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EL-14-1130 1 � Ott J Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-223830 Permit Number: EL-6-14-1130 Inspection Date: December 05,2014 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: BOURNE, ROBERT Work Classification: Alteration Job Address:490 NE 101 Street Miami Shores, FL 33138-2449 Phone Number Parcel Number 1132060170430 Project: <NONE> Contractor: AMENGUAL ELECTRIC INC Building Department Comments FIXTURE CHANGE OUT REPLACE IN ADDITION TO Infractio Passed Comments RELOCATION OF SOME EXISTING INSPECTOR COMMENTS True � Inspector Comments EaPassed CREATED AS REINSPECTION FOR INSP-223772. Failed El Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. For Inspections please call: (305)762-4949 December 08,2014 Pagel of 1 Miami Shores Village ��CEI�TED Building Department JUN 9 2 2014 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: Tel:(305)795.2204 Fax:(305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 FBC 201® L/ BUILDING Permit No.E-1 / / " /✓30 PERMIT APPLICATION Master Permit No.V c l3 r Permit Type: Electrical JOB ADDRESS: /4q® NS l o l 5tea City: Miami Shores County: Miami Dade Zip: 13 3 Folio/Parcel#: 11- 3 210(0 ©1-1 QUO Is the Building Historically Designated:Yes NO x Flood Zone: IV OWNER:Name(Fee`Simple Titleholder): Ovfo� Phone#: -"1bA 0 1 65-TIO Address: A 9® is 6 r t 1�`A®1 5t/� i City: U'•l l a It Yl 4 c) OA State: f L_ Zip: Tenant/Ussee Name: Phone#: Email: CONTRACTOR:Company Name: l�Ul Address: ';185 ) M� 1 V��n ��` City: 9"6-VY) lam.l State: 1" Zip: 53 ) 2& j� Qualifier Name: Phone#: J�� '® �c J(0 f State Certification or Registration#: 0000 13 Certificate of Competency#: Contact Phone#: Email Address: CA a YY1 C'M W Z 9ed o DESIGNER:Architect/Engineer: Phone#: �e Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑Address Aklteration ❑New ❑Repair/Replace ❑Demolition Description of Work: �x��x��+xxx��x��x�xx�xxxx�Feesxa�•��+�x��x�x�� Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ �S Bong Company's Name(if applicable) , tel Bing 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 issued. the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature IVSignature,+- . Owner or Agent K Contras or The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this da of Gryl 20 b r °` .g C[ y .L1, y l i.l�� N � � � � day of 20,�by , who is personally known to me or who has produced who is personally known to me or who has produced As iden' a' as identification and who did take an oath. NOTARY P IC: 4 NN Notary PWIc Stats 01 Florida NOTARY PUBLI � CAsC Leon ' < µ1y Cammis� W 10Wj �p*"0&104 016 Sign: Sign. • e , Print: N T '� Pant WmW M03 W ::�v My Commission Expires: My Commission-Expires: APPROVED BY AA-WE Plans Examiner Zoning Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) r � 3 G 1 i.r., �' �. � "�� Yz� f �� s�R„'a' � hr�'��,�w�c'z{ �•�ft r�s�, x �' ,x �Y- ` � a f 4 f-{ $4 y 5�►ORF,y. O... Miami Shores Village Building Department �OR10050 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. f: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.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company. Therefore,you may be uersonallv liable for the worker compensation injuries of any person allowed to work under this permit Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. weer Contractor Print Name: Print Name: Signature: Signature: State of Florida) State of Florida) County of Miami-Dade) County of Mi - Z't Acpl Sworn to wbscribed before meqs Sworn to and e ��Vday of _,20 . da of y v 6&MW0N#FF11W45 By J f ByA EXPIRES May 4,2018 (SEAL) 1� avbT stn of ° (SEAL) Type of Identific o isms 1 t�S3 Type of Identification produced �w s oeroanols AC# 6206161 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD SEW L12071701672 ' - LICENSE NBR 07/17L2012 128011539 BR0004025 The ELECTRICAL CONTRACTOR Named below HAS REGISTERED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 (INDIVIDUAL MUST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) AMENGUAL, BERNARD 3388551G ELECT THWESTI12TH TERRACE MIAMI FL 33129 s :1 n s na nm z0 � = Ql: 3 �0, v rn �z J zi v r w N Ma S 3 �• �� z -IO co C) r W N T B 3, ® �W C7 ,g m L4 F;K I m o- ' m n nD Vi CD O ;1e�S � ��C z n = s g: = n cf en CL 2 0 0 C '" al o m _ n D in CD y m� 3am n0 90 ss• oO z W 0 a M O 0 3 Z Mm -ice � � � �� S� �nnm A � {O m m mn m ff �C �g O e z2 mN s.9 Co rt, m VM m <TCD -+omi O Qn ' 3 FnO al Om O C7 �Zy r _ m 56 T sCD O f& _O• a a o Cl y r Z ■ to m s o �► z � 0 � � m � m :rm a m 3 a M % cova �D mm 'aSRt cr I I S 9�., � g DoID �D a � oN -D T m3m W Mx 0 00 _> cv a � N g D3 > o o LD 15 mfm7 m? o Wm -cu) m w Om o9m m N � Wim \° F'" kr tw 3 m 01 v •� iw'm R3 S m .. � �� CTO - �� - COrsduclim Tram aUWs"Bowra - -- ;BUSINESS CERTIFICATE OF COMPETENCY "E"o 000013861 ,Mott*ftp MENGUAL ELECTRIC INC BA.: 79 . E� CERTIFICATE OF LIABILITY INSURANCE DATE(5123/1YYYY) 05/23/14 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(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 this certificate does not confer rights to the certificate holder In lieu of such endomement(s). PRODUCER CONTAE:CT GREfELL GONZALEZ NAM Use General Insurance PHONE , (305)386-3305 ac No): (888)330-1123 5841 S.W.137th Ave. ADDRESS, GREfELL@USAGENERALINSURANCE.COM Miami,FL 33183 INSURERS AFFORDING COVERAGE MAIC t Phone (305)386-3305 Fax (888)330-1123 INSURER A: INTERNATIONAL INSURANCE CO OF HANNOVER LTD INSURED INSURER 8: PROGRESSIVE INSURANCE COMPANY BERNARD AMENGUAL/JOSE ROUSSEAU DBA AMIENGUAL ELECTRIC IN INSURER C: 3851 NW 12 TERR INSURER D: Miami,FL 33126 (954)410-6364 INSURER E: 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 ADD UBR POLICY EFF POLICY EXP LIMITS LTR 1 WM POLICY NUMBER MM/DD M/DD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 Q COMMERCIAL GENERAL LIABILITY PREMISESTO EarOrence $ 100,000.00 ❑ ❑ CLAIMS-MADE Q OCCUR 1 G06C002214-00 MED EXP(Any one person $ 5,000.00 A ❑ N N 12/18/2013 12/18/2014 PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000.00 6 POUCY ❑ JECT PRO- ❑ LOC $ AUTOMOBILE LIABILITY COMBIN�D SINGLE LIMIT Ee ecci ent ❑ ANY AUTO BODILY INJURY(Per person) $ 10,000.00 B ❑ ALL OWNED ❑ SS��ULED 023669790 08/23/2013 08!23/2014 BODILY INJURY(Per accident) $ 2,000,00 HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ 10,000.00 ❑ ❑ AUTOS Per accident ❑ ❑ $ ❑ UMBRELLA UAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS UAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑TORY WNL 1:1 OR AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ Ii yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) GENERAL CONTRACTOR/ELECTRICAL CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF MIAMI SHORES THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2 ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES FL 33138 AUTHORIZED REPRESENTATIVE FAX 305-756-8972 @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)QF The ACORD name and logo are registered marks of ACORD