EL-17-606 ff Pe A10,
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Miami Shores Village Paan: � ;'j led ca =Re0ential
10050 N.E.2nd Avenue NE
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"• Miami Shores,FL 33138-0000 Fz
go� Phone: (305)795 2204 ritatcF A
Pe PIRKOVEi
�OR1D� Expiration: 09/18/2017
issue 312212Q
Project Address Parcel Number Applicant
576 NE 97 Street 1132060171510
Miami Shores, FL 33138- Block: Lot: GUY VANDERHAEGEN
Owner Information Address Phone Cell
GUY VANDERHAEGEN 576 NE 97 Street
MIAMI SHORES FL 33138-
576 NE 97 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 1,500.00
VERES ELECTRIC INC 786-229-8294
Total Sq Feet: 0
Type of Work:ELECTRICAL WORK FOR TRELLISE Available Inspections:
Additional Info:ELECTRICAL WORK FOR TRELLISE Inspection Type:
Classification:Residential Final
Scanning:1 Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Review Electrical
W.W.
Review Electrical
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.20 Invoice# EL-3-17-63216
DBPR Fee $2.25 03/07/2017 Credit Card $50.00 $110.70
DCA Fee $2.25
Education Surcharge $0.40 03/22/2017 Check#:196 $110.70 $0.00
Permit Fee-Additions/Alterations $150.00
Scanning Fee $3.00
Technology Fee $1.60
Total: $160.70
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLU NG MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I rti the the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. uth rmo e, thorize the above-named contractor to do the work stated.
March 22, 2017
Authorized I
ignat r :Own / Applicant / Contractor / Agent Date
Building D artm;nt
Copy
March 22,2017 1
Miami Shores Village
Building Department MA 20
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 17
Tel:(305)795-2204 Fax:(305)756-8972 �rm
INSPECTION LINE PHONE NUMBER:(305)762-4949 -_
FBC 210
BUILDING Master Permit No. T `lb-3437-
PERMIT APPLICATION Sub Permit No. E L 11 - 616
❑BUILDING XELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING [:] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: k E S/
Ci Miami Shores Coun : Miami Dae Zi •
Folio/Parcel#: I Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood/Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): !!fib "' Phone#:
Address: J126 -
City: c' /2S State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: l�� ! Phone#:
p Y
Address: 'sco
City: State,__ Zip:
Qualifier Name: Z,is- ' �• Phone#:
State Certification or Registration#:TG 1?0C `�/ Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: + City: State: Zip:
Value of Work for this Permit:$ l^god Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: -'�IIC16r a( 0& .Ate U S-(
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ f�c K
Scanning Fee$ Radon Fee$ �� DBPR$
Technology Fee$ , CP e? . _. Trainii'igjEdecia Fees_ Double Fee
Structural Reviews$ - Bond$
TOTAL FEE NOW DUE$ I ®
(ReviSM02/24/2014)
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 Tip
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 certifled 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 instrumen was cknowledged before me this The foregoing instrument was acknowledged before me this
day of / ' 20 %� ,by _�day of 1-lAr t,L. .20 1-7 ,by
("'qv Im"q 2,r�bFd .who is personally known to (P e)4 Bret' ,who is personally known to
me or who has produced as me or who has produced i C 2we,e, as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC NOTARY PUBLIC:
Sign: 2
69 Sign: `
Print: / leSs Print: '
i°. - Notary Public-State of Florida
Seal: ;.''•, YANi Yt�ANTlat;� Seal: 5• :•c My Comm.Expires Nov 9,2017
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. �...,, 2� ao�Forc���.�o,� Commission#FF 037026
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#��"' � �,��#II'I
APPROVED BY -��/� �s �2i Y Plans Ekarrilher Zoning
Structural Review - Clerk
(Revised92/24/2014)
VERES ELECTRIC , INC
EC#13006465
Date: 3/17/17
State Of : Florida
County Of: Dade County
Before me this day personally appeared ��Y� �� who being
duly sworn , deposes and says:
That he or she will be the only person working on the project located at:
Sworn to (or affirmed )and subscribed before me this �� day of hLkf&
2019 , ��
by �c`QSe��S
rsonally Know -
Or Produced Identi ication
Type of Identification Produced
Its I.,w- ACHIEL ALSINA
;ter° e`er Notary Public-State of Florida
• '•
My Comm.Expires Nov 9,2017
Print, i��on#FF 03
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Ito" aQ.e��t Miami Shores Village
Building Department
AIL? ` 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 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 if
1. The officer owns at least 10 percent of the stock of the corporation,or in the case of
an LLC,a statement attestiug 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 Phis 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,parttime employees or subcontractors.
BY SIGNIN 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 ,2017 .
By V who is personally known to me or has produced
G as i tcation.
Sandra A=
Notary: G(/!
*_ Expires: May 26,2020
SEAL: Bonded thru Aaron NOWT
,