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EL-15-2472 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-244993 Permit Number: EL-9-15-2472 Scheduled Inspection Date: October 06, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: FAYS, SORAYA Work Classification: Alteration Job Address: 1296 NE 99 Street Miami Shores, FL Phone Number Parcel Number 1132050090140 Project: <NONE> Contractor: POTTS ELECTRIC, LLC Phone: (850)528-2978 Building Department Comments Remove branch circuits in 2 bedrooms, living rooms and Infractio Passed Comments dining area that currently have aluminum wire ub emt. INSPECTOR COMMENTS False replace it with#14 and#14 THHN.Also installing smoke detectors and AFF breakers on circuit worked on. Inspector Comments Passed Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. For Inspections please call: (305)762-4949 i October 05,2015 Page 39 of 39 SNORES Miami Shores Village f ' �� Cat \ _ 10050 N.E.2nd Avenue NE ? a - tin •• Miami Shores,FL 33138-0000 � a h 3 '48wra Phone: (305)795-2204 � � 3 3� ���� R ; k Expiration: 03/28/2016 Project Address Parcel Number/ Applicant 1296 NE 99 Street 1132050090140 Miami Shores, FL Block: Lot: SORAYA FAYS Owner Information Address Phone Cell SORAYA FAYS 1296 NE 99 Street (816)456-3507 MIAMI SHORES FL 33138- 1296 NE 99 Street MIAMI SHORES FL 33138- Contractor(s) 3138- Contractor s Phone Cell Phone ( ) $ 3,000.00 Valuation: POTTS ELECTRIC, LLC (850)528-2978 Total Sq Feet: 400 _., Type of Work: Remove branch circuits in 2 bedroom Available Inspections: Additional Info: Inspection Type: Classification:Residential Review Electrical Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.80 Invoice# EL-9-15-57239 DBPR Fee $2.25 DCA Fee $2.25 09/30/2015 Credit Card $ 118.30 $50.00 Education Surcharge $0.80 09/29/2015 Credit Card $50.00 $0.00 Permit Fee-Additions/Alterations $150.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $168.30 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. Futh more, I authorize the above-named contractor to do the work stated. September 30, 2015 Authoriz d Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy September 30,2015 1 Miami Shores Village Building Department SAT4 2015 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 5r-- FBC 20 lel BUILDING Master Permit No. �i I t--- ) ���� PERMIT APPLICATION Sub Permit No. ❑BUILDING ECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL F-1 PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP , �j CONTRACTOR DRAWINGS JOB ADDRESS: 1 -2, 'j Vn - / " City: Miami Shores County: Miami Dade Zip: x l Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): f"LC`y P—y S Phone#: W6 4 5 6— 3 5707 Address: F 2 !f6 /Q � 0 City: State: Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: C_-C" Lt. Phone Address: � >O v 6cc e, City: U'V a D l°l-5 State: R_ Zip: 3 Qualifier Name: MLC4/tce- Phone#: State Certification or Registration#: CSG ` © a t,GL �� Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: /+ City: State: Zip: Value of Work for this Permit:$ / J Square/Linear Footage of Work: ! Lo % Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: ke4noVe— h 20'v(L-6K G�`fru'1 11�� 7- b '�rdeA-,,s m� f'cryj*ik.S ��y`�v`� C�!`C'�• � �vJ�•�i��'�V �Q- G tu,,�,y1JI� i�,. a n-�T. 1'����G�1.r ( i^ L1/ 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) r 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 OC Signature -4ri Vk� OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 t� by 4),Y day of 20 f ,by 15Q,2 �J a RN-F+nA who Is personally known to /( �T S ,who is personally known to me or who has produced me or who has produced F194L— as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: k P Seal: go Py, Notary Public State of Florida Seal: �o�►'"�,'�, Notary Public State of Florida 4^ Sindia Alvarez `,/ Joanna M Feliciano < My Commission FF 156750 ,p< My Commission FF 082753 Of F� Expires 09/03/20180,fid" Expires 01/12/2018 ###### # ################################################################################################## APPROVED BY / �S�j'lS�Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA t- DEPARELECT,RICAL.CENT OF I ESS AND PROFESSIONAL TCATION RACTORS CENS NG REGULATION } � OFtt(; L CGNTRAETOR . RT15 EQ e;t�rt/��s�pyrom i[o� [sg h �der 489 FS 1L1�i+1�1u~� ,,,.✓V'^�f`FJ�./" �...�'C7 �'�•MM \ j �✓ ���� �f�Ay— � ..rte"" �� .`.s'. _�r.+.r...,,, +., ' t�4� t •,� 1 fin' .r"',',y a✓ ....a^"""^ �.,r." IIwGs; .� ,.r,y�, 3'�•'� 4'>. rk '%.. °� ', 1 ,*. �°. \ %,.' €" - rt�..`..•f"'""` ,. ,.,,'\ ", _ t �'''+�µ� 4 i P + w ISSUED: 09/03/2015 DISPLAYAS REQUIRED BY LAW SEQ# L1509030000578 t COLLIER COUNTY BUSINESS TAX BUSINESS TAX NUMBER: 150801 - _ E COLLIER COUNTY TAX COLLECTOR-2800 N.HORSESHOE DRIVE-NAPLES FLORIDA 3410"39)252-2477 E VISIT OUR WEBSITE AT:www.colliertax.com THIS RECEIPT EXPIRES SEPTEMBER 30, 2016 - "' DISPLAY AT PLACE OF BUSINESS FOR PUBLIC INSPECTION 1 LOCATION:300 SABAL PALM RD FAILURE TO DO SO IS CONTRARY TO LOCAL LAWS. l -LEG AL FORM , ZONED: HOME OCCUPATION-E LLC - THIS TAX IS NON-REFUNDABLE - i BUSINESS PHONE: 850-528-2978 .. STATE LIC: EC13006926 POTT ELECTRIC LLC POTTS,MICHAEL 300 SABAL PALM RD _ - NAPLES FL 34114-0000 NUMBER OF EMPLOYEES: 1-10 EMPLOYEES CLASSIFICATION:ELECTRICAL CONTRACTOR DATE 09/24/2015 CLASSIFICATION CODE: 05100601 T AMOUNT 18.00 I This document is a business tax only.This is not certification that licensee is qualified. RECEIPT 3783.40 I It does not permit the licensee to violate any existing regulatory zoning laws of the state,county or cities nor does it exempt the licensee from any other taxes or permits that may be required by law: ,t- _. m DATEYAC RoCERTIFICATE OF LIABILITY INSURANCE 0912212016 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 poftcy(1e3)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 endorsements. PRODUCER CONTACT Academy Insurance Agency Inc. William Mahler NAME: 7330 CORTEZ RD PHONE 941-758-4600 Fax o.941-761-9232 BRADENTON FL 34210 .w.rnahler@academyins.net INSURERS AFFORDING COVERAGE NAIC 0 INSURERA:Covington Specialty Insurance Co. INSURED Potts Diving,LLC 8r Potts Electric,LLC INSURER B: 300 Sabal Palm Rd INSURERC: Naples FL 34114 INSURER D: INSURER E. ENSURER 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 iNSURANC EUOR POLICY EFF POLICY EXP LTR POLICYNUMBER MWOD(YYM (MM1ODnTYY1 LIMITS ✓ COMMERCIAL GENERAL LIABILITYLi EACHOCCURRENCE $ 1,000,000_ A CLAIMS-MADE OCCUR VBA336170 09130/2014 09/3012015 PRENtI E Eaocourre Un $100,000 MED EXP one person $6,000 PERSONAL&ADV INJURY $ 1,000,000 GERL AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE s2,000,000 ✓ POLICY EI JERCT El LOC PRODUCTS-COMP/OPAGG $1,000,000 OTHER: S AUTOMOBILE LIABILITYLi Li fEs Pycident) COMBINED SI RULELIMIT S ANY AUTO BODILY INJURY(Perperson) $ ALL AUTOS AUTOS AUTOS EO BODILY INJURY(Per accident) $ HIREDAUII AUTOS�ED PR PERTY E S S (Per accident) UMBRELLA LIAO OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS•MADE AGGREGATE S DEO I I RETENTION I'lS WORKERS COMPENSATIONT E E AND EMPLOYERS'LIABILITY Y 1 N Li ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMSER EXCLUDED? N J A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ Ify ss doscribe undo DESGtRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S H1H ET DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more apace Is required) Boat maintenance,repair and cleaning Electrical Contractor-Lic.#ER13013199 CERTIFICATE HOLDER CANCELLATION Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 Northeast 2nd Ave THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores,FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE William Mahler 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Web sorts are.vrmv.Forrn*E1*ss.com;?Impressive Publishing 890.208.1977 M' F1 100% M . .s JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 6/22/2015 EXPIRATION DATE: 6/21/2017 PERSON: POTTS MICHAEL FEIN: 900597036 BUSINESS NAME AND ADDRESS: POTTS ELECTRIC LLC 300 SABAL PALM RD NAPLES FL 34114 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chaplar 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or 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 certificate.The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 Potts Electric LLC 300 Sabal Palm Rd. Naples FL 34114 (850) 528-2978 Phone (866) 419-4319 Fax To whom it may concern, Potts Electric LLC will be commencing electrical work on property address 1296 NE 99th St Miami Shores, FL 33138 for property owner Soraya Fays, Michael Potts the owner of Potts Electric and license holder will beerformin the work on this ' p 9 property for the property owner Michael Potts ,4Pyy pUB, THOMAS J. DISSELHORST Notary Public-State of Florida .• My Comm.Expires Feb 21.2016 f f Commission#EE 171838 %` `�' Bonded Through National Notary Assn. log• .....� Miami shores Village e Building Department �lORiDA 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 2-cl day of01 - By N)A r� i cs �[, S who is personally known to me or has produced as identification. Notary: SEAL: ;Oxy °oayNotary Aubhc State of[1nrd2 Sindia Alvarez oQ My Commission FF 15675 mor a Expires 09.'03!26 g