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DEMO-15-1710 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-238659 Permit Number: DEMO-7-15-1710 Scheduled Inspection Date: October 22, 2015 Permit Type: Demolition Inspector: Rodriguez,Jorge Inspection Type: Final Owner: CHURCH, Work Classification: Building Job Address:602 NE 96 Street Miami Shores, FL Phone Number (305)754-9541 Parcel Number 1132060141410 Project: <NONE> Contractor: CSI COMMUNICATIONS INC Phone: (954)854-9863 Building Department Comments REMOVING TELECOMMUNICATION EQUIPMENT 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. October 21,2015 For Inspections please call: (305)762-4949 Page 5 of 55 Permit No. DEMO-7-11-1711 �sHO1t �,t Miami Shores Village ! Permit Type,Demolition <yn 10050 N.E.2nd Avenue NE e',nol I WNorkClassifrcaton:SuIIdIng .... ""'`" Miami Shores,FL 33138-0000 yY�N O� lt Phone: (305)795-2204 Permit Status:APPROVED Fxpiration: OW1 1 016 Issue l��ltec 7!1712015 Project Address Parcel Number Applicant 602 NE 96 Street 1132060141410 MIAMI SHORES PRESBYTERIAN Miami Shores, FL Block: Lot: Owner Information Address Phone CeII v MIAMI SHORES PRESBYTERIAN 602 NE 96 ST (305)754-9541 - -- MIAMI FL 33138-2742 Contractor(s) Phone Cell Phone Valuation: $ 1,500.00 CSI COMMUNICATIONS INC (954)854-9863 _ Total Sq Feet: 0 I , i Type of Demo:Building Available Inspections: Additional Info:REMOVING TELECOMMUNICATION EQUIPMEN Inspection Type: Classification:Residential Final Scanning:3 Review Electrical Review Building Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# DEMO-7-15-56278 DBPR Fee $2.00 07/17/2015 Credit Card $66.20 $50.00 DCA Fee $2.00 Education Surcharge $0.40 07/09/2015 Credit Card $50.00 $0.00 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $116.20 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 ce fy that all the f mg information is accurate and that all work will be done in compliance with all applicable laws regulating constructi ng. ermore I auj the above-named contractor to do the work stated. �� 1 July 17, 2015 ® ut orized Si tures Owner / Applicant / Contractor / Agent Date Building e artment Copy July 17,2015 1 Miami Shores Village .. Building Department JUL ® 9 015 oy 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 i- Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 SFL616 CBC 20(LL SYU BUILDING Master Permit Nolyicno 15- 1-110 T PERMIT APPLICATION Sub Permit No. QBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL []PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOBADDRESS: 602 NE 96th Street City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel#: 11-3206-014-1410 Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder):Northeast Presbyterian Church Phone#: Address: 602 NE 96th Street City: Miami State: FL Zip: 33138 Tenant/Lessee Name: MetroPCS Phone#:954-854-9863 Email: dolores.alcantara@civilsolutionsne.com CONTRACTOR:Company Name: CSI Communications Inc. Phone#: 954-854-9863 Address: 4100 N. Powerline Road, Suite X1 City. Pompano Beach State: FL Zip: 33073 Qualifier Name: Russell S. Nattrass Phone#: 954-854-9863 State Certification or Registration#: CGC1520348 Certificate of Competency#: DESIGNER:Architect/Engineer: N/A Phone#: Address: City: State: Zip: Value of Work for this Permit:$1,500.00 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Q Demolition Description of Work: Removing Telecommunication Equipment Specify color of color thru tile: of Submittal Fee$ t. Permit Fee$ 00 CCF$ CO/CC$ i Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ / r TOTAL FEE NOW DUE$ i0 KJ .evised02/24/2014) Bonding Company's Name(if applicable) N/A Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) N/A 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 1 Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 07(0 IX day of tvx.2, 20 S/ 11 by Is} day of '20 i5 by D Av t al p HGAe i1 who is personally known to Vlu-,.)�- A 1 who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: 7*4�GGc. Sign: Print: A' 7a/� � Print: Sheryl Peters SYLVIA HALTER l Seal: .��� °. Seal: _ `�!�!�}'- � TERS Commission#FF 238075 r r" ur, • State of Florida ' Expires June 8,2019 € M ��mm. Fxpires Mar 21,2017 8WA*dTtnTmyFainlnam=WM85d019 L � Commission # FF 001615 Bonded Thrah`�r a't o �_ �444�' 11 APPROVED BY Q-71 Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) i t 'NSORES tI .... NJ .....M Miami Shores Village Building Department AIRIDp' 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305)756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. ......................................................................................... BUSINESS NAME: CSI Communications Inc. BUSINESS ADDRESS: 4100 N. Powerline Rd. Ste X1 CITY Pompano Beach STATE FL ZIP 33073 BUSINESS PHONE: 9� 54 ) 623-5038 FAX NUMBER 9( 54 ) 623-5039 CELL PHONE9( 54 ) 854-9863 QUALIFIER'S NAME: Russell S. Nattrass QUALIFIER'S LIC NUMBER: CGC1520348 STATE OF FLORIDA r DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 we 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 NATTRASS, RUSSELL S CSI COMMUNICATIONS INC 2290 FOOTHILL DRIVE VISTA CA 92084 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 CGC152034$ ISSUED 08!19/2014 serve you better. For information about our services,please log onto www.myfloridalicense.com. There you can find more Information CERTIFIED GENORAL CONTRACTOR about our divisions and the regulations that impact you,subscribe NATTRASS,RUSSELL,S'� " to department newsletters and learn more about the Department's CSI COMMUNICATIONS',INC initiatives. , Our mission at the Department is:License Efficiently,Regulate Fairly. _' "F 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 1.1408190062572 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC1520348 :- The GENERAL CONTRACTOR Named below IS CERTIFIED � wig Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 LZI 0. NATTRASS, RUSSELL S CSI COMMUNICATIONS INC' 2290 FOOTHILL DRIVE VISTA CA 92084`.' ; ISSUED: 08/19/2014 DISPLAY AS REQUIRED BY LAW SEQ# L140819OW2572 i BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100. Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2014 THROUGH SEPTEMBER 30,2015 DBA:CSI CIVILSOLUTIONS INC COMMUNICATIONS IOINC Receipt :GENERAL 74 Business Name: Business Type: CONTRACTOR Owner Name:RUSSELL S NATTRASS Business Opened:o9/22/2014 Business Location:2501 NW 17 LN State/County/Cert/Reg:CGCl520348 POMPANO BEACH Exemption Code: Business Phone: 954-623-5038 Rooms Seats Employees Machines Professionals 5 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty T Prior Years I Collection Cost Total Paid 27.00 0.00 1 0.00 0.00 1 1 10.00. 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements.This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: RUSSELL S NATTRASS Receipt #03A-13-00010872 4100 N POWERLINE RD STE X1 Paid 09/22/2014 27.00 POMPANO BEACH, FL 33073 2014 - 2015 DATE MM/DD/YYYY ACORN CERTIFICATE OF LIABILITY INSURANCE ` ' 6/16/2015 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 endorsement(s). NT PRODUCERA NAME: -472-5947 The Rampart Group PHONE,E.01,516-472-5946 ac No 1983 Marcus Avenue E-MAIL Suite C130 ADDRESS: Lake Success NY 11042 INSURER AFFORDING COVERAGE NAIC# INSURER A INSURED CIVIL INSURER B: Civil Solutions Incorporated INSURER C: DBA CSI Communications Inc. INSURER D: 4100 N.Powerline Road Ste X1 Pompano Beach FL 33073 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:403880832 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 INSR WVD POLICY NUMBER MMIDD/YYYY MM/DD A GENERAL LIABILITY Y Y GLA427811603 1/2015 1/2016 EACH OCCURRENCE $1,000,000 X C OMMERCLAL GENERAL LIABILITY PREMISES EaENEre Dnce $1,000,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $5,000 PERSONAL BADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY X JER F-1 PRO Loc $ COMBINE INGLE LIMIT A AUTOMOBILE LIABILITY Y GLA427811603 1/2015 1/2016 Ea acc dent $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ X AL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS AUTOS Per accident) $ A X UMBRELLA LIAB X OCCUR Y AUC593320801 1/2015 1/2016 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED X I RETENTION$10,000 $ A WORKERS COMPENSATION Y WC427811703 1/2015 1/2016 X WC TORSTATU- OTH- AND EMPLOYERS`LIABILITY FR ANY PROPRIETOR/PARTNEWEXECU IVE YIN E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? NI NIA (Mandatary in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMrf $1,000,000 II' DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space Is required) With respect to all work being performed by the captioned insured;the certificate holder and other subsidiaries listed below are included as an additional insured,as required by written contract or agreement,as their respective interest may appear. All coverage is subject to the policy terms,conditions,limitations and exclusions: Russell S.Nattrass(General Contractor) License#CGC1520348 Benny A.Gordils(Electrical Contractor) License#EC13005265 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue j Miami Shores FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD MetroPCS Contract , MetroPCS Number: SFL616 South Florida Market Site Name: SFL616 1300 Concord Terrace Site Address: 602 NE 96th Street,Miami Shores, Sunrise,FL 33323 FL 33138 Contractor.CSI Communications Inc. ontact Dolores Alcantara Phone Number.9548549863 lContractor CSI Communications Inc (Russel Nattrass) Contact Name: Dolores Alcantara-(954)-854-9863 Acceptance of Scope of Work: lJz Bid Due Date&Time: Notes: Quote Materials Labor Total Ground Work Total $0.00 $0.00 $0.00 Tower/Roof Work Total $0.00 $0.00 $0.00 Miscellaneous Ground Work A.Site Work-Removal of Equipment $1,500.00 $1,500.00 B.Access Road $0.00 C.Building Modifications $0.00 D.Grounding&Test $0.00 E.Power and Telco. conduit and conductor installation $0.00 F.Concrete Pad-Forms,Rebar,Concrete $0.00 G.Steel Platforms, Structural Steel,and Foundations $0.00 H.Gas Line&Test $0.00 I.Fabric and Gravel $0.00 J.Fence and Gates $0.00 K.Landscaping,including irrigation if needed $0.00 L.Equipment Installation $0.00 M.Mounts&Antenna Installation $0.00 N.Permits&Inspections $0.00 Electrical U.Power conduit/wiring $0.00 V. Coax/Fiber Cables includes installation of waveguide) $0.00 $0.00 $0.00 Miscellaneous $0.00 1.Pick-up and delivery $0.00 2.Fuel $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Verification of Total $0.00 $1,500.00 $1,500.00 Completion Schedule(calendar days): t State of Florida County of ,-L�1,, c� 5\ _ The foregoing instrument was acknowledged before me this I day of ���` \ �e.S by �\ �kr\\•c+5 who is personally known to me or who has produced (type of identification)and who did take an oath. „ ", 5rii HVi FE TE13S 1.'�� Notary P,,, Lc - S(a;c of Honda ,.(S' a e of N Mary Public) T SEAL J Comrnission AIN Sflopts PPtSbTTtP1fin ONO ,0 July 8, 2015 To Whom It May Concern, Please be advised that David S. Kinchen, Business &Operations Manager for Miami Shores Presbyterian Church, is authorized to serve as Agent and Representative for Miami Shores Presbyterian Church in any and all matters pertaining to physical plant operations, including construction, site use and leasing. Sincerely, Gordon Moyer, Corporate Secretary Miami Shores Presbyterian Church 602 NORTHEAST 96Th STREET • MiAMi SNORES, Fl0RidA 33138 • TEIEPhONE: 305.754-9541 • FAx: 305-758.9597 E,MAil: MSPC@bEllS0UTh.NET 9 WEb SITE: WWW.MSPC.NET