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EL-11-2373Permit Number: EL -12 -11 -2373 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 inspection Number: INSP- 168251 Inspection Date: December 27, 2011 Inspector: Devaney, Michael Owner: POLLA, LAWRENCE Job Address: 121 NE 92 Street Miami Shores, FL 33138- Project: <NONE> Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Contractor: DATA BASE ELECTRIC CONTRACTORS & CONSULTANTS 11 Phone Number (305)205 -2711 Parcel Number 1132060133160 Building Department Comments RE- ATTACH RISER TO METER MAIN DAMAGED BY CITY GARBAGE TRUCK Passed Inspector Comments //0:40111111% / I j/ 00War A. 0%-----0- a) // Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until March 12, 2013 For Inspections please call: (305)762 -4949 Page 1 of 1 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit No. Imouvz-- Master Permit No. Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): L AviI?AJC ,0 Phone#: Address: 1 2 / g Z City: " am ; � Ve s [% //., State: PCL Zip: 3 3/ Ze / 3 Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: /2./ /`V E 70- -sue City: Miami Shores County: Miami Dade Zip: ✓a✓ /3 Folio/Parcel #: 4/ 3 2. 06 0/ 3 3/ !o 0 Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: ) rd- e E ie e ;6 Phone#: %Sf- i' • (o - rZ, S' Address: 3 32-5- r' 14..i /2oA -41 rA- 3J City: ,4 a l Z. A eat 4.44-62_ State: FC- Zip: 53 3 / ?/ Qualifier Name: 3 i _ O Phone#: State Certification or Registration #: • E c- 000 3Q 0 Lo Certificate of Competency #: Contact Phone #:iStf- 2f -rte 77 "2- Email Address: "6d-se_ (ee- 42, e ..).4 ,'le± DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 2- 5D Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ONew 1air/Replace ODemolition Description of Work: Re - A- 4-A4-e-4, r-/ _e_._ or-' i—e, / .L "9-, , ***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ ********** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** /t (OW CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE Bonding Company's Name (if applicable) Bonding.Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City -- 1` 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 approved and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 _, by who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: Signature Contractor The foregoing instrument was ac ledged before me this day of 2 7 , 20 t/ , by tc_ who i ersonally known tom r who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: `rl L kr-w 5 n eg-- My Commission Expi * * * * * * * * * * * * * * * * * * * * ** ************************************************** * ** * * ** ** *** *** * ** ** * ** ** *** * ** APPROVED BY Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Zoning Clerk 1 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Permi Permit N©. EL-12-11-2373 Permit Type: Electrical - Residential Work' Clessification: Addition /Alteration Permit Status:_ APPROVED Parcel Number Issue Date: 12/27/20111 Expiration: 06/24/2012 Applicant 121 NE 92 Street Miami Shores, FL 33138- 1132060133160 Block: Lot: LAWRENCE POLLA Owner information Address Phone Cell LAWRENCE POLLA 85 RIVERSIDE LANDING MACON GA 31210- (305)205 -2711 Contractor(s) Phone DATA BASE ELECTRIC CONTRACTOF Cell Phone Type of Work: ELECTRICAL Additional Info: METER MAIN DAMAGED Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $0.60 $2.00 $2.00 $0.20 $100.00 $3.00 $0.80 $108.60 Pay Date Pay Type Amt Paid Amt Due Invoice # EL -12 -11 -42971 12/27/2011 Check #: 7227 $ 108.60 $ 0.00 Available Inspections: Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Underground W. W. 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 all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. December 27, 2011 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date December 27, 2011 1 OP ID: .1 A14...'e✓°R °� CERTIFICATE OF LIABILITY INSURANCE DATE(M27 //YYYY) 12J27/11 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 policy(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 lieu of such endorsement(s). PRODUCER 954 -735 -5500 Gateway Insurance Agency Fort Lauderdale Branch 954- 735 -2852 2430 W. Oakland Park Blvd. Fort Lauderdale, FL 33311 PJK Old business CONTACT FAX INC. No. Ext): (A/C, No): E -MAIL ADDRESS: CUSTDOOMMERID/ DATBA02 INSURER(S) AFFORDING COVERAGE NAIC d INSURED Data Base Electric Contractors & Consultants, Inc 3325 Griffin Road, Ste 300 Fort Lauderdale, FL 33312 INSURER A : North Pointe Insurance Company X INSURER a : Brldgefield Employers Ins. Co. 10701 INSURER C : 3094118373 INSURER D : 01/01/12 INSURER E : $ INSURER F : PREMISES (Ea occurrence) 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 LTR TYPE OF INSURANCE ADDL INSR SUBR wvD POUCY NUMBER POUCY EFF (MMIDDMIYY) POLICY EXP (MM/DD/YYYY) UMRS A GENERAL X LIABILITY COMMERCIAL GENERALUABILITY X OCCUR 3094118373 01/01 /11 01/01/12 EACH OCCURRENCE $ 500,000 PREMISES (Ea occurrence) $ CLAIMS -MADE MED EXP (My one person) $ 5,000 PERSONAL & ADV INJURY $ 500,000 GEN'L X GENERAL AGGREGATE $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY PECT LOC PRODUCTS - COMP /OP AGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A 83036275 04/25/11 04/25/12 X T STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Electrical Contractor & Consultant CERTIFICATE HOLDER CANCELLATION MIASMIA Miami Shores Village,FL g Building Department 10050 NE 2 Ave Miami Shores Village, 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 912 90 ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954 - 831 -4000 VALID OCTOBER 1, 2011 THROUGH SEPTEMBER 30, 2012 DBA: Business Name: DATA BASE ELECTRIC CONTRACTOR CONSULTANTS INC Owner Name: RICHARD L GREEN Business Location: 3325 GRIFFIN ROAD STE 300 FT LAUDERDALE Business Phone: 966 -9669 Rooms Receipt #:181-1020 Business Type :ELECTRICAL /ALARMS /CONTRACTO] (CENTRAL MASTER ELECTRICI Business Opened:05/22/1989 State /County /CertlReg:ECO 0 03006 Exemption Code:NONEXEMPT Empleyee$ "? 10 Machines Professionals For Vending Business Only • Vending Type: Tax Amount Transfer Fee NSF Fee Penalty _; Prior Years ,Collection Cost Total Paid 27.00 0.00 0.00 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: RICHARD L GREEN 3325 GRIFFIN ROAD STE 300 FORT LAUDERDALE, FL 33312 Receipt #035 -10- 00002018 Paid 07/19/2011 27.00