-1883 Cv Z � Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-242597 Permit Number: ELC-7-15-1883 Scheduled Inspection Date: September 02, 2015 Permit Type: Electrical - Commercial Inspector: Devaney, Michael Inspection Typ-e�+� qhf Owner: Work Classification: Additionxt�ra�id�i Job Address:9823 NE 4 Avenue Miami Shores, FL Phone Number Parcel Number 1132060170330 Project: RETAIL Contractor: HICKEY ELECTRIC INCORPORATED Phone: (407)259-2640 Building Department Comments CHANGING LIGHT FIXTURES REPLACING 4 LIGHTS Infractio Passed Comments INSPECTOR COMMENTS False r Z Inspector Comments Passed �✓ Iz/ L�j LX � Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. September 01,2015 For Inspections please call: (305)762-4949 Page 33 of 47 �`'H° S yMiami Shores Village �'t�f7wtType E#BCtrical u.Cc tnirllelrcia# 10050 N.E.2nd Avenue NE ,:� tfVl7ttf Cf83sYfiCrifJ 'AddWoWAftel`atlQt7 :_.. Miami Shores,FL 33138 0000 'exri tlttts � oV�?'. Phone: (305)795-2204 „ k \ Due, Expiration: 02/02/2016 Project Address Parcel Number Applicant 9823 NE 4 Avenue 1132060170330 ” _. .__.•."" ` MIAMI SHORES COMM CHURCh Miami Shores, FL Block: Lot: Owner Information Address Phone Cell L!M!1AMISHORES COMM CHURCH INC 9823 NE 4 AVE MIAMI FL 33138-2402 Contractor(s) Phone Cell Phone Valuation: $ 1,000.00 HICKEY ELECTRIC INCORPORATED (407)259-2640 _ Total Sq Feet: 00 Type of Work:CHANGING LIGHT FIXTURES REPLACING 4 Available Inspections: Additional Info: Inspection Type: Classification:Commercial Final Scanning:3 Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical Underground W.W. Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee Invoice# ELC-7-15-56487 $2.25 DCA Fee $2.25 07/27/2015 Credit Card $50.00 $ 109.10 Education Surcharge $0.20 08/06/2015 Check#:56585 $ 109.10 $0.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $159.10 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 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. —� August 06, 2015 Authori a ure:Owner / Applicant / Contractor / Agent Date Building Department Copy August 06, 2015 1 PT Miami Shores Village JUL 2`7 2015 Building Department BY: 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 ao iy BUILDING Master Permit No. GC-5-16 -015 PERMIT APPLICATION Sub Permit No.Ze-lC/S~ �XT3 F]BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION ❑RENEWAL ❑PLUMBING (J MECHANICAL ❑PUBLIC WORKS (] CHANGE OF ❑CANCELLATION ❑SHOP r� / CONTRACTOR DRAWINGS JOBADDRESS• R AV im , t�-m( �ySyke's �L City: Miami Shores County;_ Miami Dade Zip � �� Folio/Parcel#:_ 3,2:Q60 170330? Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: SFE: FFE: OWNER:Name(FeeSimpleTitleholder): VK(621&I � - ,I�yV► a�phoneJl:_ b�,(.?S �5 ;�� � Address E City: ( State: L _ zip: Tenant/Lessee Name: / Phone#: Email: �`- CONTRACTOR:Company Name:_ Hicke Electric, Inc. .Y Phone#: 4{ 07) 259-2640 Address: 1319 Green Forest Court, Suite 412 city: Winter Garden State: FL Zip: 34787 Qualifier Name:_ Robert F. Hickey Jr. Phone#• State Certification or Registration#: EC 13001379 Certificate of Competency#: DESIGNER:Architect/Engineer: QCvJrµS Phone#: R5`f-4 Address: 1011 cr�recd �%-V t� 3a Gty: I�eM�praV-t��State' �.. Zip: ^, Value of Work for this Permit:$ 1 .00U Square/Linear Footage of Work: Type of Work: ❑ Addition ® Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: L Pi e5 ( Specify color of color thru tile: Submittal fee$ Permit Fee$_ls Oe CO CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ _� 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 falth 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 certifled 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 reinspectlon fee will be charged. Signature �/, ,�, �j ""�G� ,s " t� � gnature y OWNER or AGENT CONTRACTOR The`foregoing instrument was acknowledged before me this The f'o`regoing instrument was acknowie d before me this 1 3 day of 1�1 20 1S'— ,by 7! day of . 20 /5 by. N, who Is personally known to iC who is personally known to me or who has produced_ (. n Z :^as me or who has produced L ,Q)n as Identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: Print: Seal: A.,%k RNELYNARTOLA Seal: •, "„ MAIRANOVOA Notary Public-State of Florida MY oom� missWEFeb.7,2018 �:t=My Comm.Expires Fab 19,2016 sssssssssss sssssssrssrsssrs*sass si�1�`sw11�• Commission#EE �deeYAr�fi���xfiafiR�ary�bsssn ssssssssss APPROVED BY 2944 V/,f-Plans Examiner Zoning Structural Review Clerk STATE OF FLORIDA - � DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 HICKEY, ROBERT FRANCIS JR HICKEY ELECTRIC INCORPORATED 2137 BLACKJACK OAK STREET OCOEE FL 34761 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 barbegue 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 EC13001379 ISSUED: 07/20/2014 serve you better. For information about our services,please log onto www.myfloridalicense.com. There you can find more information CERTIFIED ELECTRICAL CONTRACTOR about our divisions and the regulations that impact you,subscribe HICKEY,ROBERT FRANCIS JR to department newsletters and learn more about the Department's initiatives. HICKEY ELECTRIC INCORPORATED Our mission at the Department is:License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, i5 CERTIFIED under the provisions of Ch.489 FS. and congratulations on your new license! ,Exp,tatien date:AUG 31.2016 L1407200002235 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD EC9300137H ���, �< The ELECTRICAL CONTRACTOR Named below IS CERTIFIED r Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 HICKEY, ROBERT FRANCIS JR HICKEY ELECTRIC INCORPORATED 2137 BLACKJACK OAK STREET OCOEE FL 34761 a-, ISSUED: 07120/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1407200002235 ............... CITY OF WINTER GARDEN 300 WEST PLANT STREET man WINTER GARDEN, FL 34787 W I R I I R P: 407,656.4111 G9 R D I R VOM.WINTERGARDEN-FL.Gov WINTER GARDEN A charming little city with a juicy post. LOCAL BUSINESS TAX RECEIPT FOR CITY OF WINTER GARDEN Business Name: HICKEY ELECTRIC INC Location: 1319 GREEN FOREST CT S 412 Receipt No: 16-00006319 Class: ELECTRICAL CONTRACTOR Tax/Add'ti Tax: $86.00 $ Issue Date: August 14,2014 Late Penalty: $0.00 Expires: September 30,2015 Total Paid: $0.00 Restrictions: Comments: ELECTRICAL CONTRACTOR HICKEY ELECTRIC INC 1319 GREEN FOREST CT S 412 WINTER GARDEN FL 34787 BUSINESS TAX RECEIPT MUST BE POSTED IN CONSPICUOUS PLACE AT ALL TIMES. ............................................................................... * PLEASE NOTE THE TOP PORTION IS YOUR 2015 LOCAL BUSINESS TAX RECEIPT AND IS PAID THRU SEPTEMBER 30, 2015' 1. Business Tax Year is from October I through September 30.Tax fees are prorated after April I for a half-year fee. 2.All new commercial business tax must be inspected by the Fire Department to meet all applicable state and city code requirements.You will be contacted to make arrangements for your inspection. 3.An Orange County Business Tax must be paid AFTER YOU HAVE BEEN ISSUED THE WINTER GARDEN BUSINESS TAX RECEIPT.They are located at 201 S Rosalind Ave,2nd FL,Orlando, (407)836-6650. DATE(MM/DD/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE 7/27/2015 IIII 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(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 CONTACT Linda Whiting g Lassiter-Ware Insurance, Inc. PHONE (800)845-8437 FAX C No: t888)883-8680 1317 Citizens Blvd. E-MAIL ADDRESS: LindaW@lassiter-ware.com Leesburg, FL 34748 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Ohio Casualty Ins. Company 24074 INSURED INSURER B:Ohio Security Insurance Company 24082 Hickey Electric, Inc. INSURER C:Bridgefield Casualty 10335 1319 Green Forest Ct INSURER D: Suite 412 INSURER E: Winter Garden, FL 34787 INSURER F: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM DD MM DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED 300,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE FXI OCCUR BKO1654565912 2/8/2015 2/8/2016 MED EXP(Any one person) $ 15,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 11000,000 X ANY AUTOBODILY INJURY(Per person) $ ALL OWNED SCHEDULED BAS1654565912 2/8/2015 2/8/2016 B AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident PIP-Basic $ 10,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 11000,000 A EXCESS LIAB CLAIMS-MADEAGGREGATE $ 1,000,000 US01654565912 2/8/2015 2/8/2016 DED I X RETENTION$0 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITYY/N X TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? r---1 /A (Mandatory in NH) 019619430 2/8/2015 2/8/2016 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) EC13001379 Project:Miami Shores Community Church Changing Light Fixtures CERTIFICATE HOLDER CANCELLATION Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 N.E. 2nd Ave. ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 (305) 756-8972 AUTHORIZED REPRESENTATIVE I Linda Whiting/LINDWH ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD