EL-16-3176Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
mit
Permit NO. EL -11-16-3176
Permit Type: Electrical - Residential
Work Classification: Addition/Alteration
Permit Status: APPROVED
Issue Date: 11/29/2016
Expiration: 85/28/2817
Parcel Number
Applicant
12 NE 96 Street
Miami Shores, FL 33138
1132060130660
Block: Lot:
GDS HOLDINGS GROUP LLC
Owner Information
Address
Phone
Cell
GDS HOLDINGS GROUP LLC
151 N NOB HILL Road
PLANTATION FL 33324-
(754)244-4697
151 N NOB HILL Road
PLANTATION FL 33324-
Contractor(s)
TRS ELECTRIC, LLC
Phone
(954)671-6365
CeII Phone
Valuation:
Total Sq Feet:
$ 2,000.00
0
Type of Work: REMOVE EXISTING LIGHTS
Additional Info: REMOVE EXISTING LIGHTS
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$1.20
$3.38
$3.38
$0.40
$225.00
$3.00
$1.60
$237.96
Pay Date Pay Type
Invoice # EL -11-16-62131
11/21/2016 Check #: 57
11/29/2016 Credit Card
Amt Paid Amt Due
$ 50.00 $ 187.96
$ 187.96 $ 0.00
Available Inspections:
Inspection Type:
Final
Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Review Planning
Review Planning
W. W.
Review Electrical
Underground
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.
November 29, 2016
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
Date
November 29, 2016
1
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
7-0._ 16 -2310
Inspection Number: INSP-273645 Permit Number: EL -11-16-3176
Scheduled Inspection Date: December 23, 2016
Inspector: Devaney, Michael
Owner:
Job Address: 12 NE 96 Street
Miami Shores, FL 33138
Project: <NONE>
Contractor: TRS ELECTRIC, LLC
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Addition/Alteration
Phone Number (754)244-4697
Parcel Number 1132060130660
Phone: (954)671-6365
Building Department Comments
REMOVE EXISTING LIGHTS
Infractio Passed Comments
INSPECTOR COMMENTS
False
Passed
Failed
Correction
Needed
Re -Inspection
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
Inspector Comments
CREATED AS REINSPECTION FOR INSP-271469.
/‘(6
December 22, 2016
For Inspections please call: (305)762-4949
Page 31 of 32
BUILDING
PERMIT APPLICATION
BUILDING 7 ELECTRIC
❑PLUMBING ❑ MECHANICAL
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
NOV 2
7016
BY:
S'n
FBC 20 (t4
Master Permit No. a.c. 1 b- Z ae56
Sub Permit No..fi - I (p -?, «(C) .
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: / 2 Ale 9' 6 Sfrect-
City: Miami Shores County:
Miami Dade Zip: 3 313 0
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type:
Load: Construction Type:
Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �'1'b S Vokjlvj 6- i'Uu f Phone#: q-54-/-7,(11.04(077
Address:
City: V.-bY S,1 4,4_ State: Zip: �%j34/3
Phone#:
75
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: TR S
Address: / 0/ 670 ,t, w 24 t Z G T
City::Sunn'se
Qualifier Name: /-edroy Sr►'t i
State Certification or Registration #: 130 0 7S $ 7 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Square/Linear Footage of Work:
E %CCf rt'G/ I. L C
Phone#: /34.4 -4. 71- (s Z S
State:
zip: 3.332Z
Phone#: irSkt.'if 7/ - 43 LS
Value of Work for this Permit: $ % 00 J
Type of Work: 0 Addition 0 Alteration
Description of Work: Q-e,wA_Ok.. � C3-01 s I-, ✓�
❑ New
[t Repair/Replace ❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 275 ' et, CCF $ 1 • 2-C:7 co/cc $ --
Scanning Fee $ apO Radon Fee $ 3$ D((BP''R$ 3 , 38 Notary $
Technology Fee $ I Training/Education Fee $ ' `10 Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE$ i R c=?Vq •
(Revised02/24/2014)
BondingCtimpany'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
Signature
OWNER or AGENT CONTRACTOR
The foregoing instrume t was acknowledged before me this The foregoing instrument was acknowledged before me this
(% day of l'A4 1 , 20 1 , by /1s!+tti' day of eGfQrie.., 20 1(0 , by
(gtel J f GkG(Gj , who is personally known to % IeO j
I J � y/ 5..12;#1 ,who is personally known to
me or who has produced as me or who has produced ICL,Q/thiede LiCeN5e as
identification and who did take an oath. SSD gl ( g64ro
NOTARY PUBLIC:
identification and who did take an oath.
NOTARY PUBLIC:
,-1
Sign:
Print:
Seal:
BENJAMIN A STEPHENSON
* * MV COMMISSION t FF 056205
EXPIRES: September 22, 2017
•,4rEO n p Bonded TAN Budget Notary Servkes
APPROVED BY
(Revised02/24/2014)
Sign:
Print:
Seal:
2 2.-1gy4"!//6 Plans Examiner
on
BETTYANTOS
MY COMMISSION # FF 960401
EXPIRES: February 14, 2020
Bonded Thru Notary Public Underwriters
Zoning
Structural Review Clerk
11/21/2016 13:55 9545812999
ACE UND GRP PLTN
PAGE 01/01
AC'CPR CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DOIYYTTI
11!21/2016
THS 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 have ADDITIONAL INSURED provisions or 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 Ilau of such endorsament(s)_
PRODUCER CONT CT
Ace Underwriting Group NA
M Alice Francis
Customer Service Center
5305 West Broward Blvd.
Plantation FL 33317
INSURED
TRS Electric LLC
10190 NW 24th CT
Sunrise FL 33322
COVERAGES
CERTIFICATE NUMBER: REVISION NUMBER:
THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AOOVE FOR THE POLICY PERIOQ
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,
IN9R lq ooL SUER
LE3 TYPEOF INSURANCE I POLICY EFF POLICYI;XP
JNS1 jnry PGLICYM1MBER JMMODDNYYyt IMM/DD/YYYYI LIMITS
PHONE 95.4x81-0202
.al
, ol
954-5812999
iA/C. NeE: FA N.
INAfL
ADDRESS: servIcegunderwriting,com
INSURER(3) AFFORDING COVERAGE
INSURERA: Federated National
NAIC N
10790
INSURER H ;
INSURER C :
INSURER D
INSURER E :
INSURER F
I COMMERCIAL GENERAL LIABILITY
ICLAIMS -MADE OCCUR
GEN1- AGGREGATE OMIT APPLIES PER:
POLICY ❑ PRO- ❑
JECT LOC
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTos ONLY
GL -0000036864-00
08/27/2016
ASUCHEEDULED
NON-OVVNED
AUTOS ONLY
LJ LI
08/27/2017
UMBRELLA LIAO
EXcess UAB --
DED 1 1 RETENTIO:N1$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
AN YPROPRIETOR/PARTN ENEX E CUTI VE
OFFICER1MEMBER EXC W or; 09
(Mandatory In NW
Ifea. describe raider
DESCRIPTION OF OPERATIONs below
OCCUR
CLAIMS -MADE
YIN
d
NIA
I1
EACHOCOURRENCE
$ 1,000,000
PREMISES ((a occurrence),
MED EXP (Any one person)
3
$ 5,000
PERSONALS ADV INJURY
31,000,000
GENERAL AGGREGATE
$ 2,000,000
PRODUOTS - COMP/OP AGG
$ 2,000,000
COMBINED SINGLE OMIT
(Ea accident)
3
S
'BODILY INJURY (Per person)
i
BODILY INJURY Mer accident)
PROPERTY DAMAGE
(Per acclilm tj
S
3
8
EACH OCCURRENCE
AGGREGATE
3
S
TATUTE
EACH ACCIDENT
ETTH
i
E.L. DISEASE -EA EMPLOYEE
s
E.L. DISEASE -POLICY LIMIT
£JL7
uL
DESCRIPTION OP OPERATIONS f LOCATIONS f VEHICLES (ACORD 101, Add(Uonal RemArke Schedule. m;y b8 attached If mare epees le requfrudj
Electrical Services
CERTIFICATE HOLDER
Miami Shores Building department
10050 NE 2nd Avenue
Miami Shores, FL 33138
FAX (305) 756-8972
ACORD 25 (2016/03)
3
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ORRED REPRESENTA
A053623
m 1988-2018 ACORD CORPORATION. All rights reserved.
The ACORD name and. are registered marks of ACORD
Produced usleg Forms Boas Web Software. wxnnr.FormaRese,com (c) Impressive Pybllehing 800.202-1977
YRS Electric, LLC.
`Giving and Restoring Power to the Nation"
EC13007587
10190 North West 24th Court
Sunrise, Florida 33322
954-471-6365
trselectricllc@gmail.com
TR3ELECTRIC,LLC
EC130D7587
Date: /r
State of I' 1 , -
County of /rflr.,c:2 41�C
Before me this day personally appeared e i�
deposes and says:
who, being duly sworn,
t
That he or she will be the only person working on the project located at: 12 /V e 4 E: ST _j ka,--F51%_z.
Sworn to (or affirmed) and subscribed before me this23 day of
/A,-- i2/0 c�rsa r /,v
Evens D'Meza
MY COMMISSION * FF 918307
EXPIRES: September 27, 2019
Bonded "T'hru Notary Public Underwriters
D tie r ,e 4.0/4 by
Personally Know gX •
OR Produced Identification
Type of Identification Produced
Print, Type or Stamp Name of Notary
Page 1 1
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
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:
1. 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. /7
Signature:
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this
By 611
Pit
day of Alpo
Notary:
SEAL:
,20 i(,.
who is personally known to me or has produced
as identification.
Vrof
*
MY
EXPIRES
''e'0, ne Bated 1D
a n�'
A STEPHENSON
SION 1 FF 058205
eptember 22,2017
udget Notary Services