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EL-16-226 Inspection Worksheet L c Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (306)796-2204 Fax: (305)756-8972 Inspection Number: INSP-261699 Permit Number: EL-1-16-226 Scheduled Inspection Date:June 27,2016 Permit Type: Electrical- Residential Inspector: Devaney, Michael Inspection Type: Final Owner: PHILIZAIRE,JEAN &JENNER Work Classification: Repair Job Address:10904 NW 2 Avenue Miami Shores,FL 33168- Phone Number Parcel Number 1121360020190 Project: <NONE> Contractor: FOREVER ELECTRICAL POWER LLC Phone: (954)548-8381 Building Department Comments SERVICE REPAIR BEACUSE THE WIND PULL OUT THE Infractio Passed Comments METER CAN OF WALL. FPL ALREADY CUTS OUT THE INSPECTOR COMMENTS False POWER Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid June 24,2016 For Inspections please call: (305)762-4949 Page 29 of 37 wa } ry Miami Shores Village Y 10050 N.E.2nd Avenue NW "'• Miami Shores,FL 33138-0000 Phone., (305)795-2204 3 Expiration: 07/31/2016 F Project Address Parcel Number Applicant 10904 NW 2 Avenue 1121360020190 Miami Shores, FL 33168- Block: Lot: JEAN&JENNER PHILIZAIRE Owner Information Address Phone Cell JEAN&JENNER PHILIZAIRE 10904 NW 2 Avenue MAIMI SHORES FL 33168-4303 Contractor(s) Phone Cell Phone FOREVER ELECTRICAL POWER LLC 954 548-8381 Valuation: $ 1,000.00 ( ) (786)752-5007 a.� -�- Total Sq Feet: 0 Type of Work:SERVICE REPAIR BEACUSE THE WIND PUL Available Inspections: Additional Info: Inspection Type: Classification:Residential Final Scanning:3 Review Electrical Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee $2 25 InVOia@# EL-1-16-58471 DCA Fee $2.25 02/02/2016 Credit Card $115.10 $50.00 Education Surcharge $0.20 01/27/2016 Cash $50.00 $0.00 Permit Fee-AdditionsWterations $150.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $165.10 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDA IT: 1 certify that all the agoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction an oning. Futhermore,I a e above-named contractor to do the work stated. 14* February 02, 2016 orized gnature: Applicant / Contractor / Agent Date Building Department Copy February 02,2016 1 Miami Shores Village ' Building Department artt JAN 137 20 6 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 q Tel:(305)795-2204 Fax:(305)756-8972 �Y: INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 BUILDING Master Permit No. EL l r- U.6 PERMIT APPLICATION Sub Permit No. ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL F-JPLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: Com: Miami Shores County: Miami Dade Zip: Folio/Parcel#. Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder) F. r Phone#: Address: !®C� iN L— o2 .4 11-f r, City: I2M State: fil Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name:J2 re✓ePhone#: Address:2 12 4 t4a 0 City: ikT� State: Zip: 1)2 Q Qualifier Name: (D boo Y7 S Phone#:���-��o? State Certification or Registration#: Certificate of Competency#: V" DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work fouthis Permit:$ /� Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Specify color of color thru tile: Submittal Fee r `� Permit Fee$ CCF$ 0 CO/CC$ Scanning Fee$ °W Radon Fee$ DBPPR$ �' Notary$ Technology Fee$ Training/Education Fee$ ® Double Fee$ Structural Reviews$ Bond$ {g TOTAL FEE NOW DUE$ Y l L9 (Revised02/24/2014) ' r Bonding Company's Name(if applicable) r 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 Vr AGEN CONTRACTOR The ff or/egoi instrument was acknowledged before me this Th_e—forre_going inst7jent was acknowledged before me this day of 201 (. .by Ute' day of(' J '20 .by 1'1R�•- 1 '1�.Gu. is personally known to _t!� V`��� ,who is personally known to f me or who has produced as me or who has produced identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sig Sign: Print: Print: GASNER ANI US ��YP'" A e`er': ��' °B4•• GASNER ANILUS Seal: " MY COMMISSION#FF028480 Seal: a MY COMMISSION#FF028480 EXPIRES June 17.2017 ; se' „...• ? oa,. EXPIRES June 17.201 (407)398-0153 FioddaN o otaryrService.com (407)398.0153 Flo ridallotMService.aam APPROVED BYPlans Examiner Zoning Structural Review Clerk (Revised02/24/2014) son pp.M Miami shores Village Building Department R 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305)756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: j r�.Q 1�2 0' �� �T 0 LJe r BUSINESS ADDRESS: "31,23,1 �i E� CITY STATE—a--ZIP —33 Qao BUSINESS PHONE: ( 5� ) J`�f�—S � FAX NUMBER�) CELL PHONE( o ) 75,a a20 QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: EeI��10 ill S� STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-139 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 OWENS, MARK EDWARD FOREVER ELECTRICAL POWER LLC 760 SE 2ND AVE APT D210 DEERFIELD BEACH FL 33441 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range - S1'A7'E OF F�4RIDA from architects to yacht brokers,from boxers to barbeque restaurants, `. �EPa4R I F kJSfNESS AND and they keep Florida's economy strong. LATION day we work to improve the way we do business in order.to .r " ;�� ` 312 serve you better. For information about our services,please log onto � ~ www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact.you,subscribe w- to department newsletters and learn more about the Department's Initiatives. ,- 4 Our mission at the Department is:License Efficiently,Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida,and congratulations on your new license! DETACH HERE } BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA: D Receipt#:ELECTRICAL8ALARMS/CONTRACTOR Business Name:FOREVER ELECTRICAL OWER LLC Business Type: (ELECTRICAL CONTRACTOR) Owner Name:MARK EDWARD OWENS Business Opened:04/09/2010 Business Location:2129 MADISON ST #S State/County/CertiReg:EC13004183 HOLLYWOOD Exemption Code: Business Phone:954-548-8381 Rooms Seats Employees Machines Professionals i For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 0.00 0.00 30.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature. You must meet all 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 legal or that it is in compliance with State or local taws and regulations. Mailing Address: FOREVER ELECTRICAL POWER LLC Receipt #138-14-00009293 2129 MADISON ST #B Paid 07/27/2015 30.00 HOLLYWOOD, FL 33020 2015 - 2016 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016 DBA; FOREVER ELECTRICAL POWER L•LC Receipt#: 181-232398 Business Name. Business Type:ELECTRICAL/ALARMS/CONTRACTOR LECTRICAL CONTRACTOR) Owner Name:14ARK EDWARD OWENS Business Opened:0 4/0 9/2 010 Business Location:2129 MADISON ST #B State/County/Cert/Reg:EC13004183 HOLLYWOOD Exemption Code: Business Phone: 954-548-8381 Rooms Seats Employees Machines Professionals 1 Signature For Vending Business Only Number of Machines: Vending Type. Tax Amount Transfer Fee I NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 3.40 ' 0.0-01 C.00 G.00 1 0.00 30.00 Receipt #138-14-00009293 Paid 07/27/2015 30.00 /,+�•►�", FOREV-1 OP ID:MG .Aa..OROS DATE MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 01/26/2016 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 cNMONTEAcT Jonathan F.Remes W.F.Roemer Insurance Agency PHONE954731-5566 FAX 954731-8438 3775 NW 124 Avenue N ac No Coral Springs,FL 33065E-MAIL remesQroemer-ins.com Jonathan F.Ramos ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers 25658 INSURED Forever Electrical Power,LLC INSURER B: 760 SE 2nd Ave.,#D210 Deerfield Beach,FL 33441 INSURER C: 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 OWUL SUOR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER D LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 MIME TO REN 1hL; CLAIMS-MADE X❑OCCUR 16604AI 14407TCTI 5 07/21/2015 07/21/2016 PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY❑JEC LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SIN LE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident' $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED HIRED AUTOS AUTOS r accident $ UMBRELLA LIAR i OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PEROTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑N/A E.L.EACH ACCIDENT $ LU OFFICER/MEMBER EXCDED? (Mandatory in NN) E.L.DISEASE-EA EMPLOYEE $ If yes describe under DESCRIPTION OF OPERATIONS below I I I E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddNbnal Remarks Schedule,may be attached It more space is required) License#EC13004183 CERTIFICATE HOLDER CANCELLATION MIAMIS2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Ave. Miami Shores,FL 33138 AUTHOR®REPRESENTATIVE � .-4 ©1986-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AOL. JEFP MYM SUME IW FLORIDA � ' DMS ISM OF WOE 0 dim ar RCATESECTION TO BE,'ERfi FROM Fh LAW'� nW awiftsa t.ft#4dWAuaIllld•l tt9S tbcted;t0:b&ex9tdpt ftM I[mar. 9FFSCTWVATIl-. EM M16M DAM 6MM7 :. Mit Qom, SUMNMMMANDADDFOW. rClR:ELTiL P'Q�AtER tC i ` 21 MIbMW"T HOLMNOW 33m 9COF =910W ORTRAM' N'M1TM ' EJ .. _ ad. t t1tttetrt mit �d0. g3�,FS.,t E`e � t •��e:re+o�:.. t� r�i # #ttsof;a :" 'tiffs Et QF 24Y4V� A 2M CMTW l 5 OF El;OOOON TO R 'ReVMM:W43 t$50)40-1.09 i i • e FOREVER ELECTRICAL POWER 2129 MADISON ST, HOLLYWOOD FORMA Date: State Flonda -- ---- ------------ Country of--- --� - Before me this day personally appeared t ?7 0rtenJp4�vho, being duly sworn, deposes and says. That he or shell be the only person working �onheproject located at: N2 Sworn to or affirmed and subscribed before me this � day of a, 20� Personally know OR Produced Identification Type of Identification 104:� (D p GASNER ANILUS (� MY cOMMISSION#FF028480 `."9' oP:` EXPfRES June 17.2017 1307)3gg 0153 �eidaNOMYSerAce.cor" Miami shores Village mail am Building Department JR 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. Signatu re: t c i l ClwUr— State of County of Miami-Dade The foregoing was acknowledge before me this G day of ,20-1-b By���1 r) ho is perso y known to me or has produced as identification. Notary: �p'AaAo GASNER ANIL • MY COMMISSION*FF028480 SEAL: �!h P�'f EXPIRES June V.2017 (407)9gg 0153 FloddalloteryServlce• e . 6 r6WW ff IWO* cc, )300918 EL _(6-_ 226 r tit C.4 JAN 27 2016 BY: r0000 . . A . 0000 0000.. 00 000. .••f: 0. 6 �ql 0000.. . f��� E 9T a .0.9.40` 0000 .. "Inii �I re ge •0000 0 0000 00000 � 1 PF 0, •..•.• 009 060.. B DATE 0000.• •00 0906.6 CITYf•••6• • • f • • 0 ZONING DEPT . • • • .•66•• Awalk •006.0 • • • • • . BLDG DEPT ZY��°fd •• • 0000 • • SUBJECT iO CGNIPLIANCE VCM ALL FEDERAL STATE ANL)C;C UN t f--IUL-cS AND REGULATIONS too A