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EL-15-2703 Miami Shores Village P&X!►iT ") ?I= rte �n 10050 N.E.2nd Avenue NE C-0 tditiorO 11 Miami Shores,FL 33138-0000 h 'erYxiit�� Phone: (305)795-2204 xtonm� Expiration: 08/07/2016 Project Address Parcel Number Applicant 802 NE 99 Street 1132060142460 Miami Shores, FL 33138- Block: Lot: DONISI HOMES LLC Owner Information Address Phone Celt DONISI HOMES LLC 802 NE 99 Street (561)414-9203 MIAMI SHORES FL 3313-8 Contractor(s) Phone Cell Phone Valuation: $ 500.00 GREEN SOURCE SERVICE LLC (305)231-3632 _. . Total Sq Feet: 00 Type of Work:REPLACING 2 GFI'S OUTLETS Available Inspections: Additional Info: Inspection Type: Classification:Residential Final Scanning:3 Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical Underground W.W. Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee Invoke# EL-10-15-57529 $3.38 10/22/2015 Check#: 1041 $50.00 $186.36 DCA Fee $3.38 Education Surcharge $0.20 02/09/2016 Check#:1263 $ 186.36 $0.00 Permit Fee-Additions/Alterations $225.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $236.36 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 AFFIDAV certify at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and ni g. ut e,I authorize the above-named contractor to do the work stated. ' February 09,2016 Authori a ig re:Owner / Applicant / Contractor / Agent Date Building Department Copy February 09,2016 1 Miami Shores Village c Building Department OCT 92 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20/x' _ffh BUILDING Master Permit No. — 2-7 PERMIT APPLICATION Sub Permit No . , It ❑BUILDING ❑E ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL ❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 802 NE 99 STREET City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-3206-014-2460 Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):DONISI HOMES LLC Phone#:754-423-1989 Address:802 NE 99 STREET City: MIAMI SHORES State: FL Zip: 33138 Tenant/Lessee Name: N/A Phone#: Email: rlopez.ies@hotmail.com CONTRACTOR:Company Name: Green Source Services Phone#: 305-231-3632 Address: 13117 NW 107 Ave- 17 City: Hialeah Gardens State: FL Zip: 33018 Qualifier Name: Oscar Dominguez Phone#: 305-231-3632 State Certification or Registration#: EC13004733 Certificate of Competency#: DESIGNER:Architect/Engineer: N/A Phone#: Address: City: State: Zip: Value of Work for this Permit:$500.000 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Q Repair/Replace ❑ Demolition Description of Work: Replacing 2 - GFI outlets Specify color of color thru tile: `9a Submittal Fee$ 6 Permit Fee$ Z ZS�� 3/lam CC$ 6�h�/s' CO/CC$ Scanning Fee$ 2!.- of) Radon Fee$ y DBPR$ ° Notary$ Technology Fee$ Training/Education Fee$ Lj- A Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) r Bonding Company's Name(if applicable) N/A Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) N/A 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 CONOACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 13 day of October ,20 15 by 13 day of October 20 15 by Charles Donisi �^ who is personally known to Oscar Dominguez ,who is personally known to l� me or who has produced ` 'P4—cw lS 11 Cl )f-4s me or who has produced 114 C'Wu as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: Edwin Silver Print: Edwin Silver ov°°j EDWIN 1.SILVER EDWIN L SILVER Seal - Seal: : Vv COMMISSION#EE867375 My COMMISSION#EE867375 .... NPPgG�Ae EXPIRES January 22,2017 •,�'ry:syo," EXPIRES January 22.2017 1401.39FloritlallotaryService com X407, Flar+tl»Nota ySLMcecom Mrrk+k*rk*k rp rk rk rk rk rk rk k rM>krk*>trrk rk4k rk*Nr*rk rk rk*rk*rk**rk**rk4k*rk k**%irk rk*rk rk rk rk rk rk k r}rk rk rk rkrk+k rk rk Nr rk k rk rk rk k* APPROVED BY �� '�Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT,GOVERNOR KEN LAWSON, SECRETARY STATE OF'"FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION , ELECTRICAL CONTRACTORS LICENSING BOARD EC13004733 ADDITIONAL BUSINESS QUALIFICATION The ELECTRICAL CONTRACTOR P® Named below IS CERTIFIEDE Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 L � Mo DOMINGUEZ, OSCAR 10 GREEN SOURCE SERVICES J-,C. 13117 NW 107TH AVENUE 017 � ' .r.'° � ., '°,` ' • HIALEAH GARDENS FL 3301.8 ° ISSUED: 06/02/2014 DISPLAYAS REQUIRED BY LAW SEQ# L1406020001426 W1630 Local Business Tax Receipt Miami-Dade County, State. 'of Florida -THIS IS NOTA BILL - DO NOT PAY 6839113 LBT BUSINESS KAME/LOCATION RECEIPT NO. EXPIRES GREEN SOURCE SERVICES LLC ff"AL SEPTEMBER 30, 2016 " 13117 NIU 107 AVE 17 7112980 Must be displayed at place of business HIALEAH GARDENS FL 33018 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS GREEN SOURCE SERVICES LLC 196 ELECTRICAL CONTRACTOR PAYMENT RECEIVED EC13004733 BY TAX COLLECTOR Worker(s) 8 $45.00 08/07/2015 FPPU05-15-014930 This Local Business Tax Receipt air confirms paw of the Local Business Tax.The Receipt is not a license, m perm&,or a certification of thehoir�t a ualificatiorm,to do business,Holder alum comply with any governmental or nor�ovenunemal regulatorylaws amt requirements which apply to the brag, The RECEIPT NO.above must be displayed on all commercial vehiclesRa- Fer mom information,visit www.miamidade GREEN01 OP ID-AL ACORD® DAT$t��►h �,..,;. CERTIFICATE OF LIABILITY INSURANCE 10121f2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATNELY 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 pollcy(les) must be endorsed. If SUBROGATION IS WANED.subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certlficata does not confer rights to the certificate holder in lieu of such endorsement(s). PRoDUMAnnmarle McCartney MDW Insurance Group Inc PHOW 305-398-4665 FAX 305-444- 480 362 Minorca Ave M tip,EmitCAM,py* Coral Gables,FL 33134 E-MAIL ;am dwinsurance.com Donald W McCartney rasa AFFORm»M cova:ACE nAIC# mNSURERA:James River Insurance Comparry 12203 mNSURED, Green Source Services LLC imutER B:Granite State lnsumnce Co. 23809 13117 NW 107 Ave#17 INSURER C:FlMrossive Insurance Co. 10193 Hialeah Gardens,FL 33018 INSURER D INSURER E: INSURER P 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. LTR TYPE OF i E L POLICY NUMBER POLI EFF POLICY YY U NM GENERAL UANUTY EACH OCCURRENCE $ 1,000, A X COMMERCIAL.GENERAL LIA9LIlY 00065623 02191/2015 02!1112016 o S 50,00 cLAMISMADE I—x1 OCCUR MED EXP Any one $ excIud PERSONAL&ADV INJURY $ 1,00,E GENERAL AGGREGATE $ 2.000.00 GENT_AGGREGATE UGIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY PER- LOC �p $ AUTOMOBRE Ea a swGLE Leary $ 1,000 C ANY AUTO 01519906 02/111201 S 0211112016 BODE-Y INJURY(P-Perms+) $ ALLOWNEDX SCHEDULED BODIL � YNAM(Peridwil) $ AUTOS AUTOS NON-OWNED PR o DARAAGE $ X HIRED AUTOS X NON-0 Auros PERACCiDeM $ ue113REL LA LAO OCCUR EACH OCCURRENCE $ LlEXCESS UM HCLA%4SMADE AGGREGATE $ DID RETENTION $ y X WC STATU- OTH- AND E21PLOYERS UABRM B ANY PROPRETOMPARTNERIEXECCUTNE YtJ NIA 9248 09111P1015 09/1112016 E.L EACHACCIDENT $ (gym„ F)C1UllED9 ELDISEASE-EA EMPLOYEE $ 11000,000 Ryes descnbeun9w RESCRLPTiON OF OPERAWNS below I I-F—L DISEASE-POLICY LIMIT $ 11000. DESCWP r*N OP OPERATKM 1 LOCATIOS I VE OMM(Aitch ACORD 101,Admio"Ramaiw SdmdW%K more spxe is required) CPRICAL CONTRACTOR–=C== #SC13004733 CERTIFICATE HOLDER CANCELLATION VILLMIA SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISKMS. Building Dept. 10050 NE 2nd Avenue AUTHOMM REPRIMMATM Miami Shores,FL 33138 maxt 11188.2910 ACORD CORPORATION. AN rights mnrved. ACORD 25(2010105) T ACORD W(Ni - - GREEN01 OP 10:AN ,�►► - E IFI LIABILITY 1 DATT (MMOXYYYY) 07/1312016 THIS CERTIFICATE IS ISSUED AS A:MATTER OF INFORMATION ONLY AND CONFERS 140 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: It the certificate hoiden Is an ADDITIONAL INSURED,the Policydles)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,Corbin Policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Iieu of such end ' s. PRODUCER AT AETrtrETarie Mc�`sartn@ W Insurance Group Inc _ PHONE1 ._. ... .. ..._............_._........"I 362 Minorca Ave # , 306-398«866 t <._ .. _....... Coral Gabbs,FL 33134 MAS _.__ __ Donald W McCartney nnoa�ss,�rrTccar2ns�p ____davinSur�nce.ctTrTt____. wSurtER{sl • 0 COVERAGE NA;C _..... ...........T.....__....__.._._.........._ ._ _................._....... INSURER A &W-- _ n S CWty 14171 S _ ..__ __...___ _...._ ._... _....... _..... .__... . INsuaELl Green Source Services I.LC INSURER s,Granft S MAZO Co 23>309 13117 NW 107 Ave#17 _- .�...�......._.... ...._.... Hialeah Gardens,FL 33016 INSURER c Progresswe kmtmance Co. 10153 __. _.__.....__....._ .......................__......................_ .__ .__.....'___ INSURER D;raa irtsurar re ComPamr 17370 _....._........_.._.__........_.._ _......_................._ ..__................_................. ........_... ......--......._... __..--' ucSURSR I F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POI IClF Of INSURANCE LISTED BELOW HAVE BEE ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOJD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI CERTIFICATE MAY BE ISSUED OR MAY.PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR ; TYPE OF INSURANCE _.....__._.___._ . Mj YNUM �OtYYYY LIMITS GENERAL LIAsiL€TY EACH OCCURRENCE f> 1,000, .._... __...._ _.A X :COMMERCIAL GENERAL LIABILITY SCI C20004094300 021111201602111120171(00, cLAI,s-MADE (X occlllxSIE 5PEaSONAL8 A1, ,..............._............._.._ i I GENERA AGG#EGATE�Y 1 S 2,�,GEN'L AGGREGATE LIMIT APPLIES PEa' Fa03L3CTS G 4P1(bP AGC$ ,0{ r i P£)!#GY fRCA LOC __.... . .............__.._ _......_�.__.._.. ..... g AUTOMOBILE LIABILITY :F �COMBINED NWULLL3A91T ' {a dant t 1,000,000 ANY AUTO _......_} ¢ _ 9fi19968 02J197209602119d2017 8001LY€NJURY(Perperaon) 5 AUTOS X i SCHEDUAUTOS LEO € BODILY INJURY(Par aGCad I $ X 1 HIRED AUTOS xi ANUON-OVVNEO �TOS � F%#2$P—EEIF Y�1 t t�1tilaE _. _ ! tPERAtLYNTj__._.._� S y UMBRELLA UAB X i OCCUR � - EACH OCCURRENCE s 3,000,0 l{ EXCESSL1A® _CLAIMS-MADE AN025684 02!9112018:02/1112097 AGGREGATE 33 '___. DED IS r NTION a ; 000 ......._ .. _ WORKMS COMPENSATION $ AND EMPLOYERS'LIABILITY Y r N #f T�TjAtTUT : OTH- B 1 ANY PRLbPRIEtOTitPA12TIdERIEXECUTIVE -53-9248 691111209$109111=14 I OFFICERIMEMlSER EXCLUDED? IN 1A E.c EACH ACc€DENT S 9 0110,0 iAaamlad»y in NH) _ .. -__ ..........— PI ,dssuibo ured,x E.L DISEASE-EA EMPLOYEEi S _ yy _ ........_.._..—..._.w...._............_ f_............. DES tPtK)Il OPERATI .1.. E.L.DISEASE-POLICY LIMIT;$ 11000100C { DESCRIPTION OF OPERATIONS i LOCA VENUES(Aftch ACORD TOS,AddWonal Remarks Sdtadule,If mora sp—Is r red) ELECTRICAL CONTRACTOR-LICENSE 0EC13004733 CERTIFICATE HOLDER CAldCELLATION VILLMIA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept. ACCORDANCE VATH THE POLICY PROVISIONS. 10050 NE 2nd Avenue Miami Shores,FL 33930 AUTTaORI�ET9REPRESENTATIVE 01968-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD 1� _ -)63