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EL-16-22091 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Parcel Number Applicant 1561 NE 103 Street Miami Shores, FL 33138- 1132050310220 Block: Lot: M2J4 HOLDINGS LLC Owner Information M2J4 HOLDINGS LLC Address 1561 NE 103 Street MIAMI SHORES FL 33138- 660 NW 125 Street NORTH MIAMI FL 33168- Phone CeII Contractor(s) RAVEN ELECTRIC INC Phone CeII Phone (305)951-1210 (786)290-8051 Valuation: Total Sq Feet: $ 5,620.00 0 Type of Work: COMPLETE NEW ELECTRICAL AND NEW SER Additional Info: Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Notary Fee Permit Fee - Additions/Alterations Scanning Fee Technology Fee Amount $3.60 $3.38 $3.38 $1.20 $5.00 $225.00 $3.00 $4.80 Total: $249.36 Pay Date Pay Type Invoice # EL -8-16-60894 08/16/2016 Credit Card Amt Paid Amt Due $ 249.36 $ 0.00 Available Inspections: Inspection Type: Review Electrical 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 a foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Fu ermore uthorize the above-named contractor to do the work stated. August 16, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date August 16, 2016 1 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION UNE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION ❑BUILDING 0 ELECTRIC ❑ ROOFING ❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS JOB ADDRESiS:Ael NE 103rd Street RWORIVED AUG 0 2 2096 FBC 20(14-4 Master Permit No. gG (p - 1 Z 03 Sub Permit No. (2 ❑ REVISION ❑ CHANGE OF CONTRACTOR ❑ EXTENSION ❑RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:1132050310220 Occupancy Type: Load: Is the Building Historically Designated: Yes NO X Construction Type: Flood Zone: OWNER: Name (Fee Simple Titleholder): M2J4 Holdings, LLC / (Mark LLerena) Address: 660 N.W. 125th. Street V BFE: FFE: Phone#: 305-643-1136 City: North Miami State: Florida Zip: 33168 Tenant/Lessee Name: N/A Email: MarkL@cspaintwc.com Phone#: 786-290-8051 CONTRACTOR: Company Name: Raven Electric, Ihc. Address: 3913 S.W. 90th Avenue Phone#: 305-951-1210 City: Miami Qualifier Name: Oscar Hemandez State: Florida Zip: 33165 Phone#: 305-951-1210 State Certification or Registration #: EC 13005734 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ -- ei— 20, CbSquare/Unear Footage of Work: Type of Work: ❑ Addition ❑ Alteration C Description of Work: C- rN r Jae_ A.o,.tj ❑ New ❑ Rpair/Replace ElDemolition ICONS Specify color of color thru tile: Submittal Fee $ (J Scanning Fee $ �,," Ctj Technology Fee $ ` /. - 90 Structural Reviews $ Permit Fee $ _2.7J o av Radon Fee $ 3" (Revised02/24/2014) CCF $ ° GO CO/CC $ DBPR $ �' Notary $ . 00 Training/Education Fee $ (° 2 0 Double Fee $ 9, Bond $ TOTAL FEE NOW DUE$ 249 -',.)c;) Bonding Company's Name (if applicable) Bonding Company's Address City /.56/ /0 3, ad S� State Zip Mortgage Lender's Name (if applicable) 6 J I 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 tiye-pbsence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature RJaR.K. L.L, t! Si 14 OWNER or AGENT The foregoing instrument was acknowledged before me this n --r o�<" day of y _20 by /612k.. LL1,2i i ', me or who has produced rpf identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: (YThC- i 1 I.Aff "_Py'4 DAMAYI VEGA MY COMMISSION # FF 214016 A. rte• od: EXPIRES: April 1, 2019 Bonded Thru Notary Public Underwriters to as The foregoing instrument was acknowledged before me this act day of 64.66//e - me or who has produced ,20 /6 ,by own to as (,ter identification and who did take an oath. NOTARY PUBLIC: Sign: c. iy�Sd+'. °te�c DAMAYI VEGA " . ,�, :.: MY COMMISSION # FF 214016 i _ -rte a EXPIRES: April 1, 2019 Jam/ •: od •°e' Bonded TAru Notary Pubr Urdetwritere Print.'*,rii 1'rC A _ (1 Seal: ***** */ik A.M.:ss...,..,.,., ......* t********************************************************************** APPROVED BY 7 9/4 5-n Plans Examiner Structural Review 1Revised02/24/20141 Zoning Clerk Notice to Owner 11/1 iami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 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. Signature: Owner State of Florida County of Miami -Dade The foregoing�was acknowledge before me this day of s► By 1 -. z- ��� who is ovally known to' g' e or has produced �, 11016 ill/SIJ/// s *4-garchs�,�L ®�• o ®e 55• C o▪ c * 94760! *` JJlllftWrATE c ,201 . Notary: }7 SEAL: HA VEN ELECTRIC, IN( ' Date: August 3, 2016 State of Florida County of Miami -Dade Before me this day personally appeared Oscar Hernandez who, being duly sworn, deposes and says: Thank he or she will be the only person working on the project located at: 1561 NE 103rd Street, Miami Shores, FL 33138 or affirm) and subscribed before me this 3rd day of August, 2016 by Oscar Hernandez car Hernandez Personally know Or Produced Identification Type of Identification produced oey,c: DAMAYI VEGA ;.,•; MY COMMISSION # FF 214016 ni a< EXPIRES: April 1, 2019 '48f� ? Bonded Thru Notary Public Underwriters Pri ` pe or Stamp Name of Notary 3913 S.W. 90t" Avenue, Miami, FL 33165 1 PH: 305-951-1210 • R' A� o® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 07/27,16 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 Ileu of such endorsement(s). PRODUCER G & E Insurance Consultants,Inc. 9880 SW 40th Street Miami, FL 33165 Phone (305) 228-8988 Fax (305) 228-8969 CONTACT NAME: GRICEL GONZALEZ (ac° No Ext): (305) 228-8988- FAX No): (305) 228-8969 E•MJUL ADDRESS• PRODUCER CUSTOMER ID #: INSURERS) AFFORDING COVERAGE NAIL # INSURED RAVEN ELECTRIC INC 3913 SW 90 AVE MIAMI FL 33165 INSURER A: GRANADA INSURANCE COMPANY 0185FL00074202 -1 INSURER B : 09/09/2017 INSURER C : $ 1,000.000 INSURER D : $ 50,000 INSURER E : MED EXP Any one person) INSURER F : • • CLAIMS -MADE ►n OCCUR ❑ 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. INSRTYPE LIR OF INSURANCE ADDL INSR SUB - WVD POLICY NUMBER POUCY EFF (MM/DD/YYYY) POLL,�� EXP (MM/D LIMITS A GENERALUABIUTY N 0185FL00074202 -1 09/09/2016 09/09/2017 EACH OCCURRENCE $ 1,000.000 RENTED PREM SES GE T(Ea occurrence) $ 50,000 'n COMMERCIAL GENERAL LIABILITY MED EXP Any one person) $ 5,000 • • CLAIMS -MADE ►n OCCUR ❑ PERSONAL & ADV INJURY $ 1,000.000 ❑ GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000.000 5 POLICY • 128j- • LOC $ AUTOMOBILE LIABILITY ❑ ANY AUTO • ALL OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ • SCHEDULED AUTOS PROPERTY DAMAGE (Per accident) $ ❑ HIRED AUTOS • NON -OWNED AUTOS $ $ ❑ EACH OCCURRENCE $ • UMBRELLA UAB ❑ OCCUR AGGREGATE $ • EXCESS UAB ❑ CLAIMS -MADE • DEDUCTIBLE El I RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N N /A ^ OT I i C STA11J-Y ❑ ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L DISEASE - EA EMPLOYE $ (Mandatory In NH) Ifes describe under DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addldonal Remarks Schedule, H more space Is required) ELECTRICAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES FL, 33138 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/09) QF © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • . JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERSCOMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. 44, EFFECTIVE DATE: 9123/2015 PERSON: HERNANDEZ FEIN: 481261518 BUSINESS NAME AND ADDRESS: RAVEN ELECTRIC, INC EXPIRATION DATE: OSCAR 3913 SW 90 AVE MIAMI FL 33165 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR : _9/22/2017 STATE OF FLORIDA DEPARTIkANT...OE BUSINESS AND PROFESCWAPIEGULATION EC13005734D;09/02/2014 •'• . - CERTIFIED ELEeRip,ALPCfN TOOR HERNANDE2,4., Agr' RAVEN ELECTRIOI LS CERTIFIED under the proSisions of Ch.469 FS. Expitation' : AIJG31, 20$8 Pursuant to Chapter 440.05(14), F.S., an officer of a corporation Mfo elects exemption from this chapter by Sag may not necover benefits or compensation under this chapter. Pursuant to C.hapter 440.CetIZ.PS.. within thes of the business or trade listed= the nonce of eLeceice be tetaerryt. theater:tic Cemoter'440. ---exeMptan ce triVoFetectert toleir egaMpt-thal Stagitatemeoceespfc at ant *ear& thetingerlite, the person named on the notice or certificate no longer meete the requirenierittorthheetictionfte-Issinince of a ca. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 L1409020001954 • QUESTIONS? (850)413-1609 002692 SW' •1IAM1335 a This LOCarBosiness pennit„iirificertific or diftitiremmertral TheRECEIPTAO. ab PAYMENT. RECEIVED BY TAX COLLECTOR $75.00 09/15/2015 ...feRED1TCARD-15-046148 Business:tax. The Receipt is not a lidense. Holderkult complywith any governmental the busfrieris. . • 8 I/rola! a-276. • • ation,vist*rv'' .miamidade,geyftqtchReeto! Detail by Entity Name Page 1 of 2 Detail by Entity Name Florida Limited Liability Company M2J4 HOLDINGS, LLC Filing Information Document Number L15000121691 FEI/EIN Number 47-4576773 Date Filed 07/15/2015 Effective Date 07/15/2015 State FL Status ACTIVE Principal Address 660 NW 125TH STREET NORTH MIAMI, FL 33168 Mailing Address 660 NW 125TH STREET NORTH MIAMI, FL 33168 Registered Agent Name & Address THE TARICH LAW FIRM P.A. 19495 Biscayne Blvd Suite 606 Aventura, FL 33180 Name Changed: 02/24/2016 Address Changed: 02/24/2016 Authorized Person(s) Detail Name & Address Title MGR LLERENA, MARK A 660 NW 125TH STREET NORTH MIAMI, FL 33168 Title MGR LLERENA, MONICA 660 NW 125TH STREET NORTH MIAMI, FL 33168 http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 8/2/2016 Detail by Entity Name Page 2 of 2 Annual Reports Report Year Filed Date 2016 02/24/2016 Document (manes 02/24/2016 -- ANNUAL REPORT 07/15/2015 -- Florida Limited Liability View image in PDF format View image in PDF format Coovricrht OO and Privacy Palicies State of Florida, Department of State http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 8/2/2016