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ELC-13-2143Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 199654 Permit Number: ELC -9 -13 -2143 Scheduled Inspection Date: December 03, 2013 Inspector: Devaney, Michael Owner: INC, PUBLIX SUPERMARKETS, Job Address: 9050 BISCAYNE Boulevard Miami Shores, FL 33138- Project: <NONE> Contractor: CAM CONNECTIONS Building Department Comments Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number (863)688 -747_ Parcel Number 1132060100010 Phone: (863)583 -3343 ADD/ MOVE/ MAKE TO CCTV SYSTEM ( VIDEO Infractio Passed comments Surveillance SYSTEM) LOW VOLTAGE I INSPECTOR COMMENTS False Inspector Comments Passed Fi� Failed Correction G� Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. December 02, 2013 For Inspections please call: (305)762 -4949 Page 8 of 40 Miami Shores Village Building Department 1 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 Permit Type: Electrical JOB ADDRESS: 9050 Biscayne Blvd. FBC 20 Permit No. Master Permit N04�� s �3 City: Miami Shores County: Miami Dade Zip: 33138 -3222 Folio/Parcel #: 11- 3206 - 010 -0010 Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder)- NORTHERN TRUST BANK EfAL TRS% PUBLIX SUPERMARKET INC phone #: Address. P O BOX 32025 City: LAKELAND State: Florida Zip: 33802 -2025 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Cam Connections. Inc. phone#: 863 -583 -3343 Addrecc. 3970 S. Pipkin Road City: Lakeland State: Florida Zip: 33811 Qualifier Name: Robert Bull Phone #: 863- 583 -3343 State Certification or Registration #: EF20001044 Certificate of Competency #: _ Contact Phone#: 863- 226 -9331 Email Address: clamonica @camconn.com DESIGNER: Architect/Engineer: Chris LaMonica Phone #: _ Value of Work for this Permit: $ /Z 9 ��e Square/Linear Footage of Work: 863- 226 -9331 Type of Work: ❑Address DAlteration ONew ❑Repair/Replace ODemolition Submittal Fee $ Permit Fee $� �� ® 1' CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Y� C22 DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ � q - -/ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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. �T � o ert ull Signature Signature KLO _ U Owner or Agent ++�� Contractor The foregoing instrument was acknowledged before me/this V — day of '1 1 , 201 , by? d2�'� 3 ' t/1� Q)a -r--6 ^ t who' rs6fi ly kno to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sig : Ul-1/1 Print: ^ aO�PR >P�BI� JODILSLOAN My Commission Expires: MY COMMISSION # EE 058818 EXPIRES: February 5, 2015 -'1".'vP Bonded Thru Budget Notary SeMces APPROVED BY The foregoing instrument was acknowledged before me this_LZt�" day of & 20 -LJ by &.rk R kLtA , who is personally known So me or who has produced 14- Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) identification and who did take an oath. NOTARY PUBLIC: Sign: - !r rvsvc Print: tiro. u�. E My Commission Expir ? * MY COMMISSION #EE881823 ¢ ° ' ...... O•' EXPIRES March 7, 2017 (407) 398.0153 FloOdalloteryService.com Zoning Clerk 13 SEP 9 9. 51 Ca Lp �-- r7 cn j Miami Shores Village 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. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION) 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: Cam Connections Inc. BUSINESS ADDRESS: 3970 S Pipkin Road CITY Lakeland STATE Florida ZIP CODE 33811 BUSINESS PHONE: 8( 63 ) 583 -3343 FAX NUMBER ( 954) 321 -9717 CELL PHONE () QUALIFIER'S NAME: Robert Bull QUALIFIER'S LIC NUMBER: EF20001044 E-MAIL ADDRESS (IF APPLICABLE): rbull @camconn.com Created on 3119109 BY MLDV / RV 3126109 MLDV STATE OF FLORIDA s = =Q` DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD 1940 NORTH MONROE STREET 1", ' VA TALLAHASSEE FL 32399 -078 BULL, ROBERT WILLIAM JR CAM CONNECTIONS, INC. 3970 SOUTH PIPKIN RD LAKELAND FL 33811 (850) 487 -1395 Congratulations! With this license you become one of the nearly one million STATE OF FLORIDA AC# S 2 38 t. 5 5 i Floridians licensed by the Department of Business and Professional Regulation. ; DEPARTMENT OF BUSINESS AND PROFESSIQNAh REGULATION Our professionals and businesses range from architects to yacht brokers, from C u; •; boxers to barbeque restaurants, and they keep Florida's economy strong. EF20001044 -x°12 12000838'1 Every day we work to improve the way we do business in order to serve you better.€ � For information about our services, please log onto www.myfloridalicense.com. CERT ALARN tiRACTOR I There you can find more information about our divisions and the regulations that BULL, ROB :IR impact you, subscribe to department newsletters and learn more about the ! CAM CONNE 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! IS CERTIFIED under the provisions of ch.489 gs i=atioa date; AUG 311, 2014 L12080100303 DETACH HERE AC# 6238455 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD SEQ# L12080100303 The ALARM SYSTEM CONTRACTOR I Named below IS CERTIFIED. Under the provisions of Chapt Expiration date: AUG 31, 2014 BULL, RO CAM CONN 3970 SOU LAKELAND slit ' FL 33811`' RICK SCOTT KEN LAWSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW /"� IMPORTANT! All businesses are required to file an annual Tangible Personal Property Tax Return (Form DR 405). • • www.PolkPA.org and check to see if you have already filed' If you have not already filed, do so right away and see if you qualify for up to $25,000 exemption! For more information contact the Property Appraiser's Office at (863) 534-4777 POLK COUNTY LOCAL BUSINESS TAX RECEIPT ACCOUNT NO, 106693 CLASS: B LESNEWSKI, CHRISTOPHER A BUSINESS NAME AND MAILING ADDRESS CAM CONNECTIONS INC BULL, ROBERT JR - ST CERT 3970 S PIPKIN RD LAKELAND, FL 33811-1422 EXPIRES: 9130/2014 LUF,,A I IUN 3970 S PIPKIN RD LAKELAND - IN . . . . . . . . . . . . . ........ . ........... CODE ACTIVITY TYPE 230050 CONTRACTOR ALARM SYSTEM I PROFESSIONAL LICENSE (IF APPLICABLE) EF20001044 . ......... THIS POLK COUNTY LOCAL BUSINESS TAX RECEIPT MUST BE OFFICE OF JOE G. TEDDER, CFC* TAX COLLECTOR CONSPICUOUSLY C)iSP AY DAT THE AUSINESS LOCATION I, E ............. PAID-lS21021•0001-0001 0910412013 09/04/2013 SLS 155 57.75 CAM CONNECTIONS INC 0 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. CAMCO -1 OP ID: KD ' CERTIFICATE OF LIABILITY INSURANCE F D TE(MMM0 3n 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 Phone:727- 797 -0441 Connelly, Carlisle, Fields & Fax: T27- 669 -0673 Nichols P.O. Box 1027 Clearwater, FL 33757 CONTACT NAME: PHONE FAx C No A/C No): E -MAIL ADDRESS` 05113/2014 05/13/2014 EACH OCCURRENCE Michael Devereux INSURERS AFFORDING COVERAGE NAIC S INSURER A: St.Paul/Travelers Insurance Co 25658 PERSONAL & ADV INJURY INSURED Cam Connections Inc INSURER B: Lexington Insurance Company 19437 Chris Lesnewski 3970 S Pipkin Road INSURER C: GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC PRODUCTS - COMP /OP AGG $ 5,000,00 Lakeland, FL 33811 INSURER D: 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 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MID LIMITS B GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR X Professional Liab AUTHORDED REPRESENTATIVE ��LL Miami Shores, FL 33138 4427008602 4427008602 05/1312013 05/13/2013 05113/2014 05/13/2014 EACH OCCURRENCE $ 5,000,00 DAMAGE ET Ea RENTED occurrence) 100,00 MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 5,000,000 GENERAL AGGREGATE $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC PRODUCTS - COMP /OP AGG $ 5,000,00 Deductibl $ 2,500 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NON-OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ A X UMBRELLA LIAB EXCESSLIAB X OCCUR CLAIMS -MADE I 11N73353 I 03/10/2013 03110/2014 EACH OCCURRENCE $ 3,000,00 AGGREGATE $ 3,000,00 DED I X I RETENTION$ nil AUTO ONLY $ WORMERS COMPENSATION AND EMPLOYERS' LIABILITY }, / N ANY PROPR(ETORIPARTNERIE)(ECUTIVE F—] OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- T Y LIMIT E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ I E.L. DISEASE - POLICY LIMB $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) nooTterrwrc unt nc0 t'AWCPI I ATInkI MMA11118 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores Village Bldg Dept 10050 NE 2nd Ave. AUTHORDED REPRESENTATIVE ��LL Miami Shores, FL 33138 O 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD f . IL I'11._ 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPONTHE CERTIFICATE HOLDER.THiS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, MI TEND OR ALTERTHE COVERAGE AFFORDED SYTHE POLICIES BELOK 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 po ft certain policies may require an endorsement. A statement on this cerdficate does not confer rights to the certificate holder in lieu of such endon amentfsL PRODUCER Stortehe+tge Insurance Schltbns., [re- p Box 3442 Tequests, FL 33489 INSURED Progresshm Emplgr Mornoment Company, Inc. Pr�r�efie Empkryer Menegemant Company II, Inc. 8407 Parkland Dr. Sarasota, FL 34243 COVERAGES CERTIFICATE NUMSER.SPY493N8 RE BI014 NUMBER! THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RE(3UIREMENT, 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, DRSR TYPE OFD4IKWANCE ACCORDANCE WATNTHE POLICY PROViMONS. Miami Shores V)Iage Bldg Dept POLICYNWIBL3t tmpw arm POLICY LaBTB v. GENEtALLL481UTY EACH OCCURRENCE $ ppEMl comwerice) $ S COMMERCIAL GENERAL LIABILITY CLADA&MADE EJ OCCUR MED EXP orre ) PERSONAL 8 ACV INJURY $ GENERAL.AGGREGATE $ GM AGGREGATE LIMIT APPLIESPFJi: PRODUCTS- CCMPIOPAGG $ POLICY F 1 M Loc $ AUTOMOBILE LL48NM ANYAUTO -- BODILY INJURY (Per poraw) S OWNED �OIX1LED � LIODILY INJURY (Per ecad®nQ S HIRED AUTOS NAO� NED $ $ la9aREL A UAB OCCUR EACH OCCURRENCE $ EXCESS UAR CLAIMS -MADE AGGREGATE S DED I I RETENTION 5 $ WORKERSCOMPENSATTON AND EMPLOrtERa' LIABILITY ANYPROPRIETORniIRiNER1DfECUTNE YIN OFF.EMEMe =CLUDEDT (firMNHI K�t�, desaPoeundar DESCRIPTION OF OPERATIONS below NIA 11M112012 MUMS X afGSTATU EL EACH ACCIDENT i 1,ODO,000 EJ..DISEASE- FAEMPLOYEE S 1,000,W0 E.L DISEASE - POLICY LIMIT $ 1,0(IO,Oz $ DESCRIPnOX OF OPEtMMS I LOCATIONS IVEHICLES (Attach ACORD 101, Addahmd Remarks Schelde, If more apace N mquhod) Coverage Is extended to used employees, but not subcontractors of Cam Connections, Inc., el(e adve 12 -13-08. Stonehenge Insurance Soldons Inc. Phone 581 -746 -5027 Fax 561 748.5028 Imiel)e@stonehengeis.00m CERTIFICATE HOLDER CANCELLATION Page 1 of 1 ® 9988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registared marks of ACORD SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATET HIEREOR NOTICE WALL BE DELIVERED IN ACCORDANCE WATNTHE POLICY PROViMONS. Miami Shores V)Iage Bldg Dept AUTHORIZED REPRESENTATIVE 1 W50 NE 2nd Ave Mlam) Shores, FL 33138 iF i;1 v. Page 1 of 1 ® 9988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registared marks of ACORD