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ELC-16-1073 • M 7 2— Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-257294 Permit Number: ELC-4-16-1073 Scheduled Inspection Date: May 18,2016 Permit Type: Electrical-Commercial Inspector. Devaney, Michael Inspection Type: Final Owner: , Work Classification: Repair Job Address:9601 NE 2 Avenue Miami Shores, FL 33138-2721 Phone Number (954)348-0479 Parcel Number 1132060134060 Project: <NONE> Contractor: OLEX ELECTRIC INC Phone: (305)781-2215 Building Department Comments DISCONNECT&CONNECT 4 DISPENSERS Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed 21 Failed 40 191111e'111/� Correction Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid May 17 2016 For Inspections please call: (305)762-4949 y Page 21 of 44 � Miami Shores Village 10050 N.E.2nd Avenue NE Miami Shores,FL 33138-0000 s Phone: (305)795-2204 � �� �� i . sExpiration: 10/2612016 k ' fl Project Address Parcel Number Applicant 9601 NE 2 Avenue 1132060134060 Miami Shores, FL 33138-2721 Block: Lot: Atlantic Oil Incorporated Owner Information Address Phone Cell Atlantic Oil Incorporated 1308 E Atlantic Boulevard (954)348-0479 Pompano Beach FL 33060- 1308 E Atlantic Boulevard Pompano Beach FL 33060- Contractor(s) Phone Cell PhoneValu $ 500.00 Total Sq OLEX ELECTRIC INC (305)781-2215 Total Sq Feet: 0 Type of Work:DISCONNECT&CONNECT 4 DISPENSERS Available Inspections: Additional Info: Inspection Type: Classification:Commercial Final Scanning:1 Review Electrical Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee Invoice# ELC-4-16-59488 i $2.25 04/28/2016 Credit Card $109.10 $50.00 DCA Fee $2.25 Education Surcharge $0.20 04/21/2016 Credit Card $50.00 $0.00 Perot Fee $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 an in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRI L,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDA rtify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zo i uthermore,I authorize the above-named contractor to do the work stated. April 28,2016 Authoriz re:Owner / Applicant / Contractor / Agent Date Building Department Copy April 28,2016 1 r I�ED Miami Shores Village = Building Department ' APR 21 20 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 `a V- Tel:(305)79S-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 5-M1=8c 20N� BUILDING Master Permit No. kc- 4(0- 1077 2) PERMIT APPLICATION Sub Permit No. Eu 1�6- (4)�3 (]BUILDING 0 ELECTRIC ❑ROOFING REVISION ❑EXTENSION (7RENEWAL ❑PLUMBING ❑MECHANICAL []PUBLIC WORKS ❑CHANGE OF [:)CANCELLATION ❑SHOP CONTRACTOR DRAWINGS JOBADDRESS: 9601 NE 2 AV City Miami Shores County Miard Qade 7J 0: 33138 Fogo/Pard#: 11-3 24103 6-013-4 0 60 is the sutlding Historicagy Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): MIAMI SHORES SERVICE STATION, INC phone#: Address: 9601 NE 2 AVENUE aw MIAMI SHORESState; FLORIDA gyp. 33138 Tenant/Lessee Name: Phone#: Email: coNTRACTOR:Company Name: OLEX ELECTRIC phone#: 305.781.2215 Address: 16275 SW 95 ST City: MIAMI State: FLORIDA Dp: 331.96 Quaig9er Name: OLEXIS JAM Phone#• 786.991.5000 State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: JORGE FIALLO FIALLO'S M DESIGN phone#; 305.877.1845 Addresv 10010 SW 83 ST qty: MIAMI State: FL Zip: 33173 Value of Work for this Permit:$ -&() Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ® Repair/Replace ❑ Demolition Description of Work: REPLACE EXISTING FUEL DISP SERS I �a ��� �/►n!� � is en.tt� �' Specify color off color thru tiles Submittal Fee S 5y -Co Permit CCF$ 0 co/ccs: Scanning Fees `00 �Radon Fee$ �. . DBpPRR$ • ? Notary S Technology Fee s b` eo Trainhtg/Education Fee$ l 1•CyJ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ laevbe0W4/2014) sorting Company's Name of applicable) ti 43onding 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 is nce of a building permit with an estimated value exceeding$25W, the applicant must promise in g!iWNER a forAGENT Fn to of commencement and construction lien law brochure will be delivered to the person whose propo,a certified copy of the recorded notice of commencement must be posted at the job site for the first (7) days after the building permit is issued. in the absence of such posted notice, the inspection wvction fee will be charged Signature Signature ` TRACTOR The foregoing instrument as acknowledged before me this The foregoing instrument was acknowledged before me this �a day of-APA / ,2014 .by 3 day of Oc. L ,20 16 .by MANHOOD SHEklAOEH o is personally knownto ��-EXIS JAM who is personally known to �mJor who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: .���Fi Sign: Print: s�. ?� O Print: '2:" :°` Notary Public-State of Florida Seal: =� 4. _ Seal: ;oma;My Comm.Expires Apr 25,2016 ' , ��„�i�;' cr�o;:� Commission#EE 192809 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Redisedo2/24/2014) �FLORWA, DEPARTt FENT Of uSI &S AND.PROFESSIONAL RF-GtUL.ATIOM , ELeCTRICA>t.�G+ 'TfiACTQR$^S.lC3ENSING BQARD x� E E0-TRICAL.CONTRACTOR IS..OERT'IFIED t v TITS of phap#er488 FS: h [�MrI I,,+.>YR f •.:.0 k Sze.^• u - � d�' T-- Si >h �>' i '. > ':.� {..hv�. •..�...,.,�aW� .��,�.aw�'kr A....nY'"i>v...��'b x+� h ISSUED: 0111112015 DISPLAY AS REQUIRED BY LAW SEQ# 1.150111Ni � k kCCg{ Y k4 u i 4/20/2016 i magel.j peg I Local Busine v Miami-= i�� C Y �^ e rH s% „ ! � E 0' EX ELECTRIC NO I E275 S'V'V 95 ST to r tnf dk #err nt lslo 3F-; f f", S'J.'i t.9l;fit 11+_f:1 Jf f, (-,Or 4 WA?,f 41 Ibis CncatnlrsssTaxtrr#{Yvuer ttdiihoLa wf1 ?tt00 , da .+tt3 it .permab ort a r s 3av rrfr�anrat ran ands N l�3kN� ; s Th,t RECEIPT NO, be dispy i 11,Ow MW r/ �� s /'` �''� / a ✓ , \�\���v •�e��` �k � '. r u ��y�r� - cry n � r ��•� ,.�� d ���� .a�.t C 31� �klr�;�a �� t' t� �Z'd.�aaee: i ya �, https://m ai I.google.com/mai I/u/0/#inbox/15434cfa9c5270bd?projector=1 1/1 ACC:> CERTIFICATE OF LIABILITY INSURANCE DATE(MIMIDDIYy1M �.,...•~ 04/18/16 THIO 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. Astatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Agustin EstiWaB General Insurance Group Corp. PHONNo,E (786)280-4113 F No): (305 51-8461 10350 SW 64th St - agustin@genins.net Miami,FL 33173 INSURER(S) AFFORDING COVERAGE MAIC 0 Phone (786)280-4113 Fax (305)351-8461 aSURERA: Granada Insurance Company 16870 INSURED INSURER B: OLEXIS JAM d/b/a/ OLEX ELECTRIC INC INSURER C: 16275 SW 95th Street #6 INSURER D: Miami,FL 33196- (305)408-2330 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. ILTR TYPE OF INSURANCE ADD UB POLICY NUMBER DY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 0 PREMISESS COMMERCIAL GENERAL LIABILITY DAMAGE (RENTEDEa occurrence) $ 100,000.00 F-1 ❑ CLAIMS-MADE R] OCCUR 0185FL000309% MED EXP(Any one penton $ 5,0 .00 A F-111/09/2015 11/09/2016 00 PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000.00 ❑ POLICY ❑ PRO- [:] LOCJECT $ AUTOMOBILE LIABILITY MBINED SINGLE LIMIT acddent ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ AA�OWNED ❑ SSCC,HrD ULED BODILY INJURY(Per accident $ F-1 HIRED AUTOS ❑ AUTOS AU NED POPE dYnDAMAGE $ 1:1 11Ore $ ❑ UMBRELLA UAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAS ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑WC STATU- ❑OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS i VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) License#EC13006490 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Miami Shores THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd AV AUTHORIZED REPRESENTATIVE _ Miami Shores,FL 33138 ©1988-2010 ACORD CORPORATION. All rights reserved ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD 2/23/2016 20151222_122322.jpg STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF 'WORKERS' COMPENSATION CONSTRUCTION INDUSTRY IXEMPTIC)IN CERTIFICATE OF ELECTION TO SE EXEMPT FROM FLORIDA WORKERS`COMPENSATION LAW Wol!� FFFE TIVE DATE: Ii3tl=16 EXPIRATIONOATE: ,, p PERSON: JAM OILEXIS FIN: 2 5i} 1WN UUZRRI https://drive.googIe.com/drive/folders/0Bw4Jrx3l2EvOeElnQm 1 xNTdDdEk 1/1 OLEX ELECTRIC INC EC 13006490 16275 SW 95 ST MIAMI, FL 33196 (786)991 5000 4/15/2016 To : City of Miami Shores State of p r,' Q County of pe Before Me this day personally appeared Ole who, being duly sworn deposes and says That be or she will be the only person working on the project located at 9601 NE 2nd ave Miami Shores 33138 Sworn to or ao firmed and subscribed before me to this 1 a day of #P r! Personally Known V Produced Identification Type of identification duced GtJSTAVO ARISTIZABA[. MY COWSSION*FF175273 EXPIRES November 29,2018 Print, Type011 a p Name of Notary (407)3"-0153 FloridallotaryService.com 9601 NE 2ND Av 7 C Miami shores Village Building Department ORID 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 Notice tOwner Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapler 440 of the Florida Statutes. Fla. Slat. § 440,05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining abuilding permit. Pursuant tel the Florida Division ol"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,mist obtain 11orkers'LOMPOISaliOn coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if- I I. 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-, I The officer i., listed as an officer of the corporation in the records of the Florida Department of State,Division ofCorporationsl-and 3. The corporation is registered and listed its actin` with the Florida Depannient of State,Division of Corporations. No more than three corporate officers.per corporation or limited liability company members are allowed to be exeryipt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by(tic Division. Your contractor is requesting a pq iii u ider this workers'compensation exemption and has acknowledge that he or she will not use day labor,part-time employees s ntractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to or your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insur c crape from the contrictoCs company for day labor,part-time employees or subcontractors. BY SIGNING BELO _KN0WLFDGF THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND 11-S CON*rENTS. Signature: 0 er MAHMOUD SHEHADEH State of Florida County of Miami-Dade Iq da The foregoing was acknowledge A ge belbre me this yof_ By, 11/�00� 4 personally known to nm has produced �0/�e&h (,%vho is M I S& 8z Notary. FFi96224 5 SEAL: EXPIRES Feb.4,2019 Z I&