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ELC-16-27 I0 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-250514 Permit Number: ELC-1-16-27 Scheduled Inspection Date: January 22,2016 Permit Type: Electrical -Commercial I Inspector: Devaney, Michael Inspection Type: Final ` Owner: CHURCH,ST ROSE OF LIMA CATHOLIC Work Classification: Addition/Alteration Job Address:415 NE 105 Street CHURCH BLDG Miami Shores, FL Phone Number (305)758-0539 Parcel Number 1122310430010 Project: <NONE> Contractor: SUN POWER ELECTRIC CO Phone: (305)297-6678 Building Department Comments AMUSEMENT RIDES FOR TEMPORARY CHURCH Infractio Passed Comments CARNIVAL(JAN 22-24,2016) INSPECTOR COMMENTS False Inspector Comments Passed 1E Failed ❑ �',�- / �' 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 15 of 40 Permit NQ 4,LC4 w . Miami Shores Village4475 M Pem' lit 7ppe,;ale c -C4 tC 1 S. 10050 N.E.2nd Avenue NE �#?IfC C t.a"�CBtlDi? 1 ddltiontAliterati00- Miami Shores,FL 33138-0000 Phone: (305)795-2204 Perr+i>�St�€ s ARf? �G Essue;l -1111/201 Expiration: 07/0912016 N,. Project Address Parcel Number Applicant 415 NE 105 Street Number: CHURCH BLDG 1122310430010 Miami Shores, FL Block: Lot: ST ROSE OF LIMA CATHOLIC C 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: $ 500.00 SUN POWER ELECTRIC CO (305)297-6678 Total Sq Feet: 0 Type of Work:AMUSEMENT RIDES FOR TEMPORARY CHURC Available Inspections: Additional Info: Inspection Type: Classification:Commercial Final Scanning:3 Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical W.W. Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee Invoke# ELC-1-16-58246 $15.00 DCA Fee $15.00 01/07/2016 Check* 10411 $50.00 $990.60 Education Surcharge $0.20 01/11/2016 Check#:10421 $990.60 $0.00 Permit Fee $1,000.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $1,040.60 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 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 and zoning. Futhermore,I authorize the above-named contractor to do the work stated. �I: ' )A-- January 11,2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy January 11, 2016 1 Miami Shores Villaqkj�& e g Building Department JAN ® 7 2016 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 zx- . Tel: (305)795-2204 Fax(305)756-8972 _4 INSPECTION LINE PHONE NUMBER:(305)762-4949 �FBC20I� BUILDING Master Permit No. 2�) PERMIT APPLICATION Sub Permit No. ❑BUILDING ® ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS 415 NE 105th Street City: Miami Shores County: Miami Dade zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): Archdiocese of Miami Phone#: (305) 757-6241 Address: 9401 Biscayne Blvd. city: Miami Shores State: FL zip: 33138 Tenant/Lessee Name: St.Rose of Lima Catholic Church Phone#: (305) 758-9568 Email: CONTRACTOR:Company Name: Sun Power Electric Co.Inc. Phone#: (305) 297-6678 Address: 1363 NE 182 Street city: North Miami Beach State: FL zip: 33162 Qualifier Name: Silvio Medina Phone#: (305)297-6678 State Certification or Registration#: EC13002897 Certificate of Competency M DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ $500.00 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Amusement Rides for temporary Church Carnival-January 22=24,2016 Specify color of a)lor thru tile: Submittal Fee$ Permit Fee$ CCF$ 0 . 600 CO/CC$ Scanning Fee$ 01 ) Radon Fee$ , DBPR$ Notary$ Technology Fee$ Q ' CQ Training/Education Fee$ ® Double Fee$ Y2 _ Structural Reviews $ Bond$ r,.T.. .. .,,.... 4-19 0 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 aplak must promise in good faith that a copy of the notice of commencement and constructidien 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 jbb site for the first inspection which occurs seven (7) days after the building)ermit 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 forQgoing instrument was acknowledged before me this it TA day of 0 'a` 20 i ,byday of 20 /5 ,by FA-rw.z ac-4,1.6 4,1.6 C.a2`�s ,who is o o J to J .00 ��D�%'�� ,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: ry warp State of Florida Sign: ' Brian ?LL�orrisse Sign: FF 18 170 Print: ly " ��1 Print: Seal: Seal: "00 PASACHE '4 � _�� MY COMMISSIOM a FF 194364 fo for •,t 4s�, ,+ - EXORES March 22.2019 � ..ems FF/R --'� �. � �f •¢C.Fj�fl`a X071 J9QO'97 �, ti• ry,i APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD EC13002897 The ELECTRICAL CONTRACTOR Named below IS CERTIFIED *'z WSz Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 a v MEDINA, SILVIO J SUN POWER ELECTRIC CO INC 1363 NE 182ND ST ' NORTH MIAMI BEACH FL 33162 ISSUED: 08/26/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408260002262 W1823 Local Business Tax Receipt Miami-Dade County, State of Florida —THIS IS NOTA BILL — DO NOT PAY LBT 6513403 BUSINESS NAMEIL.00ATION RECEIPT NO. EXPIRES SUN POWER ELECTRIC CO INC RENEWAL EXPIRES 30, 2016 1363 NE 182 ST 6783683 Must be displayed at place of business NORTH MIAMI BEACH FL 33162 Pursuant to County Code Chapter 8A—ArL 9&10 OWNER SEC.TYPE OF BUSINESS SUN POWER ELECTRIC CO INC 196 ELECTRICAL CONTRACTOR PAYMENT RECEIVED EC13002897 Worker(s) t BY TAX COLLECTOR $45.00 09/11/2015 CREDITCARD-15-045646 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit or a certification of the holder's qualificatiotm,to do busiaess Holder must comply with amry governmental or ooagovemmremal regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec Ba—27& For more infommtion.Vlait 4Vttrwmiamidede agi to cailector CERTIFICATE OF LIABILITY INSURANCE13ATE(MWDDIYYYY) 02/12/2015 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 CONTACT NAME: Alistair Direct Insurance PHONNo (305)754-7414 arc No' (305)754-7416 16123 Biscayne Boulevard L joe@alistardirectcom Aventura,FL 33160 INSURER(S)AFFORDING COVERAGE NAIL it Phone (305)754-7414 Fax (305)754-7416 INSURER A: Cypress Poroperty and Casulty Insurance Co. INSURED INSURER B: Sun Power Electric Co Inc INSURER C: 1363 NE 182nd St INSURER D: INSURER E: North Miami Be FL 33162 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. IN8R ADD SUB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INS POLICY NUMBER MMIDDNYYY MMIDD LIMITS © COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 ❑ CLAIMS-MADE Q OCCUR DAMAGE TO RENTED 100 000.00 PREMISES a occurrence) $ A F1MED 1027371 02 09/25/2015 09/25/209 6 MED EXP(Anyone person $ 5,000.00 [i PERSONAL&ADV INJURY $ 1,000,000.00 GEMLAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000.00 ❑ POLICY El JEST ❑ LOC PRODUCTS-COMPIOP AGG $ 1,000,000.00 ❑ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ AUTOS NED ❑ SCHEDULED BODILY INJURY(Per accident $ NON-OWNED PROPERTY DAMAGE $ F-1HIREDAUTOS ❑ AUTOS Poraccident ❑ ❑ $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑ PER TE L]OTH- AND EMPLOYERS'LIABILITY Y I N ER ANY PROPRIETOR/PARTNERIEXECU E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N I A (Mandatory M NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) Electrical Contractor number:EC13002897 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Hall Building Dept THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHORIZED 7REP A ©19 -2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01)QF The ACORD name and logo are registered marks of ACORD we JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUC71ON INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 10/14/2015 EXPIRATION DATE: 10/13/2017 PERSON: MEDINA SILVIO J FEIN: 943472315 BUSINESS NAME AND ADDRESS: SUN POWER ELECTRIC CO INC 1363 NE 182 STREET NORTH MIAMI BEACH FL 33162 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL ELECTRICAL WIRING CONTRACTOR-PROJECT BURGLAR AND FIRE CONTRACTOR WITHIN BUIL MANAGER,CO ALARM INSTALL Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the flung of the notice or the Issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for Issuance of a certlflcate.The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 f 4 t` j� =CTIA POWER ELECTRIC D 1363 N.E. 182 Street—North Miami Beach-Florida—33162 Phone:305-974-4540 EC-13002897 State of Florida County of Miami-Dade Before me this day personally appeared Mr.Silvio Medina who,being duly sworn,deposes and says: That he or she will be the only person working on the project located at: Miami Shores letter is for St. Rose of Lima Catholic Church.415 NE 105th Street Miami Shores FL 33138 Sworn to(or affirmed)and subscribed before me this 9th day of January of 2016, by Mr.Silvio Medina Personally known---Or produce Identification type------ CIr� MY COMNUUMM•FF194M EXPMS Mane 22.1019 .fit O/D Print,Type or Stamp Name of Notary ORFS b1 s� ��► Miami shores Village logo Building Department Lys 9 p 10050 N.E.2nd Avenue �LORIDp` 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 coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this 7 day of ,20 1 . By er. ? C' t ue who is personally known to me or has produced •9ud�1 �P.sS�.•�. L as ion. Notary: LR-LA. •''•MISSp41 '%c��L���%� i�'�gtabe/1Ff SEAL: ® *;�ymQ _*+ ,y: • •*= i9 ' • Q'S per_ ra