REV-16-653 AVIP
Miami Shores Village
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Building Department
AUGs 2016
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 2004�
BUILDING Master Permit NoC--c1c
PERMIT APPLICATION Sub Permit No.p—FyI (P ®(6SS
❑BUILDING 0 ELECTRIC ❑ ROOFING 0 REVISION ❑ EXTENSION [-]RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
/ CONTRACTOR DRAWINGS
JOB ADDRESS: 11300 NE 2 Ave 0a CKL Ill y c(', �d t (�_
City: Miami Shores Countv: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):Barry University Phone#:
Address:11300 NW 2 Ave
City: Miami Shores State: Florida Zip: 33161
Tenant/Lessee Name: Phone#:
Email: 011 $ !21W o
CONTRACTOR:Company Name: C Davis Electric Phone#: 954-432-4334
Address: 1701 SW 100 Terrace
City: Miramar State: Florida Zip: 33025
Qualifier Name: Ed Davis Phone#: 954-432-4334
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Gallo Herbert Architects Phone#: 954-794-0300
Address: 1311 W Newport Center Dr. Suite C City. Deerfield Beach state: FL Zip: 33442
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition 0 Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Electric As Built '� '`��' ^' 4%—e F4 �" �' I— Lls�r
Specify color of color thru tile:
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$
(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.
Signat a Signature
OWNER or AGENT CONTRACTOR
Th foregoing in rument was acknowl dged b ore me this The�foregoing instrument was acknowledged before me this
d of d dt3 20 1490 by "! day of August ,20 16 by
V h/7v« who is personally known to Ed Davis ,who is personally known to
r�r or who has produced as me or who has produced as
identification and who did take an oath. identificatiojanwho
did take an oath.
NOTARY PUBLIC: ��t11111!l1111//� NOTARY PU
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" �a� , •�pISS1pN••. ��
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28
g � Sign:
Print:
• #FF220337 •
Seal: *X` Seal:
N/ �STA �mm Asian#FF905054
H/IjININH��� My Commission Expires
xxxxwx * ****a* * ***xxx** x * * *** *** **x * *x x* *A $fsH *** x** ***a* **
APPROVED BY f t' /0"40' Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
uL- 11"%�01 1 1 1L-IN�
RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION -,
ELECTRICAL CONTRACTORS LICENSING BOARD ' ''
700001038 • -
The ELECTRICAL CONTRACTOR " z
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS. f '"
Expiration date: AUG 31, 2018
Rig,, 0
DAVIS, CHARLES E JR .
C DAVIS ELECTRIC CO, INC a
1701 SOUTHWEST 100TH TERRACE
MIRAMAR FL 33025
ISSUED: 07/11/2016 DISPLAY AS REQUIRED BY LAW SEa# L1607110000962
-'""1 CDAViSE-01 LGLEASON
'`��RLX CERTIFICATE 4F LIABILITY INSURANCE DA's""°" '°"'r'rc'
3123/2016
THIS CERTIFICATE iS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING,INSURER($),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polley(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 Neu of such endorsement(s).
PRODUCER CONTACT Lori B. Gleason
Collinsworth,Alter,Lambert,LLC PPHHO E
23 Eganfuskee Street MIC,No AiC No:(561)427-6730
Suite 102 111. :I leaso calllc.com
Jupiter,FL 33477 ADDRESS
INSURE AFFORDING COVERAGE NAIC B
INSURERA:Amerlsur'e Insurance Co 19488
INSURED WSURERB:Amerisure Mutual Ins Co 23396
C.Davis Electric Company,Inc. iNBURERc:Bridgefield Casualty ins Co 10335
1701 Southwest 100th Terrace INsuRERD:Travelers Property&Casualty Co.of America 25674
Miramar,FL 33026
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 CONTRACTOR 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.
( CY EXP
NSR
ADIX SUHR POLICY E"TYPE OF INSURANCE 1 D POLICY NUMBER MMID FN pDNYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE P(I OCCUR CPP20919620201 04/01/2016 04/01/2017 PREMISE
EI e $ 1001
T XCU,Contractual,BFPD
X MED Independent Contr. �'IAnr�e > $ 6,000
PERSONAL&ADV INJURY $ 1,000,00
GEN'L AGGREGATE LMiT APPLIES PER: GENERAL AGGREGATE $ 2,000,00
POLICY Q jE&- E-1 LOC
PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY C aMF SINGLE LIMIT S 1,000,000
A X ANY AUTO CA20677670701 04/0112016 04/01/2017 BODILY WJURY(Per person) s
ALL AUTOSS AUTOS BODILY INJURY(Per acciderd) $
X HIRED AUTOS WNED L
NON-OWNED pG
AUTOS Per acddent $
PIP Coverage $ 10,000
X UMBRELLA UABOCCUR EACH OCCURRENCE $ 5,000,00
[�.CLAIM84AADE
B EXCESS UAB CU20677640602 04/01/2016 04/01/2017 AGGREGATE $ 51000,0
DED I X 1.RETENTION$ 0 $
WORKERS COMPENSATIONOTH
AND EMPLOYERS'LIABILITY X 1TAT 1TE
Ci ANY PROPRIETORiPARTNERA-XECU11VF Y/N 19634344 04/0112016 04101/2017 E.L.EACH ACCIDENT $ 1,000,00
OFFICERAAEMBER EXCLUDED? Q N I A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00
Fyes desaR>e under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00
D RentedlLeased Equip. QT6602G167243TILIS O4101/2016 04/0112017 Limit 250,00
D Inland Marine QT6602018724371LIS 04/01/2016 0410112017 Scheduled Equipment
DESCRIPTION OF OPERATIONS i LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Scheduie,may be attached M mors spate is required)
Certificate Holder Is named as additional insured Including products and completed operations for general lbeblilty per C07048,auto liability,and umbrella
liability when required by written contract. General Liability,Auto Liability,and Umbrella are primary and non contributory when required by written contract.
Waaiver of subrogation applies to general liability,auto liability,umbrella liability,and workers'compensation when required by written contract. Umbrella
extends over general liability,auto liability,and employer's liability.Cancellation applies as per policy terms and conditions.
ELECTRICAL CONTRACTOR-LICENSE#EC0001038
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Building Department ACCORDANCE WITH THE POLICY PROVISIONS.
10060 NE 2nd Avenue
Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD