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EL-16-747 I 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-255457 Permit Number: EL-3-16-747 Scheduled Inspection Date: March 28,2016 Permit Type: Electrical- Residential Inspector: Devaney,Michael Inspection Type: Final Owner: NICHOLS,ALLAN Work Classification: Alteration Job Address:113 NW 106 Street Miami Shores,FL 33150- Phone Number (305)758-9630 Parcel Number 1121360080310 Project <NONE> Contractor: MIAMI ELECTRIC INC Phone: (954)444-5079 Building Department Comments PROVIDE POWER FOR A/C UNIT Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed P�r CREATED AS REINSPECTION FOR INSP-255448. Failed Correction Needed Re-Inspection a Fee No Additional Inspections can be scheduled until re-inspection fee is paid March 25,2016 For Inspections please call: (305)762-4949 Page 20 of 31 Miami Shores Village 10050 N.E.2nd Avenue NWS Miami Shores,FL 33138-0000 Phone: (305)795-2204 � s� M� �£.. ,,:,. >s=. . ;, �€ :.,,�� .• `�, •� _ r Expiration: 010/ 01 Project Address Parcel Number Applicant 113 NW 106 Street 1121360080310 ALLAN NICHOLS Miami Shores, FL 33150- Block: Lot: Owner information Address Phone Cell ALLAN NICHOLS 113 NW 106 ST (305)758-9630 MIAMI SHORES FL 33150-1247 Contractors) Phone Cell Phone Valuation: $ 700.00 MIAMI ELECTRIC INC (954)444-5079 Total Sq Feet: 0 Type of Work:PROVIDE POWER FOR A/C UNIT Available Inspections: Additional Info: Inspection Type: Classification:Residential Review Electrical Scanning:1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# EL-3-16-59100 DBPR Fee $2.25 03/24/2016 Check#:8076 $109.10 $50.00 DCA Fee $2.25 Education Surcharge $0.20 03/22/2016 Check#:8077 $50.00 $0.00 Permit Fee-Additions/Alterations $150.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $159.10 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 ' rate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-n ed contra r to do the work stated. March 24, 2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy March 24,2 16 1 Miami Shores Village R7,� 2 2616 Building Department10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-88972 INSPECTION LINE PHONE NUMBER:(305)762-4949 S+1k FBC 201q `L BUILDING Master Permit No. 0 L 16 PERMIT APPLICATION Sub Permit No. ❑BUILDING M ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑MECHANICAL ❑PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1I3 /V W l City: Miami Shores County: , Miami Dade Zip: �3/fid Folio/Parcel#:�sZ�3(�' ®31 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Typee:' Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): /0&j �' /"I C �s Phone#:(/_30 -7 s� / 25—3-ES Address: 413 D-w 104? City: a/04m ) � State: L Zip: �j 3 fS 0 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Miami Electric, Inc. Phone#: 954-444"5079 Address: 5201 SW 195th Terrace City: Southwest Ranches State: Fi Zip: 33332 Qualifier Name: Rene Gomez Phone#: 954-444-5079 State Certification or Registration#: EC-0002200 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: value of work for this Permit:$700.00 Square/Unear Footage of work: Type of Work: ❑ Addition Q Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Provide power for a/c unit. Specify color of color thru tile: Submittal Fee$ IJ� Permit Fee CCF$ V " CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (ReviseW2/24/2M4) 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/s 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. /n 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 ,;,711 day of M,J-IZC FI ,20 by k(day of �� , '20 �Q .by 1 le!�a �S ,who is pgrsonally known to �e n� (- CYN'Q- -,who is personally known to me or who has produced as me or who has produced aV 4%5- JO S identification and who did take an oath. identification and who did talo an oath. NOTARY PUBLIC: NOTARY PUBLIC: J Sign: Sign Print: PH : `'.. CQ ►SS Seal " " MY COMMISSION#FF075729 l4ori�1� January 25.201; ... E XPIFIES December 11,2017 Sed: �t�tlallotaryService.com y > •01i5i Iegtld�Nota nilne.00m APPROVED BY � Pians Examiner Zoning Structural Review Clerk (Rev1sed02/24/2M4) ,I .,_ w BRAWARD COUNTY LOCAL BUS114ESS TAX RECEIPT � 115 S.Andrews Ave., Rm.A-1-10,FL to aha,FL 33301-1895—954-831-400.0 x; VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016r OBA:MIAMI ELECTRIC INC Receipt#:E CTRICAL/ALARMS/CCaTR C Business Name: Business Type:(ELECTRICAL CONTRACTOR) Garner Name: oiEz RENE JR Business Opened:12/17/2 004 Busing Location:5201 sw 195 TER State/Courg1Cert1Reg:EC0002200 SOUTHWEST RANCHES Exemption Code: BusinesS Phone:954-444-5079 rrt t Seats E"10y+ees Inee Professionals 3 For vending austrma only 1�riflflbo{of . nes: VeMkdooft Tax Amount TranSW Fee NSF Fee Penalty Primo`ears Colton Cost Total Paid 27.00 0,001 0.00 1 0.00 0.00 0.00 X7.00 THIS RECEIPT DUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax IS IbviOd for the privilege of doing business within Broward County and is non-regulatory in nature.You must meet an 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 lei or that it is in compliance with State or local laws and regulations. Mailing Address: GOMEZ RENE JR Receipt #OSA 1e-00009054 5201 SW 195 ICER Paid.09/11/2015 27.00 SOUTHWEST RANCHES, FL 33332 2015 - 2016 _ ,� „ s � d -4 CERTIFICATE OF LIABILITY INSURANCE DA 3/11416 PRODUCER ,Accredited Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 6099 Hollywood Blvd ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Hollywood,FL 33024 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (954)964-5444 Fax (954)964-0772 INSURERS AFFORDING COVERAGE NAIC# INSURED MIAMI ELECTRIC INC INSURER A: MAXUM INDEMNITY 5201 SW 195TH TERRACE INSURER B: INSURER C: SOUTHWEST RANCHES,FL 33332 INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY POLICY EXPIRATION LIMITS ID DATE IDD MDATE D GENERAL LIABILITY EACH OCCURRENCE 11000,000 ®COMMERCIAL GENERAL LIABILITY DA AGgD00083075-02 08/01/15 08/01/16 PREM SES Ea occurRENTED 100,000 ❑❑ CLAIMS MADE © OCCUR MED EXP(Any one person) 5,000 A ❑ ❑ PERSONAL&ADV INJURY 1,000,000 ❑ GENERAL AGGREGATE 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 2,000,000 © POLICY ❑PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS URY F-1 ❑ SCHEDULED AUTOS (eDperIon) ❑ HIRED AUTOS BODILY INJURY ❑ NON OWNED AUTOS (Per accident) ❑ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC ❑ AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE ❑ ❑ OCCUR ❑ CLAIMS MADE AGGREGATE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND ❑ WC STATU- ❑ OTH- EMPLOYERS'LIABILITY TORMITE ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ELECTRICAL CONTRACTING CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL CITY OF MIAMI SHORES 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NE 2ND AVENUE THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY MIAMI SHORES,FL 33138 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE asx I ACORD 25(2001/08)OF 0 ACORD CORPORATION 1980 Repo,, fior4w pap 9 C62 U -WP AIWAMR 4 DEPARTMENrOFFMAICIALSEMMES N OPWORIOWC TION "• CERTIFICATEOFE. CIN Teams EXBWT FROM FLORIDAWOMMW COMPENSATION LAw g aCONSTRUCnON INDUWW EXEMPTION k 'this coMme thatthe lndMdual listed below has ofected tD be exempt from Flordds fd b"rs'Compensation lamer. PERSOM GOMEZ REHE FEM 6=20740 MM ELECTRIC INC 5201 SW 998TH TERRACE 3 SOUTHIYEBT RANCHES FL 33332 SCOPES OF BUSINM OR Y. TPAM- LICENSED ELECTRICAL. CONTRACTOR �art4s.aB.,�, are vaa "' ad doft 0 WW au ' ere m a a. aria tee. . oe + e� m l aw �sdr�r � ra mei mt� m+� i OrS412 CERWICAU£1'R gC`4N TO MIS f i a { e I 8 � I i I f q CERTIFICATE OF LIABILITY INSURANCE DATE 03121 DDNY 016 THIS CERMFICATE 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 terns 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 endomement(s). PRODUCER CONTACT Michael D.Holleman PRONEI Work Comp Associates,Inc c .e a (561)863-9581 ,-1: (561)881-9745 P.O.Box 33297 S°""` mail@WorkCompAssoc.com Palm Beach Gardens,FL 33420-3297 INSURER(&)AFFORDING COVERAGE Nac e INSURER A: BusinessFirst Insurance Company INSURED INSURER S: Miami Electric,Inc. INSURER C: 5201 S.W.195th Terrace Southwest Ranches,FL 33332-1215 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. INSR AD UB POLICY EFF POLICY EXP GENERAL LIABILnY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY $ —EICLAIMS-MADE ❑ OCCUR DF—] MED EXP(Any one $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY EPRO LOC $ AUTOMOBILE LIABILITY E� $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MAD AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X YI A ANY PROPRIETORIPARTNERIEXECUTIVIME.L.EACH ACCIDENT $ 1,000,0 (Mandatory M NH) N/ ® 0521117310000 8/1/2015 8/1/2016 E.L.DISEASE-EA $ 1,000,000 If yes,describe under E L DISEASE-POLICY LIMrr $ 1,000,00 ❑ ❑ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) For City of Miami Shores:According to the Department of Business and Professional Regulation,Rene Gomez,Jr.is the license holder for Miami Electric Inc., license number ECO002200. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Miami Shores Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N E 2nd Avenue Miami Shores Village,FL 33138-2382 AUTHORIZED REPRESENTATIVEAf 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD