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ELC-15-3100 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-251421 PermitNumber: ELC-12-15-3100 Scheduled Inspection Date: January 22,2016 Permit Type: Electrical- Commercial Inspector: Devaney, Michael Inspection Type: Final Owner: CHURCH,ST ROSE OF LIMA CATHOLIC Work Classification: Low Voltage Job Address:415 NE 105 Street CHURCH BLDG Miami Shores, FL Phone Number (305)758-0539 Parcel Number 1122310430010 Project: <NONE> Contractor: MOODY ELECTRIC INC Phone: (305)758-2000 Building Department Comments CARNIVAL TEMPORARY HOOK UP OF ELECTRIC FOR Infractio Passed Comments 26 CARNIVAL TENTS INSPECTOR COMMENTS False Inspector Comments Passed 1:2 Failed � J Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. January 21,2016 For Inspections please call: (305)762-4949 Page 36 of 40 Permit No. ELC4 245-31o t�: ype., .'1e �� Miami Shores Village Ft ?t � tII-�#ltitXiBii '� 7 10050 N.E.2nd Avenue NE O)� e+ Or�f- c3� X17 .c> .i/ Miami Shores,FL 33138-0000 h � Phone: (305)795 2204 Pel7�t7 =5",:APPROVED F ORIDA sue Date;�J6120'i� Expiration: 07/04/2016 Project Address Parcel Number Applicant 415 NE 105 Street Number: CHURCH BLDG 1122310430010 ST ROSE OF LIMA CATHOLIC CI Miami Shores, FL Block: Lot: Owner Information Address Phone Cell ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD (305)758-0539 MIAMI FL 33138-2970 Contractor(s) Phone Cell Phone Valuation: $ 100.00 MOODY ELECTRIC INC (305)758-2000 Total Sq Feet: 00 Type of Work:CARNIVAL TEMPORARY HOOK UP OF ELECT Available Inspections: Additional Info: Inspection Type: Classification:Residential Review Electrical Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.00 Invoice# ELC-12-15-58055 DBPR Fee $0.00 01/06/2016 Check#:2702 $953.00 $50.00 DCA Fee $0.00 Education Surcharge $0.00 12/15/2015 Cash $50.00 $0.00 Permit Fee $1,000.00 Scanning Fee $3.00 Technology Fee $0.00 Total: $1,003.00 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 pertain ing: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 ELECTRIrAl PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS`AFFID t II the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constructs a zo ing. F e orize the above-named contractor to do the work stated. January 06, 2016 Autho / Applicant / Contractor / Agent Date Building Dep ent Copy January 06,2016 1 Jan 06 16 12: 02p Moody Electric Inc 305-754-1333 p. 2 .4 R / 7 v MOODELE-01 WENDY CERTIFICATE OF LIABILITY INSURANCE F �"�` ''' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 161201"S 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 BL=TWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. If SUBROGATION IS WANED,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(e). PRODUCER Acrlsure,LLC d/Wa InSource NAND 9600 South Dadeland Boulevard PN ONE 305 670-6 t 11 — -- — — 4th Floor Atc N '�— ]AIC,No>�30b�70-8699 Miami,FL 33186-2867 AooREss:.etnall a nsource-inc,com INBURER(B)AFFORDI LG--co RAQE—... ._.—._. NAIcO -- _ ---- .-- -------•--. —— __—....— q! uRERA•.MonroeGuaranp/Ins.Co. _ alsuaaD nc, INsuREn e:FCCI Insurance Compa�r __ 10178 Moody Electric I — Mr.John Moody --"- 669 NW 90 Street INSURER D: - - -- — -- Miami,FL 33150 -- — — — BISURERE: -- -- — —.._ 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. LTR TYPE OF INSURANCE 1 Bp POUCYNUEreER — — --- A X COMMERCIAL GENERAL LIABILITY D UUM CLAIMS-MADE XEACH OCCURRENCE OCCUR CPP000669411 12/31/2015 12131/2016 DAMAGM'RENMD-- $- --x'000,00 — EMISES(Ee ocwirenee)_._ $ 100,000 MED EXP(Any ace 5,000 OEML AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ 1,000,0 POLICY I X�PECOT Cl LOC GENERAL AGGREGATE _ $_-- 2,000,00 OTHER: 1 PROOUCTS-COMP/OPAG_G $ 2,QOD,000 auroMOBILEL4gBIL11Y EMPLOYMENTPRAC s 900100 COMBIN D SINGLE U IT B X ALL OW o CA0028888 2 Eek)-- $. _.. 1=000,00 ALL OWNED --" SL"EDULEp 17131120'15 12/31/2016 BODILY INJURY(Per Person) S — AUTOS AUTOS X HIREDAUTOS X "OWNED BODILYINJURY(Pereodderd) $ —•— .. X UMBRELLA LIAS X OCCUR EXCESS LIAR CLAIMS 114ADE UMB0004787 10 ��OCCURRENCE —._. . 12/31/2015 12/31/2016 — $---_--2,000,000 DED X RETENTIONS 10 ON AGGREGATE $ _ 2,000,00 WOPjC—%OMPENBATI01 .. --'---• 5 ... .—' AND EMPLOYERV LIARILnY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN SfATUiE _ ER _ OFFICER/MEMSER EXCLUDED? N/A $ E.L.EACHACCIOENT .....— —_~ (IVkna4,etory In NH) _ DESCRI ONN OF OPERA TIONS below E.L aSFASE—EA EMPLOYE S _ ___--- E.L.DISEASE-POUCY LIMIT S DESCRIPTION OF OPaRgTtONg/LOCATIONS/YENICLaB(ACORD 101,Addltlond Electrical Contractor Remerlm Schedule,may be attaehed R more epaoe is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami Shores THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 10050 Shores, 2nd.Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33158 AUTHOREeD REPResENTanva PA-4 ACORD 26(2014101) The ACORD name and logo are registered marks of1ACORD CORPORATION, AN rights resetyed g3u - 2� 1�73 `�� �5 Miami Shores Village --- Ee� - Building Department ®EE 15 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 BY- INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 BUILDING Master Permit No.-S-10-f,S -- 3)OJ PERMIT APPLICATION Sub Permit No. ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP J CONTRACTOR DRAWINGS JOB ADDRESS: L//6- AIE &15-s- s City: Miami Shores County Miami Dade Zip: 3313 Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: / Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): 577 ko5iE 6 L//�A9 Phone#: -506--75,9-��39 Address: 16- A16 16 .6 S / City: /�/� / 45800,5 State: jd�1- A Zip: 3313 LF , Tenant/Lessee Name: e zi-C-14-C phone Z� Email: 8CEa.� C� �jO -`� '00: � /V CONTRACTOR:Company / eoaq 07,91 C M01 Phone#: �3 6 5- 75S• 2�® Address. � /2' 2q )qV6/��� �n City: i4ottu/� ®0State: Zip: ?,A02-6 Qualifier Name:Rh)�J— 00 DY Phone#: 36—�--25-r"d State Certification or Registration#: 0190 11 ,99 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:;$ 1 n 6)Q Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ��nn ❑ Demolition Description of Work: 0,0R )l IJAL IMPO96" 86015- UP Or gi,eciceIG fine Z4 dA�Wl( qe_ fief Specify color of color thru tile: Submittal Fee$ Permit Fee$ �® °®� CCF$ CO/CC$ Scanning Fee$3 1 W Radon Fee$ ! DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ !9 S3, VV (Revised02/24/2014) 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. �SignatureC'C Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20_1 by day of �D/,Z' & ,20 ( 6 ,by �c_?cdtva� CoercR.S , who ersonally known :2� Moo oo ,who is personally known to me or who has produced 5-.¢..kf 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: ,1111111111111//�% `�O�ORIANOO�F4i/i •"oMISS%pv.�ti��� /� � Sign: r : mherr s Sign: fP&WL� Print: ��w �� 'x�'_ - �.� �Ca . = Print: • #FF05S949 ?o�"""°"y;;% MARY PAT BRIGGS .�7--.� rod t�. Qom. Seal: Seal: 9:o, :ate: -r: NotaryPublic-State of Florida 0*-.Ni;U'Ai.0. . d��` ;,. .oa My Comm.Expires May 11.2018 7C STAT EO�� �'.;;o�,��;,".�°� Commission #FF 120746 r f5 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Dec. 22, 2015 12:45PM No. 4435 P. 1/1 �N 1V1W jy-1 JP 1D:NG ACORU` CERTIFICATE OF LIABILITY INSURANCE DAA "' 12/117/2017/201 5 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 AI-TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATl: OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER- IMPORTANT. OLDERIMPORTANT. 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 Ilau of such endorsement(s). PRODUCER cNAOM6AcT Workers Compensation Group Workers Compensation Group PHONE FAX P O Box 410 •561-302-3300 c Na 561-361-1132 Boca Raton,FL 33428-0410 na msa,Certs orkeracom rou .corn INSURERS)AFFORDING COVERAGE MAIC B INSURERA:Bred afield Employers Ins 10701 INSURED Moody Electric,Inc INSURER B: 3312A North 29th Avenue INavat:Rc. Hollywood,FL 33020-1008 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 18 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT.115RM 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. 1lTR YPE OF INSURANCEINSb WVb POLICY NUMBER MNypp pi EFF MlppJ1�YY LNmz COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE FIOCCUR AGE TO RVZKTE13MMI $ MED EXP orle n 3 PERSONAL BADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERA!AGGREGATE $ POLICYPRO- JRCT LOC PRODUCTS-COMP/OF AGO S OTHER: $ AUTOMIOEILE LIABILITY COMEINID SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per per--) $ ALL OWNED SCHEDULED AUTOS NOUN-0WNED BODILY INJURY(per sodderd) $ HIRED AUTOS AUTOS PROPERTY DAMAGE $ $ UMBRELLALIAB OCCUR EXCESS lIAB EACH OCCURRENCE $ CLAIMS MADE AGGREGATE $ DID I I RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIAWUTY X PER x �H A ROPRIETORIPARTNGIRiMEERR�M®ERE�(CLUDDE1f6CUTIVE YIN NIA 830-286x3 01/01/2015 01/01/2017 EJ,EACH ACCIDENT $ 1,000,000 (Mandefory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,00 DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT I$ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 1H,AddiVanal Ramo to Schedule,army be offiched If mora apooe Jr.aegadred) Electrical Contractors CERTIFICATE HOLDER CANCELLATION MIAMIS3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave. ACCORDANCE,WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHOR961)ROMESENTATME ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD