EL-16-3209 Permit NO. EL-11-16-3209
Rcs Miami Shores Village Permit Type:Electrical -Residential
10050 N.E.2nd Avenue NE Work Classification: Pool -Private
' Miami Shores,FL 3313&0000
••`�!' �` Per Phone: (305)795-2204 Permit States:APPROVED
F�ORtOA
Issue Date: 12/15/2016 Expiration: 06/13/2017
Project Address Parcel Number Applicant
1561 NE 103 Street 1132050310220
Miami Shores, FL 33138- Block: Lot: M2J4 HOLDINGS LLC
Owner Information Address Phone Cell
M2J4 HOLDINGS LLC 1561 NE 103 Street (786)290-8051
MIAMI SHORES FL 33138-
660 NW 125 Street
NORTH MIAMI FL 33168-
Contractor(s) Phone Cell Phone Valuation: $ 1,000.00
YORK ELECTRIC CORP (786)287-7380
_._. _.. ........ m... _. Total Sq Feet: 0
Type of Work:POOL LIGHTS&EQUIPMENTS. Available Inspections:
Additional Info: Inspection Type:
Classification:Residential
Final
Scanning: 1
Light Niche
Bonding
Review Electrical
Alarms
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60
DBPR Fee Invoice# EL-11-16-62168
$4.50 11/23/2016 Check#:2964 $50.00 $263.60
DCA Fee $4.50
Education Surcharge $0.20 12/15/2016 Check#:3002 $263.60 $0.00
Permit Fee-Additions/Alterations $300.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $313.60
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 AF I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construct' n a Futhermore thorize the above-named contractor to do the work stated.
December 15, 2016
Auth i r / Applicant / Contractor / Agent Date
Building Department Copy
December 15,2016 1
YORK ELECTRIC CORP
45 NW 7 AVE MIAMI FL 33125
EC13004787
12-15-16
State of Florida
County of Dade
Before me this day personally appeared, Roberto Moreno who, being duly sworn,
Deposes and say:
That he will be the only person working on the project located at 1561 ne 103 St
Miami Shores FL 33138.
Sworn to (or affirmed) and subscribed before me this 15 day of December, 2016,
by Roberto Moreno (quilifier).
Personally known xx
Or produced Identification
?� A IVIS SAMCa i
ON# U4-32EXPi �pte er
4 - RoridaNatarySeryice.com
rint, Type or amp me of Notary
DECEIVED
Miami Shores Village NOV 23 1016
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 S
FBC 2//01\4
BUILDING Master Permit No. (b'
PERMIT APPLICATION Sub Permit No. L
❑BUILDING �pLECTRIC F-] ROOFING REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING F-J MECHANICAL PUBLIC WORKS ❑ CHANGE OF 0 CANCELLATION [:j SHOP
i (_ ' 1 CONTRACTOR DRAWINGS
JOB ADDRESS: I��L7 1 V In� 2
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): PtuPhone#:
Address:
City: \()n $ _State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: 1� C Phone#� ® �
Address: 4: KX a:a _P- , _
City: KA-krA Qn c State: Zip: Z)3
Qualifier Name: Phone#:
State Certification or Registration#: T- I� Certificate of Competency#:_
DESIGNER:Architect/Engineer: Phone#:
Address: .• ^ City: State: Zip:
Value of Work for this Permit:$_ J(`SCJ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New f Repair/Replace ❑ Demolition
Description of Work: -�
�L
Specify color of color thru tile:
Submittal Fee$ _Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$_ DBPR$ 0 Notary$ �----
Technology Fee$ Training/Education Fee$ _Double Fee$
Structural Reviews$ _ _ Bond$
TOTAL FEE NOW DUE$ L�l/
(Revised02/24/2014)
Bonding Company'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
Th foregoing instrument was ack owledged before me this The oregoing instrument was acknowledged before me this
day of 20. by day of 20 , by
who is perin..ta-. wn to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
IVIS S NCHEZ
O
=°s�?l`e4o`': 1 I. I�IC, SK�
' I .i F 58 2
Si n: =` Sign:
Print: r'� ttzmber 9 Print: F a servic:.
r '� '�•• t' yServlri;.cam
Seal: Seal:
APPROVED BY �i�, ��r,ttb4 /6 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
`Sg C.I
goal aaaaam Miami shores Village
oR
�2 - 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
71
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 fall-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 i£
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 !;I Yhy- ,20_]_L.
By ," aTVI .c • L. E T`e VLQ. who is personally known to me or has produced
entification.
Notary: s '� ice YANADYPRIETO
MY COMMISSION Y FF 214031
ii° EXPIRES:March 25 2018
SEAL: p;c Bonded Thru Notary Pubic Und*Aw*t3
0
AQUARAMA POOLS
304 Indian Trace Dr.
Weston FL
305-934-4226
12-15-16
State of Florida
County of Dade
Before me this day personally appeared, Jose Yzquierdo who, being duly sworn,
Deposes and say:
That he will be the only person working on the project located at 1561 ne 103 St
Miami Shores FL 33138.
Sworn to (or affirmed) and subscribed before me this 15 day of December, 2016,
by Jose Yzquierdo (quilifier).
Personally known xx
Or produced Identification
'pJ
A IVIS SANCHEZ
C ice':
n':
M OMMISSION#F
ptember 41
n a o ary ervice.com
P ' , Type tamp Name of Notary
`5goRs Gi
... ..,,. Miami shores Village
Building Department
IRS
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
t
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 CKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
0 Owner
State of Florida
County of Miami-Dade ;�" �`" 1
The foregoing was acknowledge before me this 14th day of �J'r(1(M LTC r. ,20 16 .
By_MQtrk A . lktiv-(yX q who is personally known to me or has produced
ms as identification.
Notary:
tin+'Pyr, YANADY PRIETO
SEAL: ' . MY COMMISSION#FF 214031
a€ EXPIRES:March 25,2019
%:f'F Bonded Thru Notary Pubfic undenrtiters
R X14``
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