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EL-15-2746 Miami Shores Village Building Department 21116 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 _ INSPECTION LINE PHONE NUMBER:(30S)762-4949 t4 FBC 20 BUILDING Master Permit No. EL(g- �1 PERMIT APPLICATION Sub Permit No. ❑BUILDING FA ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [—]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9118 NE 5th Ave City: Miami Shores County: Miami Dade Zip. 33138 Folio/Parcel#: 11-3206-014-0010 Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): Kenneth Nichols Phone#: Address. 9118 NE 5th Ave City: Mie Shores State: Zip; 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: MARDECK ELECTRIC, INC Phone#: 954-888-1765 Address: 13750 SW 37th Court City: Davie State: FL Zip; 33330 Qualifier Name: Marc Deckelbaum Phone#: 954-478-2257 State Certification or Registration#: EC13002592 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State Zip: Value of Work for this Permit:$ 9 0 0 • 0 0 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ® New C Repair/Replace ❑ Demolition Description of Work: Install 5 receptacles and relocate phone outlet Specify color of color thru tile: Submittal Fee$ '� Permit Fee$ 44, iP,<0Z�' CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology.Fee$ Training/Education Fee$-- Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Rev1sed02/24/2014) Prmit No. EL 10-15-2746 Miami Shores Village Permit1^� :Eiectlf�[-'Res�sntiai 10050 N.E.2nd Avenue NE t+ *Cfassificafon:Alteration '• ""�' Miami Shores,FL 33138-0000 e rml Permit Ste APF OVED `tie a6 Phone: (305)795-2204 ORO' Exp.iration: 0°4126/2016 issue Pate: Project Address Parcel Number Applicant 9118 NE 5 Avenue 1132060140010 Miami Shores, FL Block: Lot: REBECCA MOORE Owner Information Address Phone Cell REBECCA MOORE 9118 NE 5 AVE MIAMI SHORES FL 33138-3141 Contractor(s) Phone Cell Phone Valuation: $ 900.00 MARDECK ELECTRIC INC 954/888-1765 Total Sq Feet: 0 Type of Work:INSTALL 5 RECEPTACLES AND RELOCATE Available Inspections: Additional Info: Inspection Type: Classification:Residential Review Electrical Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# EL-10-15-57581 DBPR Fee $2.25 10/29/2015 Credit Card $ 115.10 $50.00 DCA Fee $2.25 Education Surcharge $0.20 10/28/2015 Credit Card $50.00 $0.00 Permit Fee-Additions/Alterations $150.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $165.10 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 and1oning. Futhermore,I VuthoUnize#ieabove-named contractor to do the work stated. October 29, 2015 Authorized Signature: wner / Applicant / Contractor / Agent Date Building Department Copy October 29,2015 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-247006 Permit Number: EL-10-15-2746 Scheduled Inspection Date: November 02, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: MOORE, REBECCA Work Classification: Alteration Job Address:9118 NE 5 Avenue Miami Shores, FL Phone Number Parcel Number 1132060140010 Project: <NONE> Contractor: MARDECK ELECTRIC INC Phone: 954/888-1765 Building Department Comments INSTALL 5 RECEPTACLES AND RELOCATE PHONE Infractio Passed Comments OUTLET. INSPECTOR COMMENTS False Inspector Comments Passed Failed/ Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. November 02,2015 For Inspections please call: (305)762-4949 Page 44 of 44 r � • 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 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 Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 ( byL—day oma,' �� 20 by E ��{' D(1►{ ,who 1,isp�anally known to @(�_I �[-;J-a l-��U who is per known to me or who has produced as me or who has produced !- identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: Print: Lspp P.ey Notary Public Stets of Florida r Seal: Sindia Alvarez Seal: n Notary Public,Stag®f Fl"& " PAY Commission FF 156750 r°� Sindla�AIV21f�9E v e� Expires 00103 9/0 312 01 8 < MY ComPriln§lelj FF 18�9g® O ¢Q Explr®s 09/03/2018 wwww*www****wwwww*w**ww*w***w*w*ww***w*www*******w*w********* ********wwww*******www**** APPROVED BY �l d'�r' Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) r9NORt9aE`�' Ross MiamishoresVillage 4" '�� Building Department. �vR10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 CONTRACTORS' REGISTRATION Fax: (305) 756.8972 IFCONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A.�OPY 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. ■■eemmeseeaseaeeemeeeemeeeeseeeeeeaemeeaeeeeeeememeeeeeaeeemeeeeeeeeeeeseemeeeeemeeeeseoee BUSINESS NAME:_10 A P-D c L r- BUSINESS ADDRESS: (3-740 J" -t c-T STATES ZIP ��10 BUSINESS PHONE: ( 51Y ) JAZ- l 7� FAX NUMBER 7 C-7 CELL PHONE 4-7?4- LZ -7 QUALIFIER'S NAME: /P%aC / 111 QUALIFIER'S LIC NUMBER: F <<3o o Zr,5 2— STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION - ELECTRICAL CONTRACTORS LICENSING BOARD EC 3002592 _- The ELECTRICAL CONTRACTOR - Named below IS CERTIFIED =- Under the provisions of Chapter 489 FS. Expiration date: AUG 31. 2016 DECKELBAUM. MARC JOEL m MARDECK ELECTRIC INC 13750 SW 37TH CT DAVIE FL 33330 ISSUED: "S'27'2011, DISPLAYAS REQUIRED BY LAWe_ _ ', - �a - -.�- 032�v 2zo j BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 I VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA: Receipt#-181-2335 DECK ELECTRIC INC ELECTRICAL/ALARMS/CONTRACTOR i Business Name: Business Type: (ELECTRICAL CONTRACTOR) , I Owner Name:MARC DECKELBAUM Business Opened:o5/01/1999 Business Location:13750 SW 37 CT State/County/Cert/Reg:Ec 13002592 DAVIE Exemption Code: Business Phone:954-888-1765 Rooms seats Employees Machines Professionals 1 i For Vending Business Only Number of Machines: Vending Type: j Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 ii i 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 j 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: f MARDECK ELECTRIC INC Receipt #ICP-14-00023845 13750 SW 37 CT Paid 09/03/2015 27.00 DAVIE, FL 33330 2015 - 2016 AC40R ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMMD/YY" `16� 1 10/26/2015 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). PRODUCER SECT Yulia Gonzalez Rainbow Insurance PHONE (954)977-0047FAX AIC No:(Q54)9T7-5004 1344 N. State Road 7 aoDLss;Yulia@rainbowinsurance.com INSURERS)AFFORDING COVERAGE NAIC# Margate FL 33063 INSURER A Western Herita a Insurance Co. INSURED INSURER B:Pro ressive Express Insurance Co. Mardeck Electric, Inc INSURER C: 13750 Sw 37 Ct INSURER 0: INSURER E: Davie FL 33330 INSURER F: COVERAGES CERTIFICATE NUMBER-CL15102604334 REVISION NUMBER:1 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. 1NSR TR TYPE OF INSURANCE AINSO DDL POLICY NUMBER MMIDDIYYYY MMIDD EXP LIMITS R COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMSWADE F OCCUR DAMAGE TO RENTED 100,00 PREMISES Ea occurrence) $ SCP1512279-01 06/05/2015 06/05/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JET � LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS B HIRED AUTOS ANONO-0SWNED 05722747-B 04/09/2015 04/09/2016 (PROPERed�IDAMAGE $ UM $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N f A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yea,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Addidonel Remarks Schedule,may be attached It more apace Is required) ELECTRICAL WORK WITHIN BUILDINGS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVENUE MIAMI, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025/7m401I ACORU® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 10/26/2015 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 endorsemen s. PRODUCER CONTACT NAME: Bouchard Insurance for CoAdvantage PHONE 727 447-6481 FAC No; 727 449-1267 101 Starcrest Drive -MAIL Clearwater,FL 33758 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 INSURERA:American Zurich Insurance Company 40142 INSURED INSURER 8: CoAdvantage Corporation Alt.Emp:Mardeck Electric Inc 3350 Buschwood Paris Drive#200 INSURERC: Tampa,FL 33618 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:15FLO77862492 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. ILTSR L TYPE OF INSURANCE POLICY NUMBER POLICY EFF MMfDDPOLICEXP RLIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DA AG TO RENTED- CLAIMS-MADE 17 OCCUR PREM MISE Ea occurrence $ MED EXP(Any one perm) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY D PRO- JECT F--]LOC PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE UP= $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED Y INJURY NJURY OLPeracddent AUTOS AUTOS B ( ) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Par acdd t L $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY Y/N A ANY OFFICERIMEM EREEXC UDED?EC�� N/A WC 56-11-942-01 04/01/2015 04/01/2016 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 Location Coverage Period: 04/01/2015 04/01/2016 Client# 10476-FL DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Coverage Is provided for Mardeck Electric Inc only those oo-employees 13750 Southwest 37th Court of,but not subcontractors Davie,FL 33330 to: CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2nd Ave. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores,FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD