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EL-15-2688 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-252829 Permit Number: EL-10-15-2688 Scheduled Inspection Date: February 16,2016 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: JULNOR JEAN,JOSEPHINESIMEON Work Classification: Service Change Job Address:375 NW 111 Street Miami Shores, FL 33168-3303 Phone Number Parcel Number 1121360010760 Project: <NONE> Contractor: MICHAUD ELECTRICAL SERVICES INC Phone: (786)273-1270 Building Department Comments SERVICE UP GRADE Infractio Passed Comments INSPECTOR COMMENTS False Inspector CopLpmnts Passed ' Failed _ C Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid February 12,2016 For Inspections please call: (305)762-4949 Page 37 of 38 Permit nra EL ri-0-16� l Miami Shores Village P@R!?it 71p e04""c l bal-Residential 10050 N.E.2nd Avenue NW er t/I/ot C/eSsr iCF Ctt�. rV1G nge '• "'" Miami Shores,FL 3313&0000 ' ;; Permit Stators.APPR6tE© Phone: (305)795-2204 sive gave Das:11130' Expiration: 05!0112016 Project Address Parcel Number Applicant 375 NW 111 Street 1121360010760 Miami Shores, FL 33168-3303 Block: Lot: JOSEPHINESIMEON JULNOR JE Owner Information Address Phone Cell JOSEPHINESIMEON JULNOR JEAN 375 NW 111 Street MIAMI SHORES FL 33168-3303 Contractor(s) Phone Cell Phone Valuation: $ 1,100.00 MICHAUD ELECTRICAL SERVICES IN (786)273-1270 Total Sq Feet 00 Type of Work: Available Inspections: Additional Info: Inspection Type: Classification:Residential Review Electrical Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 DBPR Fee InvOiCe# EL-10-15-57511 $2.25 10/21/2015 Check#:3006 $50.00 $116.70 DCA Fee $2.25 Education Surcharge $0.40 11/03/2015 Check#:3011 $ 116.70 $0.00 Permit Fee-Additions/Alterations $150.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $166.70 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 wor one by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WI OWS,DO RS,ROOFING and SWIMMING POOL work. 4 OWNERS AFFIDAVIT: I certify that all the foregoing info c rate n all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the ve-na d con ra for do the ork stated. ovember 03, 2015 Authorized Signature:Owner / Applicant on cto / VAgent Date Building Department Copy November 03,2015 1 Miami Shores Village C 9 M Building Department OCT 91.2015 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 BUILDING Master Permit No, ®Q, PERMIT APPLICATION Sub Permit No. 7 Ss- ❑BUILDING W ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION D6RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP `� CONTRACTOR DRAWINGS JOB ADDRESS: 3� /- AzW QJ City: Miami Shores County: Miami Dade Zip: 2A 5� Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder):���L Ilk Phone#: Address: AJ (it) City: 1? .�r �C�•u �J/� Stater Zip: Tenant/Lessee Name: UV Phone#: Q rI t1 rt ct� Email: ' CONTRACTOR:Company Name: ff/t"7/M(j�� r( A Phone#: h 7 � 7d Address: -�%aW r l City: I CL Im I es 6 r State: Zip: 53 Qualifier Name: -.2 d'L4 Ik(6t Phone#: State Certification or Registration#: , ,)® t rA, Certificate of Competency#: 03 E b o o l o d• DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ Newpp Repair/Replace El Demolition Description of Work: 1 _ LJ 2-- Specify color of color thru tile: Submittal Fee$ Permit Fee$''E/� �o�� CCF$ 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) 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 signatre-LLI46ER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The*egoing instrument was acknowledged before me this 10 day of 20 (S , by ?day of �lG��Up �32►r ,20 l b , by who is personally known to m 1 e.r7lD who is personally known to me or who has produced yf�/Oy69gp as me or who producpcl pL W&j0= — �-�s identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Print: Print: Seal: "W� NNoo ary Publics ttmIth ate of Florida Seal: r a My Commission FF 150828 �4.'`'.�� IT up poi Expires 08113/9018 W� 1� 4 * * EXPIRES:August 31,2017 APPROVED BY 7-10-4, 44 Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) MICHAUD, FITZROY H MICHAUD ELECTRICAL SERVICES INC 3882 NW 207 STREET ROAD OPA LOCKA FL 33055 sne million Floridians licatulationsf With ensed by the Delicense you epparrtment of Business ome one of the and 3rofessional Regulation. Our professionals and businesses range rom architects to yacht brokers,from boxers to berbeque restaurants, and they keep Florida's economy strong. =very day we work to improve the way we do business in order to serve you better. For information about our services,please log onto vwWrnyfiorldallcense•com. There you can find more Information about our divisions and the regulations that Impact you,subscribe :)department newsletters and learn more about the Department's Iitlati ves. )ur mission at the Department Is:License Efficiently,Regulate Fairly. Ve constantly stove to serve you better so that you can serve your ustomers. Thank you for doing business in Florida, nd congratulations on your new licereel DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD ER13012793 ie ELECTRICAL CONTRACTOR imed below HAS REGISTERED ider the provisions of Chapter 489 FS. Oration date: AUG 31,2016 (INDIVIDUAL MUST MEETALL LOCAL-'LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) MICHAUD, FITZROY H a 'o MICHAUD ELECTRICAL SERVICES INC 3882 NW 207 STREET ROAD OPA LOCfCA ria "tai nv n0 oc1111tDCr1 pV I d1AJ fJ 114070=1413 t Miami-Dade County, State of Florida -THIS tS NOTA BILL-00 NOT PAY 508#30& Ln I sus m"s NAMEn oc.ATiont Rscetlnr 1V0. EXPIRES MICHAUD ELACTRICAL SERVICES INC 5280459 SEPTEMBER 30, 2016 3882 NW 207 ST RD Must be dlWayed at glace of business i MIAMI,FL. 33055 Pumnmt to County Cot Chapter RA-Art.9&10 OWNER SEC.TYPE OF BUSINESS MICHAUD ELECTRICAL SERVICES 198 ELECTRICAL PAYMENT RECEIVED INC SY TAX COLLECTOR CONTRACTOR 75,00 09/18/2016 Worker($) 1 03EO00904 024315-007497 TW s teal BMW=Taa RecWp odf aalhms pa famot od*e Leal Badam TR The Racdpt Is aw a RCeaae. Permit,m a Cmdfiadea pdtw holder's qwIfficatlem to do husftmm RoMer mast cam*wl&my geven wegW or wagwa iumftl n*UWM Ism and mgdnmeato vvblsh spptf tD the bashmm � The VMS"N0.abow mast be fth fed a W Commercial vahEolas-Mftm"ads Cods$ee 8*-M for mm lafsruaioa,visit vim. 1 i I I I I. AC`C> CERTIFICATE OF LIABILITY INSURANCE D10/0 20 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 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 NAME: CANDY MCCULLOM Cloverleaf Insurance Brokers AHI N o :305-655-1006 VC Ne:305-655-0730 18314 NW 7th Avenue E-MAIL Miami,Florida 33169 ADDRESS: Cand r cloverleafinsurance.com PRODUCER CUSTOMER INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Granada Insurance Company MICHAUD ELECTRICAL SERVICES,INC. INSURER 8: 3882 NW 207 STREET ROAD OPA LOCKA, FL 33055 INSURER C: INSURER D: 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. 1EXP LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY M DDDR MMIDD YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000• ✓ NTED COMMERCIAL GENERAL LIABILITY DAMA x50,000. PREMISES Ea occurrence) $ A CLAIMS-MADE [✓ OCCUR 0185 FL0008734 4/21/15 04/21/16 MED EXP(Any one person) $ 1,000. PERSONAL&ADV INJURY $ 500,000. GENERAL AGGREGATE $ 1,000,000• 7L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 500,000. POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LUAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STALIMTU- I 10TH AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED9 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ "r yyes desaibe under DESdRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remade Schedule,K more space Is required) Electrical Work In Buildings. CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2 AVENUE THE EXPIRATION DATE THE F. NOTICE WILL BE DELIVERED IN ACC A MIAMI SHORES VILLAGE, FL. 33138 NCE WITH THE POLI Y PR SIONs. A THOR gREP ENTATIVEF ©1988-2009 A CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of AC T D JEFF ATWATER STATE Of FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT Of FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 4/4/2015 EXPIRATION DATE: 4/3/2017 PERSON: MICHAUD FITZROY H FEIN: 043766397 BUSINESS NAME AND ADDRESS: MICHAUD ELECTRICAL SERVICES INC 3882 NW 207TH ST RD OPA LOCKA FL 33055 SCOPES OF BUSINESS OR TRADE: ELECTRICAL WIRING WITHIN BUIL Pursuant to Chapter 440.05(14).F.S.,an officer of a corporation who elects exemption from this chapter by fling 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 H,at arty time after the filing of the notice or the Issuance of the certificate,the person named on the notice or c edificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a certificate at DFS-F2-DNC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 miamiShores village Building Department 10050 N.E.2nd Avenue 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 tow on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensate msura ce c verage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING B W Y U CKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State o orida County of Miami-Dade The foregoing was acknowledge before me this *14 day of�,4Jr._ 20 !S By ���— c�cp°✓ who is personally known to me or has produced as identification. Notary: SEAL:gig of Florida 150828 Olftbaub Ckdriml Oerbtteo, 3JAC. 3882 R.1V. 2070 Otreet - R JRtamt' gacrbeuo, floriba 33055 7S6 -273 -1270 Date: � z� � State of 1:7I0 r Cl Country of B r v v3 a✓c� Before me this day personally appeared i Z e o -f 11,4f t L (A 6/ who,being duly sworn, deposes and says: That he or she will be the only person working on the project located at : :1 -7 S N-vJ J i 1 SVVYl I f- wt i 44 Sworn to (or affirmed)and subscribed before me this Z 1 S F day of IUCD b-e e"' 20iEby FI IT 2- (-07 �4iCAa(Ad Personally know "aa;89F�1�GB�B0yy�4 OR Produced Identification �"o�16 apn4� 1!,�Type of Identification Produced C1 ✓t r L< c-e�+ ���,�� •°^ °° � Fes, ®VC' `Mh 7JON��o o ° • #EE 177292 • Q � ' ��•„v'- �o�der.!thy. s®®4,�'' Print,Type of Stamp Name of Notary Lz1oz 9 A AM i 1 7 I -�--, gqAlto vAc 1 v I 3- THA/ the Z"CombuiT —I...- -I —" eotj KIECT DETER a i zo s+�A•c GomDu1",r 1101 ) ®�� N oT THAN l\\/lliami Shores Village ® r APPROVED BY DATE ZONING DEPT BLDG DEPT SUBJECT TO COMPLIANCE WITH ALL FEDERAL STATE AND COUNTY RULES AND REGULATIONS • s F-L�crRt CAL LoA D U^L.cuLATLpr r Nflr4lMjUM SIZE FIEF QF.R 6 A• C,E!V F-RA 1. Li G HT;Nc,, 1,p G1D watts To-rA L �,�6't� w,gT9`S 7 a 9 e3 : Two sr, t1h WI'Aricas • Es �er'cue 4 �� loop We1tt� 3000 wags ED-Ta l 3 00 n w�its C: A e - .IkEFi2►�gE�ATo� ,+Ott t'y wo m S 1;$0 A w ,t$ 5 00_x!'-W a its i NV4�� 4•/EiA1P�� pp '���•RO w�to+ls . R wd It's, � LID L►, s 00 ene�etts oNn E -TED LOAj) ,Lcsn AIC z FiRSk 10,000 VStq/ 3� looy 10,000 %ttc%tta . Rcev►Aine7j��2 „„��� 4oc 9� y = e ®� watt's. A/ (®� I•IEHTieel c,� 1v®�/ 7 C ® "~ 14,400 w4".5. T�tQL 34,1oE, wart's. -34,1o�/24awal`ts 14� A,, s� Ido 21f0 VNE.wDo ,4m ,SE11vlCE 6 bE