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EL-15-3060 F Perm.o. E ' tri ��'��3060 e9�° ys Miami Shores Village I en7lft Type:Electril l-Re8ldentlal 10050 N.E.2nd Avenue NE r 0 Cfassfflcatfo 1 �,., rtVi#t!` Miami Shores,FL 33138-0000 4 n" � �, Permit Status.' Phone: (305)795-2204 A1�i ROYEQ CORtV�' Is$W" 't�: 1?1151201t Expiration: 1 1 Project Address Parcel Number Applicant 361 NE 97 Street 1132060135760 Miami Shores, FL 33138-0000 Block: Lot: BLACKWELL ESTATES LLC Owner Information Address Phone Cell BLACKWELL ESTATES LLC FL Contractor(s) Phone Cell Phone :Valuation: $ 1,000.00 MESA BROTHERS INC (305)345-1974tal Sq Feet: 00 Type of Work: Available Inspections: Additional Info: Inspection Type: Classification:Residential Final Scanning:3 Light Niche Bonding Review Electrical Alarms Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# EL-12-15-58010 DBPR Fee $4.50 12/15/2015 Check#:4760 $269.60 $50.00 DCA Fee $4.50 Education Surcharge $0,20 12/10/2015 Credit Card $50.00 $0.00 Permit Fee-Additions/Alterations $300.00 Scanning Fee $9.00 Technoldgy Fee $0.80 Total: $319.60 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 assu s ibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELE RICAL,P LIM G, ECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS,AFFID V T: I all the foregoing in o tion is accurate and that all work will be done in compliance with all applicable laws regulating constructimt and F h rm re, ri he above- med contractor to do the work stated. December 15, 2015 Au ori n ure:Owner / Appli n / Contractor / Agent Date Building Dep rtment Copy December 15,2015 1 DEC 16 2015 Miami Shores Village BY: Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 BUILDING Master Permit No. _ PERMIT APPLICATION sub Permit No.ZY X ❑BUILDING 0 ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION EeRENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS 10B ADDRESS: 361 N E 97 St City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3206-013-5760 Is the Building Historically Designated:Yes X NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):Blackwell Estates LLC Phone#:828-994-2115 Address:2425 N Center St#348 city: Hickory State: NC Zip: 28601 Tenant/Lessee Name: None Phone#: Email: jim.holt@ryge-international.com T CONTRACTOR:Company Name: Phone#: Address: ` /� City: Gt ice'. State: Zip: �� Qualifier Name: �� /G��� Phone# - - v '� ✓ State Certification or Registration#: Certificate of Competenty#: c DESIGNER:Architect/Engineer: Phone#: Address: 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: Specify color of color thru tile: Submittal Fee$ Permit Fee$ 74COO'ep0 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) ti 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be app oved nd a reinspection fee will be charged. ` Signature Signatu OWNER or AGENT CONTRACTOR The foregoing instrument was ckriowledged before me this The foregoing instruments acknowledged before me this day of �O f 20 S by d of �' 20 l� by (Y�\ ®k .who is personally known to who is personally known to me or who has produced OX Q 10 `�J as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Q G Sign: - a .?� Print: Print: Seal: =,�o+`�P` ��, ANGELA BAEZ IRES:JAN 21,2018 Not Public -state of Florida Seal: Bon d through tat Stet®insurance 'Q? My Comm.Expires Mar 7,2016 _:VlFovc�o : Commission#EE 176938 m* *r**w �xx��nit1' a������,, APPROVED BY � f�'� � � Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT, GOVERNOR KEN LAWSON. SECRETARY STATE OF FLORIDA c)f g JS1 ,C S'A flPtOFF$ 10NAL RGUtAION tt±C.TOAD. D' ORS I�ICfsN$ Cy.BOARD r �ONT RACT'Q 1`.. beFQ11�- RT+f'1,ED :.w def'icer pf'c>NC(0'M,Of-Chapter489 FS i,•",r - ..._.. may.:, •� ,'i�,� �~I�!���,4,• `' � � � i r ''•r - :.FLS 33` ISSUED: 06!10/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1406100001578 + s Tex Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 405779 LBT BUSINESS NAMR/LOCATION RECEIPT NO. MESA BROTHERS INC RENEWALEXPIRES 5215 SW 103 AVE 405779 SIPTE�I A !'ER 30, 2016 MIAMI FL 33165 Must be displayed at place of business * Pursuant to County Code Chapte,8A-Art.9&10 OWNER SEC.TYPE OF BVSINBBS MESA BROTHERS INC 196 ELECTRICAL CONTRACTOR PAYMENT RECEIVED Worker(s) 10 EC13001870 BY TAX COLLECTOR $75.00 07/15/2015 CHECK21-15-095549 This Local Business Tax Receipt only confirms payment of the Local Business.lax.The Receipt is not a license, permit or a certification o1 the holder's qualiliceuons,to do business. Holderonust comply with any governmental of nongovernmental regulatory laws end requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sac 8a-278. For more information.visit lerww.mlemidadn gawtaxcollector A ROC ROC o` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YWY) 10/01/2015 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(a). PRODUCER CONTACT NAME: Risk Management Department Stonehenge Insurance Solutions,Inc. PHONE FAX 300 Avenue of the Champions,Suite 222 ac No,Ext): aee 925-2330 x20&34 aC No): 677 637.8949 Palm Beach Gardens,FL 33418 ADDRESS: certs® ro ressiveem to er.com INSURED INSURERS AFFORDING COVERAGE NAIC p Progressive Employer Management Co.,Inc.and all its affiliates and subsidiaries INSURER A:Technology Insurance Company,Inc. 42376 INSURER B: For co-employees of Mesa Brothers Inc INSURER C: 6407 Parkland Drive INSURER D:INSURER E: Sarasota,FL 34243 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. Limits shown are as requested INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LTR INSR WVD (MMIDD/YYYY) (MWDD/YYY ) LIMITS GENERAL LIABILITY ACH OCCURRENCE COMMERCIAL GENERAJLl,6BILITY DAMAGE TO RENTED REMISES(Ea occurrence) CLAIMS-MADE OCCUR ED EXP(Anyone person) ERSONAL&ADV INJURY ENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: RODUCTS-COMP/OP AGG POLICY PROJECT LOC AUTOMOBILE LIABILITY OMBINED SINGLE LIMIT ANY AUTO Each accident ODILY INJURY(Per person) ALL OWNED SCHEDULED URY(Per ODILY]NJ $ AUTOS AUTOS ODILZdant HIRED AUTOS NON-OWNED i ROPERTY DAMAGE(Per AUTOS ccident UMBRELLA UAB B OCCUR EACH OCCURRENCE EXCESS UAB r7 AGGREGATE DED I RETENTION$ WORKERS COMPENSATION t.L.DISEASE- ATU• 0TH• /{ AND EMPLOYERS'LIABILITY Y/N TWC3498277 10/01/2015 10/01/2016LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE L. ACCIDENT $1,000,000 OFFICERIMEM&ER EXCLUDED? ❑ N/A (Mandatory in NH) EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below SE•POLICY LIMIT $1,000,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required): Coverage is extended to co-employees but not subcontractors of Mesa Brothers Inc ID:416802 CERTIFICATE HOLDER CANCELLATION City of Miami Shores SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave AUTHORIZED REPRESENTATIVE Miami Shores, FL 33138-2304 ACORD 25(2010/05) The ACORD name and logo are registered marks of R10 D CORPORATION. All rights reserved. ACORD AC 0- MESAS-1 P ID: YM DATE(M O CERTIFICATE OF LIABILITY INSURANCE 06, 6/ 12015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE,DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements). PRODUCER Global Risk LLC NAME :c Yolanda Mendez_ 5959 Blue Lagoon Dr Suite 101 Ai N , :305-455-7250 — -— -- Miami FL 33136 ___L�NoL-305-455-7251 ADDRESS: EDUAFiDO R PORTAS E-MAIL mail@globairiskllc.com INSURE1S)AFFORDING COVERAGE NAIC a INSURED Mesa Brothers Inc. --- INSURERA:W@SCO In$urance 5215 SW 103 Ave INSURER B Miami,FL 33165 INSURER C; i INSURER 0: -- ---------�— -- - 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 19 ADDrSM - LTR TYPE OF INSURANCE --— �-— -- P L _P_UL_1CV1 -_ POLICY NUMBER MWOD MM/DD LIMITS — A X COMMERCIAL GENERAL LIABILITY �� EACH OCCURRENCE TE77! CLAIMS-MADE L-J OCCUR WPP122167400 01/01/2015 01/01/2016 PREMISES Ea occurrence MED EXP(Any one person) $ 5,00 PERSONAL 8 ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: ---.--__.. X POLICY❑PE LOC OTHER: (GENERAL AGGREGATE I$ 2,000,00C — —-- -- '., PRODUCTS-COMP/OP AGG $ 2,000,00 I - ---------- AUTOMOBILE LIABILITY $ COMBINED NGLE LIMI A ANY AUTO WPP122167400 Ea accident $ _ 11000,00 ALL OWNED SCHEDULED 01101/2015 01/01/2016 BODILY INJURY(Per person) $ AUTOS AUTOS --- --- ---- X �( NON-OWNED BODILY INJURY(Per accident) $ HIRED AUTOS AUTOS R A A Per acrid nl '$ UMBRELLA LIAB $ EXCESSLIAB OCCUR i EACH OCCURRENCE $ CLAIMS-MADE ;AGGREGATE $ DED RETENTION$ _..—_.--..— WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY �-STATUTE _ ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN I OFFICER/MEMBER EXCLUDED? N/A i E L.EACH ACCIDENT $ (Mandatory In NH) It yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below --- E.L.DISEASE-POLICY LIMIT i$ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) Electrical work within buildings-CG2033&CG2404-Blanket Addl Ins and Waiver of Subrogation,when required by written contract/agreement CERTIFICATE HOLDER CANCELLATION MIAMII1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 Northeast 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE ACORD 25(2014!01) The ACORD name and logo are registered marks ofACORDRD CORPORATION. All rights reserved.