EL-13-1549 ' Miami Shores Village
`� BuildingDepartment JUL 0,3
Alb 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 ;_-
Tel:(305)795.2204 Fag:(305)756.8972
1 INSPECTION'S PHONE NUMBER:(305)762.4949
FBC 20 L�
BUILDING Permit No. �� C)
PERMIT APPLICATION Master Permit No. &C, 056t0(09
Permit Type:Electrical
JOB ADDRESS:- I'1 (0 1 tj (doh Vial
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): 0..La1 hone#:
_{A�Q 1 n c
Address: b,, -f
City: , S ho �eS State: ' 3 13 S
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: SQ �YrG�t{�.U PhonekS
s,
Address: q I S A16 1a-5- Sfn o+
City: Pa 1 `La_gh l State: 0—, 61
Qualifier Name: CJ Vi e Y\ R-L Phone#:30. ,Sa$'-S9 SS
State Certification or Registration#: 6j�@0000-70:7 Certificate of Competency#:
Contact Phone#: Email Address: T,51Z0'70"J G m,l I .C o m
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit: Sg//nare/Linear Footage of Work:
Type of Work: OAddress (]Alteration ETNew ORepair/Replace ElDemolition
Description of Work: WR.A kez(L 7'r 0.
Submittal Fee$ 3 Permit Fee$ �5 d�Ate'D CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ ining(Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$ e
► Bonding Company's Name(if applicable)
Bonding Company's Address
I 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 ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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.
"WARN11% 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
4
Signature Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this r The foregoing instrument was acknowledged before me this,
day of)_,2013,by day of 203,by
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUB(.LIC:
Sign: y`` Sign:
Print: N'`<<h4iE.1 144�1: Print:
My Commission ExpireL
Notary Public state of Florida My Commission Ex per, %;; PRISCILLA PEREZ
. Michael Robert Jaar f.1Y COMMISSION#FF00786t3
My Carmnission EE 631847 y���,.o.�
Exp*s 08/x3/2018 '•.,e�� o?. EXPIRES April 14,2017
_ ZO13F
APPROVED BY �� /Z ��� Plans Examiner Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10nM)(Revised 3/15/09)
-..M~ 5000ST1 OP ID:KD
DATE(6AHWDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 04/03/2013
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.
kMPORTANT: 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 endomemen s.
PRODUCER Phone:954-883-2900 NCAAME.T
Tanenbaum Harbor of Florida Fax:954-517-7400 PHONE FAX No
2900 SW 149th Avenue
Miramar,FL 33027-6605 D L
Allna Larraz,CPCU,AAI,CRIS
INSURER(S) AFFORDING COVERAGE NAIC it
INSURER A:Bridgefletd Employers Ins.Co. 10701
INSURED 50 State Security Service,Inc INSURER B:Philadelphia Indemnity Ins.Co. 180558
915 N.E.125th Street,Ste 200
North Miami,FL 33161 INSURER C:Gemini Insurance Co. 10833
INSURER D;U.S.Fire Insurance company 21113
INSURER E:Federal Insurance Company 20281
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.
!NSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFMfflnF POLICY DLP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
DAMAGE TO RENTED
C X COMMERCIAL GENERAL.LIABILITY LSG000126002 10/15/2012 10/15/2013 PREMISES Me ocaurence $ 100,00
CLAIMS-MADE FKOCCUR MED EXP(Any one person) $ 10,00
PERSONAL&ADV INJURY $ 1,000,00
GENERALAGGREGATE $ 5,000,00
GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 5,000,00
POLICY PRT LOC Emp Ben. $ 1,000,00
AUTOMOBILE LIABILITY ROINED
WarSIN LIMIT 1,000,00
X ANY AUTO PHPK921077 09/16/2012 09/16/2013 BODILY INJURY(Per person) $
AUTOSNED ASCHEDULED BODILY INJURY(Persoddent) $
HIRED AUTOS TOANON-OWNED P err ac 'ideTMi�tDAMAGE $
UMBRELLAUAB X OCCUR EACH OCCURRENCE $ 5,000,00
D X1 EXCESS LIAB CLAIMS-MADE 5821009209 10/15/2012 10/15/2013 AGGREGATE $ 51000,00
DED X RETENTION$ $
WORKERS COMPENSATION WC STATU- OTH-
04
AND EMPLOYERS'LIABILITY TORY LIMIT.
A ANY PROPRIETORIPARTNEROMCUTIVE Y/�N 0830398 04/01/2013 04/01/2014 E.L.EACH ACCIDENT $ 500,00
OFFICERIMEMBER EXCLUDED? N I A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE1 600,00
descrbe DESCRI OF OPERATIONS below E.L.DISEASE-POLICY UMIT 12 500,00
E Crime 82105908 08/19/2012 08/19/2013
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required)
INSTALLATION OF SECURITY, FIRE ALARM SYSTEMS, ACCESS CONTROL AND CAMERAS
CERTIFICATE HOLDER CANCELLATION
MIAMIS8
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING DEPARTMENT
10050 NE 2ND AVENUE AUTHORIZED REPRESENTATIVE
MIAMI SHORES,FL 33138 a
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