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EL-15-457 %52 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-243926 Permit Number: EL-3-15-457 Scheduled Inspection Date: September 23, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: LALANNE,VILBRUN Work Classification: Addition Job Address: 190 NE 91 Street Miami Shores, FL 33138- Phone Number Parcel Number 1131010190080 Project: <NONE> Contractor: MIZPAH ELECTRICAL INC Phone: 305-620-2701 Building Department Comments ELECTRICAL INSTALLATION TO NEW BEDROOM. 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. For Inspections please call: (305)762-4949 September 22, 2015 Page 27 of 35 Miami Shores Village aE Building Department10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2016 BUILDING Master Permit No. PERMIT APPLICATION sub Permit No. HS71 ❑BUILDING ig ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: f � /UG �/ lsg� City: Miami Shores County: Miami Dade Zip• Folio/Parcel#: /3t O (jo / ( D$3 a Is the Building Historically Designated:Yes NO Occupancy Type:f.0� Load: Construction Type: CV�� Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): V11, A Az-N Phone#:-SOS' 75 7<99 y� Address: / 9O !yG G11 s% City: M;am/ SLzd-N- L/i ilt-.!� State: Zip: 10 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Nam/e::-_f In're Pct h Phone#: 52Lak S/s 9 Addre/ss:/a /t91N5� i"�1� �J City:�L/-flG�-/ln/�++ -4�f� State: - Zip: Qualifier Name: fi)s TV0 D �Cr's e Phone#: 'J0�& 'o ff —z�1gJ State Certification or Registration#: Certificate of Competency#: /Y/A DESIGNER:Architect/Engineer: Phone#: Address: /Y d City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: gD r-,44 . Specify color of color tthru tile: Submittal Fee$S//V• Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 4evised02/24/2014) � S Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) A Mortgage Lender's Address City State Z 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 inspectio which o Urs ven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be a roved nd reinspection fee will be charged. Signature - SignatureA4rJ OWNER or AGENT CONTRACTOR The foregoing i strument was acknowledged before me this The foregoing instrument was acknowledged before me this 3 day of 1',- A(LC*( ,20 14 by 3 day of M&Q_ 14 20 IS by VICn+2*0 L.A6ANN& ,who is personally known to ALSfDN W b IAS who is personally known to me or who has produced tL b6\JM �� as me or who has produced WAVEV— ucrt--�as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: h Sign: Sign: Print: Print: Sindia Alvarez Seal: , My Commission FF 156750 Seal: of w Expires 09/03/2018 Notary Public State of Florida 5india Alvarez My Commission FF 168750 Expires 09/03/2018 APPROVED BY �� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) t STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1395 -%75.A�` 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 DIAS,ALSTON W MIZPAH ELECTRIC INC 512 POINSETTIA AVENUE LEHIGH ACRES FL 33972 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, 1 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 EC0002175 ISSUED: 08/24/2014 serve you better. For information about our services, please log onto www.myfloddalicense.com. There you can.find more information CERTIFIED ELECTRICAL CONTRACTOR about our divisions and the regulations that impact you,subscribe DIAS,ALSTON W to department newsletters and learn more about the Department's initiatives. MIZPAH ELECTRIC INC 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, IS CERTIFIED under the provisions of Ch.489 FS. and congratulations on your new license! Expiration date: AUG 31,2016 L1408240004452 DETACH HERE RICK SCOTT GOVERNOR - � —KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARDs� = ECOD02175 ; The ELECTRICAL CONTRACTOR `" Named below IS CERTIFIED Under the provisions of Chapter 489 FS. e40 , Expiration date: AUG 31, 2016 DIAS,ALSTON W 0 MIZPAH ELECTRIC INC 512 POINSETTIAAVENUE LEHIGH ACRES FL 33972 1.7 ,.BeCount' Lee County Tax Collector 2480 Thompson Street Tax Cot tor Fort Myers, Florida 33901 11" www.leetc.com Tel: 239.533.6000 OfeofFlo�laa Local Business Tax Account: 0611820 Dear Business Owner: Your 2014-2015 Lee County Local Business Tax Receipt is attached below. The receipt is non- regulatory and is issued using the information currently on file with our office. It does not signify compliance with zoning, health or other regulatory requirements nor is it an endorsement of work quality. Annual account renewal notices are mailed in August to the address of record at that time; to ensure delivery of your annual notice, mailing addresses may be updated online at www.leetc.com. If there is a change in the business name, ownership, physical location or if the business is being closed, please follow the instructions on the back of this letter to transfer or to close the account. I hope you have a successful year. Lee County Tax Collector Detach and display bottom portion and keep upper portion for your records ,-eeCoUgy LEE COUNTY LOCAL BUSINESS TAX RECEIPT 2014 - 2015 Tax Co for ACCOUNT NUMBER: 0611820 ACCOUNT EXPIRES SEPTEMBER 30, 2015 sfafe of F%O'. May engage in the business of: CERTIFIED ELECTRICAL CONTRACTOR Location 506 RICHMOND AVE LEHIGH ACRES FL 33972 THIS LOCAL BUSINESS TAX RECEIPT IS NON REGULATORY MIZPAH ELECTRIC INC DIAS ALSTON W THIS IS NOT A BILL-DO NOT PAY 506 RICHMOND AVE LEHIGH ACRES FL 33972 PAID 364817-11-1 10/06/14 10:16:19 KXW 1 $53.00 DATE(MM/DD/YY) ACRO CERTIFICATE OF LIABILITY INSURANCE 03/03/15 PRODUCER Annette Willis Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 18401 N.W.27 Ave HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Miami,FL 33056 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (305)625-2403 Fax (305)625-6472 INSURERS AFFORDING COVERAGE NAIC# INSURED MIZPAH ELECRIC INC INSURER A: Granada Insurance Company INSURER B: 512 POINSETTIA AVE INSURER C: LEHIGH ACRES„ FL 33972- INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rA ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS INSRD DATE MMIDDIYY DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE 1,000,000 ❑�/ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 50,000 0185fl00015912 10/18/14 10/18/15 PREMISES Ea occurence ❑❑ CLAIMS MADE OCCUR MED EXP(Any one person) 5,000 ❑ ❑ PERSONAL&ADV INJURY 1,000,000 ❑ GENERALAGGREGATE 2,000,000 PRODUCTS-COMP/OP AGG 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: ❑d POLICY ❑ PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS BODILY INJURY ❑ ❑ SCHEDULED AUTOS (Per person) ❑ HIRED AUTOS BODILY INJURY ❑ NON OWNED AUTOS (Per accident) ❑ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC ❑ AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE ❑ OCCUR ❑ CLAIMS MADE AGGREGATE El ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND ❑ WC STATU- ❑ TH- CRY LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ELECTRICIAN CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL MIAMI SHORES VILLAGE 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NE 2 AVE THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY MIAMI SHORES VILLAGE, FL 33138 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 26(2001/08)QF ©ACORD CORPORATION 1988 -Secu:iory 1: LU wenen[s unaer this chapter. APPLOCAN7 HHFORMATOON First PE Last k1ame: Alston W Dias Sr State Driver's License Number: State 00 Humbeir: State: FL D200019580420 Date of iBirffi: 2/2/1958 Socia9 Secul,*V Number(Bast four digits): 5509 Ernai0 Address: mizpahelectric@gmaii.com @gmail.com Section 2: CONSTRUCTOON INDUSTRY APPLICANT($58 FEE REQUIRED) Officer of a Corporation (Construction) Corporate Tittle: PRESIDENT Section 3: This section should be completed with information specific to your corporation or to the limited liability company in which you are a member. The name of the corporation or limited liability company listed on this application MUST match the name of the corporation or limited liability company as registered with the Florida Division of Corporations. Name of Corporation or LLC: Mizpah Electric Inc. IF YOU NEED TO APPLY FOR A FEIN,CLICK HERE FEIN: 65-0485336 Business Name (DBA): Mizpah Electric Inc. Applicant's Address of Record: 512 Poinsettia Avenue Phone: (305)244-8189 City Lehigh Acres State: FL Zip 33972 County: Lee Click on the arrow(s) next to the text box(s)to view a list of available Scope classifications/trades for the form tye chosen in Section 2. Click on the appropriate scope to select. If you are unsure as to which classification/trade to choose, please contact your workers'compensation insurance carrier. If you do not have a workers compensation insurance policy, contact the National Council on Compensation Insurance (NCCI)at 1-800-622-4123 option 5 to obtain a classification code. Scope 1: 00009 LICENSED Scope 2: 00009 LICENSED ELECTRICAL Scope pe 3: LICENSED ELECTRICAL Scope 4: 00009 LICENSED CONTRACTOR ELECTRICAL ELECTRICAL Section 4: CONTRACTOR CONTRACTOR The corporation of which you are an officer or limited liability company of which you are a member must be registered and in with the Florida Division of Corporations.Applicants applying as an officer of a corporation must be listed as an officer of the Corporation with the Florida Division of Corporations. List the document number on file with the Florida Division of Corporations. ACTIVE status P94400002781 Section 5: Pursuant to Chapter 489, F.S. (contractor licensing law), list certified or registered licenses related to the scope of business or trade listed in Section 3 he by the applicant, or the certified or registered license numbers held by the qualifier for the corporation or limited liability company listed on this application. The business name listed on the license MUST match the name of the corporation or limited liability company as registered with the Florida Division of Corporations and on this Notice of Election to be Exempt. EC0002175 Section 6: If you have submitted an electronic payment for this application,the transaction confirmation number is listed in the following space: Confirmation Number: 198108879 Application Number: E00221895 Section 7: N/A Are you affiliated with any corporation or limited liability company other than the corporation or limited liability company to which this application applies? Name: FEIN Name: FEIN Name: FEIN Section 8: CONSTRUCTION INDUSTRY AND NON-CONSTRUCTION INDUSTRY LLC MEMBERS ONLY To be eligible for a construction industry exemption or a non-construction limited liability company exemption, an applicant must have the required ownership of the corporation or limited liability company. I am a shareholder owning at least ten percent(10%)of stock of the corporation listed on this application. Section 9: 1 certify that any employees of the corporation or members of the limited liability company listed in Section 3 are covered by workers'compensation insurance. Please identify the workers'compensation insurance carrier that covers any non-exempt employees. Carrier Name: My business does not have any non-exempt employees Section 10: FRAUD NOTICE A. Any person who, knowingly and with intent to injure, defraud, or deceive the department or any employer or employee, insurance company or any other person,files a Notice of Election to be Exempt containing any false or misleading information is guilty of a felony of the third degree. B. Attestation of applicant—By providing my name below, I attest that I have read, understand and acknowledge the foregoing notice. C. Acknowledge that this Notice of Election to be Exempt does not exceed limits for corporate officers, including any affiliated corporations as provided in Section 440.02, Florida Statutes. First Name: Alston Last Name: Dias Note: The Division has 30 days to review your application to determine if it meets the eligibility requirements for the issuance of an exemption. The Division will either issue a Certificate of Election to be Exempt or notify you that your application is incomplete. The Division reviews and processes exemption applications in the order they are received. Exemption information is reflected on the Proof of Coverage database the day following the issuance of the exemption. Visit the Division's website at http://www.myfloridacfo.com/wc to print your certificate. 11/29/2014 Proof of Coverage ,JEFF ATWATER. CHIEF FINANCIAL OFFICER FLORIDA DF.PARI'MRK'1' OF FINANCIAL. SFRVIC_F.S Exemption Detail Page `-N s9 ,r„t She z+,es last ululated :tiaturda}, November 29,2014 12:11 AM. Return to Previous Page ALSTON W DIAS PR Jun 18 2014 Jun 17 2016 Construction ALSTON W DIAS PR Jun 18 2012 Jun 18 2014 Construction ALSTON W DIAS PR Jun 16 2010 Jun 15 2012 Construction ALSTON W DIAS PR Jul 2 2008 Jun 16 2010 Construction ALSTON W DIAS PR Jun 26 2006 Jun 25 2006 Construction ALSTON W DIAS PR Jun 11 2004 Jun 112006 Construction ALSTON W DIAS PR Feb 20 2004 Jun 5 2004 Construction ALSTON W DIAS PR Jun 6 2002 Dec 31 2003 Construction ALSTON W DIAS PR Sep 14 1999 Sep 13 2001 Construction ALSTON W DIAS PR Dec 31 1994 Sep 14 1999 Construction Return to Search Page https://apps8.fldfs.com/proofofccoverage/EKemptionDetail.aspx?pr_Wson_id=115084250 1/1 ' ,gtltpg nS Miamishores Villagesoon Building Department lOR1DA 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 cov ge from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELO YOU K OWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: caner State of Florida County of Miami-Dade The foregoing was acknowledge before me this Q-a day of MQQ�( ,20 15. By V1L:EW.AXV L.,PL,AN NIZ; who is personally known to me or has produced FLt>4z-1\W— UZIEPvS� as identification. Notary: SEAL: , Notary Public state of Florida y Co Alvarez Mz My Commission FF 156750 Expires 09/03/2018 MIZPAH ELECTRIC INC. 512 Poinsettia Avenue Lehigh Acres, FL 33972 239-368-6783 (Business) mizpahelectric@gmail.com March 4, 2014 State of Florida County of Miami-Dade Before me this day personally appeared, S who, being duly sworn, deposes, and says: He is the President of Mizpah Electric Inc. and declares that the job addressed as /' y% 57J will be done solely by him. Swo t "or affirmed" wd subscribed before me this 2S day of C` , 2015, by Personally known : V Or produce identification Type of ID produced: Notal MIR YAN MAWA GARCIA MY COMMISSION#FF196058 •.,,a EXPIRES February 0e.2019 Pnn ., ' o •r M9 Miami Shores Village 10050 N.E.2nd Avenue NE •"' ""' Miami Shores,FL 33138-0000 Phone: (305)795-2204 A� Olt I�Dp' Expiration: 09/09/2015 Project Address Parcel Number Applicant 190 NE 91 Street 1131010190080 VILBRUN LALANNE Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell VILBRUN LALANNE 190 NE 91 Street MIAMI SHORES FL 33138-2810 Contractor(s) Phone Cell Phone Valuation: =�:�O�� MIZPAH ELECTRICAL INC 305-620-2701 Total Sci Fee Type of Work:ELECTRICAL INSTALLATION TO NEW BEDR Available Inspections: Additional Info: Inspection Type: Classification:Residential Review Electrical Scanning: 1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# EL-3-15-54653 DBPR Fee $2.25 03/03/2015 Cash $50.00 $110.70 DCA Fee $2.25 Education Surcharge $0.40 03/13/2015 Cash $ 110.70 $0.00 Permit Fee-Additions/Alterations $150.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $160. 00 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 AFFI AIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction an z ning. uthermor uthorize the above-named contractor to do the work stated. March 13, 2015 thorize ignature:Owner / Applicant / Contractor / Agent Date Building Department Copy March 13,2015 1