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REV-16-884 " Miami Shores Village CL*rE Building Department AP 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795.2204 Fax:(305)756.8972 7 INSPECTION'S PHONE NUMBER:(305)762.4949 FBC 20 1 BUILDING Permit No. 2 6 '� PERMIT APPLICATION Master Permit No. I� Permit Type:Electrical , JOB ADDRESS: �V, s-i 'D �E Lo `GYpP, City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11 -zZ 31 - o 1 3 - d SH 0 Is the Building Historically Designated:Yes NO Flood Zone: OWNER:Name(Fee Simple Titleholder): -\'F-,S &J6 LL G Phone#: '�Uo G I S 68 7Z Address: Z�D C> �•3� c�.n Dry/� C�--e. C, rLZL city: State: Zip: 3 ��d Tenant/Lessee Name: Phone#: A0 fe 61 S(0 3 Z Email CONTRACTOR:Company Name: VICON ELECTRIC INC Phone#: 954-972-8017 Ate: 520 SW 63RD TERRACE City: MARGATE Ste; FL. Zip; 33068 Qualifier Name: GLEN GRANT Phone#: State Certification or Registration#: EC 0002072 Certificate of Competency#: Contact Phone#: 954-801-0615 —Email Address: GLEN.GRANT1@COMCAST.NET DESIGNER:Architect/Engineer. Phone#: Value of Work for this Permit:$ Z 5� Square/Linear Footage of Work: Type of Work: OAddress dAlteration ONew ORepair/Replace ODemolition Description of Work: rtJy Cy�,_,,P �-s o-N%eA ( »!�A-k4 m r\ b o Submittal Fee$ Permit Fee$ CGF$ CO/CC$ Scanning Fee$ Q Radon Fee$ DBPR$ Bond$ Notary$ T=hdng/Education Fee$ Technology Fee$ Double Fee$ Stractural Review$ TOTAL FEE NOW DUE$ 3 e• M ILo 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 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. "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 COMIV ENCEMENT." Notice to Applicant. As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged Signature Signature Owner or Agent Co tractor The foregoing instrument was acknowledged before me this—'I!J— The foregoing instrument was acknowledged before me this 14 day of 20 LL,by 57.E Ppte-DGt' %gl!! a day of MARCH ,20_,by GLEN GRANT who is ally known to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. ;NOTY PUBLIC: pAv 0v Notary Public State of Florida NOTARY PUB*Expirmes: Vanessa Romeror � My Commission FF 129458 HELENA FAE361,Y Expires 06/04/2018 h1Y COMMISSION#FF 145237 Si EXPIHic8:March 20,2019 HE &W thmmiaylau` " Print. My Commission Expires: • �• My Co ion 4iz s�r�$a*e>$ar�e�as,ears**ese�*s,ssr�s�e�aeeerrsar��sa$sre��r*$**esr�m�**a �a��eee�se�e�e*v�e APPROVED BY �d� 'ltr Plans Examiner Zoning Structural Review Clerk (Revised 3112/2012)(Revised 07/1QI07)(Revised 06/I 2009)(Revised 3/15/09) '0 DATE(MMMD/WM C40 CERTIFICATE OF LIABILITY INSURANCE 3/16/2016 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 policypes)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: David Ragno Keyes Coverage Insurance PHONE 5900 Hiatus RoadN 994-724-7000 A/C No: - L-7094 Tamarac FL 33321 ADDRESS. dra oQke escovera e.com PRODUCER CUSTOMER ID 9:13 2 2 8 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA:Wesco Insurance Co 25011 Vicon Electric, Inc. INSURERB:Asso 520 SW 63rd Terrace ciated Industries Ins. Co. 23140 Margate FL 33068 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:676513664 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 ADDTYPE OF INSURANCE LSUBR POLICY EFF POLICY EXP LIMITS POLICY NUMBER D D A GENERAL LIABILITY y WPP1155789-01 3/19/2016 3/19/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO REN X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurcence $50,000 CLAIMS-MADE FTI OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PROT F - LOC $ A AUTOMOBILE LIABILITY WPP1417712 00 10/29/2015 10/29/2016 COMBINED SINGLE LIMIT $350,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS X HIRED AUTOS PROPERTY accident)DAMAGE $ X NON-OWNED AUTOS $ UMBRELLALIAR OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION ANC1054130 11/20/2015 11/20/2016 X I TORY WCSTATIT O R AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE a N/A E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLE(Attach ACORD 101,Additional Remarks Schedule,N more apace Is required) License no. EC0002072 CERTIFICATE HOLDER CANCELLATION 30 Das Notice 10 Das for Non-Pa SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores Village Building Department 10050 N.E. 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 � t ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD