EL-16-2439 Inspection Worksheet
Miami Shores Village C l 6 �� �®
10050 N.E. 2nd Avenue Miami Shores, FL L
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-266741 Permit Number: EL-9-16-2439
Scheduled Inspection Date: September 07, 2016 Permit Type: Electrical- Residential
Inspector: Devaney, Michael
Inspection Type:
Owner: WALTER, DORA 8 LEOPOLD —R%4
Work Classification: Alteration
Job Address:6 NW 106 Street
Miami Shores, FL 33150-1246 Phone Number
Project: <NONE> Parcel Number 1121360050170
Contractor: ELECTRIFIED ELECTRIC LLC Phone: (786)413-7283
Building Department Comments
ADDING POWER FOR AC UNIT Infractio Passed comments
INSPECTOR COMMENTS False
v Inspector Comments
Passed Eil� —,
Failed
Correction
Needed
Re-Inspection a
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
-ptember 06,2016 For Inspections please call: (305)762-4949 Page 26 of 40
xn n�c�. .- -' -241'
Miami Shores Village P if;T, � t ntlai
10050 N.E.2nd Avenue NW
Wor G1as� tiara Alt tion
Miami Shores,FL 33138-0000
m er
Pe»tStaws:Ap"WD
�fit"oni> Phone: (305)795-2204 ,
p�
Ex iration: 03/05/2017
.. ,� Issue Date;918/x'16
Project Address Parcel Number Applicant
6 NW 106 Street 1121360050170
Miami Shores, FL 33150-1246 Block: Lot: DORA&LEOPOLD WALTER
Owner Information Address Phone Cell
DORA&LEOPOLD WALTER 6 NW 106 Street
MIAMI SHORES FL 33150-1246
Contractor(s) Phone Cell Phone Valuation: $ 500.00
ELECTRIFIED ELECTRIC LLC (786)413-7283 t
Total Sq Feet: 0
Type of Work:ADDING POWER FOR AC UNIT Available Inspections:
Additional Info: Inspection Type:
Classification:Residential
Review Electrical
Scanning:1
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60
Invoice# EL-9-16-61179
DBPR Fee $2.00 09/01/2016 Credit Card $50.00 $58.60
DCA Fee $2.00
Education Surcharge $0.20 09/06/2016 Credit Card $58.60 $0.00
Permit Fee-Additions/Alterations $100.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $108.60
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 I the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction annin uthermo ,I orize the above-named c actor to do the work stated.
September 06, 2016
Aut zed Signa re:Owner / Applicant / C &tractor / Agent Date
Building Department Copy
September 06,2016 1
Miami Shores Village
Building Departmentp ' 16
10050 N.E.2nd Avenue,Miami Shores, Florida 33138 ICA
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 2014 s4
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
4, & L or, '± CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip: y � 3F
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder)- t1 I�1 J Phone#: !7> S7;97
Address: 3. b
City: P t A-..,., State: Zip:
Tenant/Lessee Name: Phone#:
Email: / 1
CONTRACTOR:Company Name: /C C�'>�, 9 le t�rc\ L L�- Phone#:
Address:—&-WLSJ 33rq ,s�'s
City: H I k7Pr M 0 9, °�-� State: L. Zip: 33o 3
Qualifier Name: Ar n re, i Ijnr 0V% Phone#:
State Certification or Registration#: C I ®0 Y �� Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ sc o-0'0 Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: f O t j e'g' �Oa' Ric L..,ns ,5
Specify color of color thru tile:
Submittal Fee$ 40 Permit Fee$ ®� t�® CCF$ ® CO/CC.$
_� 0 C3
Scanning Fee$ ?I Radon Fee$ Z_00 DBPR$ 2. Notary$
Technology Fee$ 0 .?)o Training/Education Fee$ Q ° zo Double Fee$
Structural Reviews$ Bond$ r
TOTAL FEE NOW DUE$ �� • ��
(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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature JAta Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this Theforegoinginstrument was acknowledged before me this
3 0 day ofSv ,20 L`Q , by J" day of 20 , by
W A who is personally known to 1� — who is p rsonall nown to
me or who has produced R b•L. as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
2kc
Sign: Sign: � n�w -
Print: aaA..�+"$ Print: G�' 1 �VF�.1Cvw"�
Seal: Seal:
�•"" GERLONDAYOUMANS GERLONDAYOUMANB
+°i'�••s. MY COMMISSION#FF 129038
!AV COMMlSS10N#FF 129080
EXPIRES:June 32018 3^ EXPIRES:June 3.2018
�� S Bonded ThN Noom/Pubic Undenxdte e '; :� Bended Thru Notary Pub is Underrdtlfe
•.Pj:NF
SII%**�>K>K*>K•�*�>!�** 7IC>k>B>k>��>K>K>K***>k>k**�>K>K>k>K*>K�ffi���***>K 1{t 1k 7k*•� *�*�*$�>k>k>k*#>k>k>k>K>h>K*
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
C STATE OF FLORIDA
p DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
EC 13004627 ISSUED: 08/15/2016
CERTIFIED ELECTRICAL CONTRACTOR
THORNTON,ANDRE LEVAR
ELECTRIFIED ELECTRIC LLC
IS CERTIFIED under the provisions of Ch 489 FS
Expiration date AUG 31,2018 L1608150001904
A C# OIL 6 'c98724
NATURE
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For additional information, including any complaints or discipline, click on the name.
Name License
License Type Name Type Number/ Status/Expires
Rank
Certified Electrical ELECTRIFIED ELECTRIC EC13004627 Current, Active
Contractor LLC SBA Cert Electrical 08/31/2018
Main Address*: 2001 NW 58TH TERRACE LAUDERHILL, FL 33313
Certified Electrical TH T ANDRE LEVA Primary EC13004627 Current, Active
Contractor Cert Electrical 08/31/2018
Main Address*: 2001 NW 58TH TERRACE LAUDERHILL, FL 33313
t I&1� ;^
t. .
* denotes
Main Address-This address is the Primary Address on file.
Mailing Address-This is the address where the mail associated with a particular license will be sent(if different from the
Main or License Location addresses).
License Location Address-This is the address where the place of business is physically located.
2.601 Blair Stone Road,Tallahassee FL.32399 :: Email: Customer Contact Center:: Customer Contact Center; 850.487.1.395
The State of Florida is an AA/EEO employer.Copyright 2007-2010 State of Florida.(Privacy Statement
Under Florida law,email addresses are public records.If you do not want your email address released in response to a public-records
request,do not send electronic mail to this entity.Instead,contact the office by phone or by traditional mail. if you have any
questions, please contact 850.487.1395.'Pursuant to Section 455.275(1),Florida Statutes,effective October 1,2012,licensees
licensed under Chapter 455,F.S.must provide the Department with an email address if they have one.The emails provided may be
used for official communication with the licensee. However email addresses are public record.If you do not wish to supply a personal
address,please provide the Department with an email address which can be made available to the public. Please see our
455 page to determine if you are affected by this change.
https://www.myfloridalicense.com/wlII.asp?mode=2&search=LicNbr&SID=&brd=&typ= 9/1/2016
� y
RNER LPCENSE CLASS E f
' ANCRE LEVAR
m THOR TON
r
SDI tea'S8 TER
t',t ER�i+4 -FL 4Z ME
z- - i a
aiT.ATE OF FLORIDA
� F DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
{ 013004627 ISSUED: OS/24/2014
CERTIFIED EL.ECTMGF1l.CONTRACTOR
THORNTOIN,A,M&E LEVAR
ELECTRIFIED ELItCTRIC LLC
!+ SER W9E: a under the provisions of Ch.466 FS,
Expiration 6c19: AUG 31,2016 L1408244^ii4553
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: Receipt#:181-276393
ELECTRIFIED ELECTRIC ELECTRICAL/ALARMS/CONTRACTO',
Business Name: Business Type: (CERTIFIED ELECTRICAL
CONTRACTOR)
Owner Name:ANDRE THORNTON BusinessOpened:04/15/2016
Business Location: 6412 SW 33 ST State/County/Cert/Reg:EC13004627
MIRAMAR Exemption Code:
Business Phone:
Rooms Seats Employees Machines Professionals
1
I
For Vending Business Only
Number of Machines: Vending Type:
Tax Amount Transfer Fee NSF Fee Penalty Prior YearsCollection Cost Total Paid
13.50 0.00 0.00 0.00 0.00 0.00 13.50
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 laws and regulations.
Mailing Address:
ANDRE THORNTON Receipt #52A-15-00006621
2001 NW 58 TERR Paid 04/15/2016 13.50
LAUDERHILL, fl 33313
N'
2015 - 2016
__ r%r%0%.ANA ten, 4'►/1K t r1/'►A 1 .M � G
From:Depace Insurance 9547520837 08/24/2016 10:06 #806 P.002/002
DATF.(MMOD/YYY1� ---
CERTIFICATE OF LIABILITY INSURANCE______ , 0 8/1417 0 1 6
THIS CERTIFICATE IS ESSUED AS A MATTER OF INFORMATION ONLY ANP CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I
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 certifiaato holder is an ADDITIONAL INSURED,the policy(iss)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($).
PRODUCER CONTACT JOS Ph L.Depace
Depace Insurance&Financial Svcs. PHONE (.9,5_4)752-0837 -c��--(954)752-0989
11440 W.Sample Roadd ADeA1RIFss: JdepaceLadepacc�imurance.com —TA52-989
Garai Springs,FL 33065 INSURER(Sl AFFORDING COVERAGE
Phone (954)752-0837 Fax (954)752-0989 INSURER A: Lloyd's of London
- ---------- --------- ------ --.
INSURED
INSUREk B
ELECTRIFIED ELECTRIC,LLC INSURERC:
6412 SW 33 St INSURER D: _
MIRAMAR INSURER E:
FI33023- ----... --------------......_..-.-
•--------__--- •--- INsuRER F: ______
COVERAGES _ CERTIFICATE NUMBER:
REVISION NUMBER:
17IIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 10 THE INSURED NAMED ABOVL FORTH POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDFTION 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 INSURANCE -------POLICY NUMBER ADD UBRPW_M_DCYD!YYYFl7�( A/DD(YYYPY1 LIMITS
COMMERCIAL..GCNERAL LIABILITY •-------—rACH -- --'----
I CLAIMS-MADE IJ OCCUR DAMAGE TORiR ENN $ 300,000.0()
TED
PREMISES Eaacamenoa) S_100,000.00
-- '- CIBFL0019960 MED EXP An cine )
A ---- y person $. ._ 0.00
05128/2016 05/28/2017 ------
PERSONAL A ADV INJURY $ 300,000.00
G�EE�NL AGGREGATE LIMIT APPLIES PER;
POLICY I—] PRGENERAL $ 800,000.00
LJO I AGURECAI E •-------_--_-_-_
JECT U LOC;
PRODUCTS-COk iP/DP AGG
O'IHER $ 600,000.00
AUTOMOBILE LIABILITY I .=SINGLE LIMIT'-_-
U ANY AUTO BODILY INJURY(Peer puraun) $
ALL AUTOS OWNED ❑ AU*OSULEO BOOILY INJURY(Peraccideris $ --
��
HINFO AUTOS AU'In NON-OWNED PROP�TTY AMAGE -- ^---------
$
----------- _ $
I1RI�iRELI.A LU►B 17 OCCl1R --------.
-- --- _EACH OCCURRENCE. $
l—J
EXCESS
-LIIAB L1 CLAIMS-MAGE AGGREGATE $. ..�—
_-_ -0 IK_Il_ LJ L2E7ENTION$
WORKERS COMPENSATION - ------
AND EMPLOYERS'LIABILITY YIN U PER OTFf
irriTsasc--__C7..FR
ANY PROPWE70R/PARTNE171EXEC E.L.EACH ACCIDENT $
OFTlCGR/MEM�R EXCLUDED? I � N/A
(Mandatory in NH) -----
If yos,describe raider E.L.D1SFA.SE-FA EMPLOYC, $
DESCRIPTION OF OPERATIONS Calow E.L.DISEASE-POLICY LIMIT $
-------
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORO 101,Additional Rernarka SehWule.H more alma kv required)
Coverage for Eloctrified Electric.LLC as Flectrical Contractor
------------ -
CERTIFICATE HOLDER - --------------
------CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Miami Shores Village THE EXPIRATION DATE THEREOF,NOTICE WILL Be DELIVERED IN
10050 NE 2nd Avenuo ACCORDANCE WITH THE POUCY PROVISIONS.
Miami Shores,FL 33138 AU1'WORMED REPRESENTATIVE -----
Joseph L.Depace,CLU,ChF ,
------..... ---- -------
ACORD 25(2014101)QF Q 1988-201 CORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
� � t
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: 10/21/2014 EXPIRATION DATE: 10/20/2016
PERSON: THORNTON ANDRE L SR
FEIN: 273026472
BUSINESS NAME AND ADDRESS:
ELECTRIFIED ELECTRIC LLC
6412 SW 33 ST
MIRAMAR 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
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609
ELECTRIFIED ELECTRIC LLC
6413 SW 33-ST.
MIRAMAR, FL 33023
DATE: I —3 a '(L
STATE OF FLORIDA
COUNTY OF MIAMI DADE
4Before me this day personally appeared who, is being duly
sworn,deposes and says:
That he or she be the only person working on the project located at:
Sworn to(or affirmed)and subscribed before me this day of 2016, by
A22ts� iIk
Personally Know ✓
Produced Identification
Type of Identification produced
GERLONDAYOUMANS
gg ; MY COMMISSION#FF 128880
EXPIRES:June 3,2018
Wyk o'
Bonded TNuNotaryPublic Underoftm
Print,Type or Stamp of Notary
♦5 xcR 3 �i�
s� , Miami Shores Village
£ - ""'?" Building Department
artment
10050 N.E.2nd Avenue
�IORNp` 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:
l. 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: p -
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of AfycoM$+
By `�� who is personally known to me or has produced
L- as identification.
Notary:
SEAL: i OMOMAYOUMANS
My Com%I SSION C FF 1280
EVJRES:June3.2(118
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