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ELC-11-1111Miami Shores Village Building Department /, ; JUN 1 7 2011 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BY. BUILDING Permit No. €l PERMIT APPLICATION Master Permit No. 11 5 '6C, FBC 20 Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): Bg0. IU r(, Tr-4A\ Phone#: 30 S ' i 9 Y —30_50 Address: 11'1 30 11 ).,,4 Pk.1E City: i+--el f4Atyri. S State: Ir I�,— Zip: ,116 Tenant/Lessee Name:ie -,,'C Phone#: Email: ‘nc. 0:1„ sA`9 / OA • V)Arri , 44\,a JOB ADDRESS: tk3OU K & ?4 k, ,e City: Miami Shores County: Miami Dade Zip: 3 L n Folio/Parcel #: lk s 94 2)6 CoOi D // Is the Building Historically Designated: Yes NO �! Flood Zone: CONTRACTOR Company Name: .v Il-i v ; Sr' r n'u c OF- , J VL Phone#: 7Fri // S 3 Address: /// 2 N w -4cg t_e 0 , %t City: F- L r t OAvC State: 6- Zip: 333 0 L( Qualifier Name: _c A't-vh .'Z H— v , Phone#: '1S'1 `P-f `/ 6 �� State Certification or Registration #: E C / 3 0 v 12 o I Certificate of Competency #: Contact Phone#: 'Y S Co 5- /15- 3 Email Address: S 1 M v5 Ss C n'Z (.6. vti DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 5 ' i G tJ U Square/Linear Footage of Work: Type of Work: °Address °Alteration Uew ORepair/Replace °Demolition Description of Work: �rc� �� '�� 4' �.� ,�o " (VAe .S 41-Xce 11 \\ *************************************** I" ees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ 1' Permit Fee 2.5 1 S00- A' CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ Technology Fee $ Bonding Company's Name (if applicable) Bonding Company's Address City State Tap 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 approve Le>td a reinspection fee will be charged Signature Signature ....4e-144tAz-e-n Contractor The foregoing instrument was acknowledged before me this / ; The foregoing instrument was acknowledged before me this 1 day of S4'„ e.i✓ , 2O I( , by t) %3'-/- day of 20 L, by 3 �,�► SP.v"' who is personally known to me or who has produced who is ner. ,,.. ll -k known to me or who has produced Owner or Agent As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: Sign: , &,&g, Print h My Commission Ex * * * * * * * * * * * * * * * ** APPROVED BY e Notary Public State of Florida Chats Beide Gerber '' My Carrots* onoDO968128 sP:ft s4�f T+ ilig******* * NOTARY PUBLIC: Sign: Print: _ O_ Vl."-(10 i it 2 ARYPUBUC -STATE OF FLORIDA ,,.��..,,., Brooke Turpin ,;; \.;; Commission #DD7 §§28 ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ,...... 2 BONDEDT&RQATL9b1TdCROA]> NG A�iC. Zoning My Commission Expires: g�Cr )2/' Y Plans Examiner Structural Review (Revised 07 /10/07)(Revised 06/10/2009)(Revised 3/15/09) Clerk Miami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. ✓ COPY OF QUALIFIER'S STATE LIC CARD B. ✓ COPY OF LOCAL BUSINESS TAX RECEIPT C. V COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPTI D. ✓ COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: SUNSHINE STATE ELECTRIC OF FLORIDA, INC. BUSINESS ADDRESS: 1112 N. FLAGLER DRIVE CITY FT. LAUDERDALE STATE FL ZIP CODE 33304 BUSINESS PHONE: ( 954 ) 565 -1153 FAX NUMBER ( 954 ) 565 -1186 CELL PHONE ( 954) 444 -6205 QUALIFIER'S NAME: SALVATORE HAUSER QUALIFIER'S LIC NUMBER: EC13001201 E -MAIL ADDRESS (IF APPLICABLE): SHAUSER @SSELECTRIC.COM Created on 3119109 BY MLDV 1 RV 3/16109 MLDV STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 HAUSER, SALVATORE ANTHONY SUNSHINE STATE ELECTRIC OF FLORIDA INC 1112 N FLAGLER-DRIVE FORT LAUDERDALE FL 33304 Congratulationsl 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 from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you batter 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 to department newsletters and learn more about the Department's initiatives. 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 v.) tit4&rAnza-4Tlifgla 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954-831 -4000 VALID OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011 DBA: Receipt #:181 -2681 Business Name: SN SHINE STATE ELECTRIC OF FLORIDA Business Type: (EELE TRICALL CONTR) Owner Name: SALVATORE HAUSER Business Location: 1112 N FLAGLER DR FT LAUDERDALE Business Phone: 954- 565 -1153 Rooms Business Opened:08 /02/2005 State /County /Cert/Reg:EC 13 0 012 01 Exemption Code: NONEXEMPT Employees' .Machines:; Professionals ,10 For Vending Business Only Number of Machines: Vendinn Tvae: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00• 00 0.00 0.00 0.00 27.00 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 laws and regulations. Mailing Address: SALVATORE HAUSER 1112 N FLAGLER DR FORT LAUDERDALE, FL 33304 2010 - 2011 Receipt #03A -09- 00020495 Paid 08/19/2010 27.00 Client#: 20109 SUNSHSTA ACORN CERTIFICATE OF LIABILITY INSURANCE DATE(PAWDD/YYYY) 6/15/2011 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 pollcy(ies) must be endorsed. If SUBROGATION 15 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 Cypress Insurance Group BO-CL P.O. Drawer 9328 Fort Lauderdale, FL 33310-9328 954 771 -0300 NAMEACT Joyce Simpson FAX N (a "a. No, Ex0; 954 771-0300 954 772 9424 (WC, o): E-MAIL ADDRESS: JoyceS@Cypresslnsurance.com INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A : FCCI Insurance Group Inc. LIABILnY COMMERCIAL GENERAL LIABIIJTY INSURED Sunshine State Electric of Fl. Inc. 1112 N. Flagler Drive Fort Lauderdale, FL 33304 -2130 INSURER B: Associated Industries Ins.Compa GL00096182 INSURER c : 12/15/2011 INSURER D $1,000,000 INSURER E : $100,0 $5,000 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 POL CIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR W VD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILnY COMMERCIAL GENERAL LIABIIJTY GL00096182 12/15/2010 12/15/2011 EACH OCCURRENCE $1,000,000 PREMISES (Ea r hence) $100,0 $5,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) X PD Ded: 500 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENT. AGGREGATE uMrrAPPLIESPER: 7 POLICY n JECT LOC PRODUCTS - COMP/OP AGG $2,000,000 $ A AUTOMOBILE X X X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS Drive oth Car X SCHEDULED AUTOS NON -OWNED AUTOS CA00149472 12/15/2010 12/15%2011 CO (5 a MBINED SINGLE LIMIT axldenU $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A x UMBRELLA LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE UMB00099312 12/1512010 12/15/2011 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED X RETENTION $10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below Y/N N N/A AWC1005293 01/05/2011 01/05/2012 X TIORYTLIMITS ER OTH- E.L EACH ACCIDENT $1,000,000 E.L DISEASE - EA EMPLOYEE $1,000,000 E.L DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space s required) Workers Compensation applies to Florida operations and employees only. CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2nd Ave. Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE itYieit A ACORD 25 (2010/05) 1 of 1 #S116591/M116307 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JS