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EL-15-1930 Inspection Worksheet Miami Shores Village Or 10050 N.E.2nd Avenue Miami Shores, FL — Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-255820 Permit Number: EL-7-15-1930 Scheduled Inspection Date: March 30,2016 Permit Type: Electrical- Residential Inspector: Devaney, Michael Inspection Type: Final Owner: , Work Classification: Service Change Job Address:149 NE 105 Street Miami Shores,FL Phone Number (786)231-5339 Parcel Number 1121360050130 Project: <NONE> Contractor: ADAN ELECTRICAL SERVICES LLC Phone: (786)285-3847 Building Department Comments UPGRADE OF SERVICE TO 200 AMP Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed as per inspector's indication Failed T � Correction j Needed <� Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid March 29,2016 For Inspections please call: (305)762-4949 Page 32 of 39 za Miami Shores Village , 7 � o 10050 N.E.2nd Avenue NE Miami Shores,FL 33138-0000 Phone: (305)795-2204 APPROVED y ,Expiration: 02/01/2016 ;-C' Project Address Parcel Number Applicant 149 N E 105 Street 1121360050130 Miami Shores, FL Block: Lot: ZURDDO CORPORATION Owner Information Address Phone Cell ZURDDO CORPORATION 12921 S CALUSA Drive (786)231-5339 MIAMI FL 33186- 12921 S CALUSA Drive MIAMI FL 33186- Contractor(s) Phone Cell Phone Valuation: $ 2,000.00 ADAN ELECTRICAL SERVICES LLC (786)285-3847 Total Sq Feet: 0 Type of Work:UPGRADE OF SERVICE TO 200 AMP 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-7-15-56541 $4.20 07/30/2015 Credit Card $50.00 $250.60 DCA Fee $4.20 Education Surcharge $0.40 08/05/2015 Credit Card $250.60 $0.00 Permit Fee-Additions/Alterations $280.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $300.60 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 is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. h e,I a e the above-named contractor to do the work stated. August 05,2015 ?9160zed Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy August 05,2015 1 Miami Shores Village Building Department JUL 302015 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20C® BUILDING Master Permit No. 2K1.5-&'- PERMIT APPLICATION Sub Permit No.`�_ G fel 3 C) ❑BUILDING (`ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL r-]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP (, CONTRACTOR DRAWINGS JOB ADDRESS: 190t Nt- �o s I City: Miami Shores County: Miami Dade Zip: 3� Folio/Parcel#: L�-Zl "�Q 5- Q l so Is the Building Historically Designated:Yes NO�— Occupancy Type: Load: Construction Type:CIS&_Flood Zone: _BFE: FFE: OWNER: Name(Fee Simple Titleholder):Z02bbb (��r ON) Phone#: 2!2A Address: ' SA ii�r trJs��� o� ._ City: tt State: FL Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Q�� ` V Address: ) © I Sly AU'E City: 00 GO State: !F7 L Zip: 2�1, Qualifier Name: 1 _17P 11 yy�� 't GG Phone#: �(o State Certification or Registrations M#: �' 00 44 57Certificate of Competency#: DESIGNER:Architect/Engineer: 1_ Phone#: ^5 ^ Address: City: State: L_ Zip: 3 Value of Work for this Permit:$ :D©t7 Square/Linear Footage of Work: Type of Work: rAddition ❑ Alter tion ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Specify color of color thru the Submittal Fee$ Permit Fee$ ` CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 'Z50 G® (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 Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 , by day of r 20J by !V personally known to /5��11'f � ,who is personally known to me or 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 PUB NOTARY PUBLIC: Sign, Sign: int: PMuLary I.— ' Seal: Joanna M Feli ' no Eov Notary public State of FiMy Commission F 082753 Seal: % Joanna M Feliciano Expires01/12/2018 ' My Corrirr�ssion FF 082753 Expires01/12!2018 APPROVED BY .;Zl- 64--Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm,A-100, Ft. Lauderdale, FL 33301-1895—954431-4000 VALID OCTOBER 1,2014 THROUGH SEPTEMBER 30,2015 DBA: Receipt ELECTRICAL SERVICES LLC Receipt#:ELECTRICAL/�+1.At;@Dv/CtiBs,' Business Name: Business Type:(ELECTRICAL. cotirtprviA1 Owner Name:ROLMDO ADAM Business Opened:wo1/2010 Business Location:3001 SW 37 AVENUE State/County/Cett/Reg:EC1300,,4453 HOLLYWOOD Exemption Code: Business Phone:786-285-384 7 E Rooms Seats Employees Machines 2 For Vending Bushme Only Number of Machines: Vending T pe: Tax Amount Transfer Fee NSF Fee Penalty Pdor Years cotiection cam Taut is 27.00 0.00 o.00 0.90 0.00 0.00 °7 ^. s' THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF SUSINE= THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business w4hin f3rvrard f,' non-regulatory In nature You must meet an County Cor ty oamv WHEN VALIDATED and zoning requirements. This Business Tax Rempt nww to b the business is sold, business name has changed or you have business location.This receipt does not indite Ihat the butwen its it M in compliance with State or local laws and regulatiorl9l Mailing Address: f'1,'.,I:f.+t ! I.I,I.r, I�e�ib�►1p ��i�mi�AQ�4iiw` paid 09/1712014 11-44 2014 - Z01-S Scanned by CamScanner 1YF A�O® CERTIFICATE OF LIABILITY INSURANCE °Aoroon'�Do1° ' 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 CONTANSE; Alexis Del Vane Qbik Insurance,Inc PHONE (866)320-7245 FAX (305)964-7715 5701 Sunset Drive Ste.256 ��, adelvallo@gbiklnsurance.com INSURER(S)AFFORDING COVERAGE NAIC 0 South Miami Fl. 33143 INSURER A: Ascendant Insurance INSURED INSURER 8: Adan Electrical Service LLC INSURER C: 3001 SW 37 Avenue INSURER D: INSURER E: Hollywood FL 3302-3-- INSURER F: COVERAGES CERTIFIME NUM11115W 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 DOGYMENT 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. ADM-5UBR LTR TYPE OF INSURANCEAM POLICY NUMBER POLICY EFF POLICY EXP LIMITS X COMMERCIAL NERAL LIABIL Y EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ( DAMAGE To F[MqTEtY-- OCCUR PREMISES omurenee $ 100,000 MED EXP(Any one person) $ 5,000 A GL-48188-0 05/21/2015 05/2112016 PERsoNALBADvINJuRY $ 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO. E-1 LOC PRODUCTS-COMPIOPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILTryBIa IN SINGLE LIMIT $ ANYAUTO BODILYINJURY(Perperson) $ ALL OiMNED SCHEDULED BODILY AUTOS BILY IN IR1RY(Per acdderlT) $ HIREDAUTOSAUT-OWNID PROPERTY DAMAGE $ AUTOS aCcideM UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNEWEXECUTIVE ❑NIA E.L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (MarWatory In NH) E.L.DISEASE-EA EMPLOYE $ nyes,tleurrfbe raxfer DESCRIPTION OF OPERATIONS below r7- POLICY LIMIT s DESCRIPTION OF OPERATION I LOCATIONS I VEHICLES(ACORD 101,AMbkw al Remarks SWeedule,may be atfadmd If more spars is requhed) License Number:EC13004453 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 AVE AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 ©1888-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA 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: 6/1/2014 EXPIRATION DATE: 5/31/2016 PERSON: ADAM ROLANDO FEIN: 272398773 BUSINESS NAME AND ADDRESS: ADAN ELECTRICAL SERVICE 3001 SW 37 AVE HOLLYWOOD FL 33023 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing 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 if,at any time after the filing of the notice or the issuance of the certificate,the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 :.- STATE OF FLORIDA DEPARTMENT OF BUSIES PROFESSIONAL REGULATION AND ISSUED: 08/12/2014 EC13004453 c CERTIFIED ELECTRICAL CONTRACTOR r ADAN, ROLANDO EST a $ o ADAN ELECTRICAL SERVICES LLC 4 J Q W? 9 �.} 4V U-) inCNI j LLJ a +oN{O N 1- Oil �N1 IS CERTIFIED under the provisions of C 4.0 12 00 380 Ow t oN 2 �N► a Expiration date AUG 31.2016 tY9 Z0000 X4nS Y S ti S�oR� y soon n,,,� Miami shores Village '-- �e Building Department R`Tgp► 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 to work on your project.In these circumstances,Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of ���° 20 h ByNICHOt—A.S who sonally known t r has produced as identification. -74 Notary: 1 SEAL: ADAN ELECTRICAL SERVICES LLC. Friday,July 10,2015 State of Florida. County of Broward. Before me this day personally a pear d Rolando Adan who,being duly sworn,deposes and Say: That he will be the only p rson working on the project located at 149 NE 105 ST Miami Shores, FI,33138. Sworn to(or affirmed)and subscribed before me this-�-�-day of---- -----------20-`--"�--,by Personally know----------------------- OR Produced Identification-- Type of Identification Produced -=--�'�i Print,Type of Stamp Name of Notary MICHAEL R.BONKOSKY Notary Public-State of Florida My Comm.Expires Apr 21,2017 Commission#FF 010248