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EL-17-904
3 33 ? 1f ltf6 Miami Shores Village @ �T)rw Hca r +� 'e 10050 N.E.2nd Avenue NES / 0 -0000 Miami Shores,FL 33138 r5tfl� I ' ''3. Phone: (305)795-2204 - � Expiration: 01/06/2018 Project Address Parcel Number Applicant 45 NE 98 Street 1132060131130 JAVIER ZAYAS Miami Shores, FL Block: Lot: Owner Information Address Phone Cell JAVIER ZAYAS 45 NE 98 Street (305)318-6738 MIAMI SHORES FL 33138- 45 NE 98 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,000.00 AV ELECTRICAL SERVICE INC (305)218-7347 Total Sq Feet: 0 .....:... .._ _ ,.. Type of Work:CHANGE SERVICE,CHANGE OUTLETS IN Available Inspections: Additional Info:CHANGE SERVICE,CHANGE OUTLETS IN Inspection Type: Classification:Residential Review Electrical Scanning:1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# EL-4-17-63543 DBPR Fee $3.38 07/10/2017 Credit Card $ 187.96 $50.00 DCA Fee $3.38 Education Surcharge $0.40 04/03/2017 Credit Card $50.00 $0.00 Permit Fee-Additions/Alterations $225.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $237.96 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFF A IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction nd z ino. F I authorize the above-named contractor to do the work stated. -� -� July 10,2017 Authors ed Signature: ontractor / Agent Date Buildin Department Copy July 10,2017 1 Miami Shores village BuildingDepartment` p AP 3 2017 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795.2204 Fax:(305)756.8972 j,, < INSPECTION'S PHONE NUMBER:(305)762.4949 FBC 2014 BUILDING PermitNo. PERMIT APPLICATION Master Permit No. E L 17 - 9 0 4 Permit Type: Electrical JOB ADDRESS: �I_,_s-1tie q O 's City: Miami Shores County: Miami Dade Zip: 33 13 Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: OWNER:Name(Fee Simple Titleholder): �� Y1 Phone#. 345) 34-407t Address: City: State: Zig: TenandUssee Name: Phone#: Email: CONTRACTOR:Company Name: 19 /c� ,®�( / �G� i�./G Phone#: -�cs Address: 29/e SW 1 Z k All City: A41�m ; II State: Zip: Qualifier Name: /r`� 19 AJQ G Y, Phone#: .30-5 ZI_ .9 State Certification or Registration#: f' l X00 Certificate of Competency#: Contact Phone#: Email Address: 0 I r®!a i 8 DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$ 2-GCO 0 O A Square/Linear Footage of Work: Type of Work: OAddress OAlteration ONew 'ARepa11ir/Replace ODemolition Description of Work: C A&i«. Se(yl Ct,Q. ON&f(Q� ( �' S /✓J (ti cJ11T N f.0 cm' I e�_ 4W GJ\ kW1 r`+ ( Ur-&W hea4Z . Submittal Fee$ ® PQd Permit Fee s SCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ I 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 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 UAPROVEMENTS 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 fzrst inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not b proved and a reinspection fee will be charged Signature Signature dwner or Agent aa tractor The foregoing instrument was ackno , g s—L The foregoing instrument was acknowledged before me this„ day of N A0 ,20_?by JA\A�r 7fiVA day of 20 t-9-,by &kx jo ye (`z L , who sonally known to me r who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: REBECCA LOPEZ .Irw Commission##FF FF 238061 �J Sign: �,�s u 19 Sign: ► �rtin.`', Bored Tft Troy Fek�kwane=187018 ,• Print: Print: My Commission Expires:JLA VX-51 Z-O I Gj My Commission Expires: 1V23'/J8 n .. oC APPROVED BY / NI&y />-Plans Examiner Zo in Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06AW009)(Revised 3/15/09) AV Electrical Service Inc. 504 SW 120 AVE Miami, FL 33184 March 21, 2017 State of Florida Count of Dade Before me this day personally appeared Felix Antonio Negrin who being duly sworn, disposes and says: That he or she will be the only person on the project located at 45 NE 98 ST Miami Shores, FL 33138 Sworn to (or affirmed) and subscribed beforj s 21 day of March, 2017, by Personal know Produced Identifica NVaS 24 k 7o�30-0 i�x� ►►►�►y`1 Type of Identification Produced "N REBECCA LOPEZ Commission#FF 238061 p= Expires June 8,2019 BwxW Thru Troy Fain{murw=8M WM9 Print, Type or Stamp of Notary a^ CERTIFICATE OF LIABILITY INSURANCE • 63/16117 —--- ---- �.. _ ��._- ---- `---- — -- THIS CERTIFICATE 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($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. Ie1PORTANT:if ft eemficoo h*Wa is an ADDITIONAL INSURED.the per)mum be eawkna .It SUBROGATION IS WAIVED,wAgoct to thg terms wtd cwdftWm a1 ft po8cy,colmn poocies"nWm an attawstmeft A smun ant an Oft cer ft m don not eor4or ft is tO the t+RQIIatC6R wAcy JULIOXMENEZ jime;em&Co..Inc. M, aJ _{305)284-9d 0 v----�pQ (30512806382 ROOD CWay Att01FE139: orel Miami.FL 33155 _ eI�etaLAf�olr�cam — _ r Phone _@*)284-8900 --- Fane (M)264.5382 WRIM A; CYPRESS INSURANCE CONPANY wouaw p _ AV ELECTRICAL SERVICES INC pt4 -- k 2412 SW 128 AVERe' � Kaft.FL 33175 (3D5)218-7341 -_ COVERAGiES CERTIFICATE NUMBER: REVISION NUMBER. TIA$IS TO CERTIFY THAT THE PCU--CIE-S,OF660-W NAVE BEEN$SSSIED TO THE INSURED NAMED ABOVE FOR THE M= ._.-. PERIOD - MCATEO. NorAiTHSTAND6NG ANY TEID,t OR CONDITION OF ANY CONTRACT OR OTHER DOCWMNT WITH REWIECT TO WHICH THIS CERTTOCATE MAY BE I.SSM OR MAY PERTAIN.THE MLWMM AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUILIECT TO ALL THE TERNS. EXCLL&ONS AND CONDITIONS OF SUCH P>3LIW-LAND$i— - _MAY HAVE SEEN REDLICED BY PAID CLAD. _ _�— p"cYs" PO TMCW01SI6iURiC$ R1 t- V4Lr♦rVVNWtFEitI OJM3rrl_ n— ---- -- 69MMAL VABUJM 6:It;H M,1.OGD.DOD.� OWAA%78 RU41W 100.0 I i F6 GOWARC AL ODOM U MUTT - `AFAW �. _.i 1 MA244V= ;6 OCC" N I GFL•1020528 0481 10!26116 10126/17 °dam � r m+o c�sm+J S 6,000'm A e A a a�aTeA1RY s I M.000.00 f ce*rw.AWREGATIE, s 2.ON 0=0 . .. �-* pR�. ___ —-- GVfL T6 LMT APPLES P� I i A66 s 100D.000.00 V POL1Cr 17 pa _L '_ — — .._ AUTOYOSILELIAaaL." ' _ _�. SDKILEluc'r 5 AW negro aoolLr Ixataaar{P a PSI i u � QDLa4EO 6DQLraia3lRr(iaH € — _ - r-� L7 MRm AJM 1AuyW UYBRELLJL LbtB OGLUR V 8KCM LIAO__. _ « I I A(iCikECa►TE a $^'gtTC STAtU-_�t MV EMLOYM UAOWW r a N j ,� I 4 Towum1SyNTff ANr 1PR[�rlkAtPAfil'Oi>Pb !N a A LCH- EXE n f Ivo_DSLW-_-FA OWLOYM s—....�..._. A a StOrm Cw 07E"TQ%s tbto•__.._ E L L1 .edL4E•i�01aCY U4at'T 6 1 aEBCRiCTON Of OPERATiM I LOCA110eQ61 VAtd69 Ei tAltaaA ACM tK AOAH WW Rte ft%t, ft'o ria so=b I ELECTRICAL WORK-WITHIN BUILDINGS'"' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE -6�f�F MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE YYtlLL W BUILDING DEPARTMENT ACCORDANCE WITH THE POIACY PA IOQSO NE 2NO AVE -- MIAMI SHORES.FL 33138 AUTMOIi�OREPRI:lt�ITATNL ` E31@8 pi;ACORD CORPORATION, AN right resiovtsl. ACORD 2$(801 OMS)QF The AGOhD name end Ingo we toglistemd amoft of ACORD �X toss am Miami shores Village Building Department �Cppf 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 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 B OW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. e: State of Florida County of Miami Dade J The foregoing wasacknowledgebefore me this 3 P- ` day of ,20�. By( CJ�V 1'e1' 01J1Q S who is personally known to me or has produced 11-J4 0 ,J�f iy'Q r C (bPiV sk- as identification. �pAYP©. YANADY PRIETO Notary: ' = MY COMMISSION#FF 214031 EXPIRES:March 25,2019 SEAL. gd n Bonded Thru Notary Pubft Underwrkers STATE OF FLt>Mt1A t EPAR MENI OF i3USINESS AND pROFESSIC3NAL REGULATION *�• EC13004404 i 't)ED' 06/19/2016 M CERTIFIED ELEC MW&CON FACTOR NEGRIN, FELIX A AV ELECTRICAL SERVICE INC IS CERTIFIED under the pr()ur ,rtrls of Ch 489 FS E)V" .jsos,g000ls34 dere AUGaur s�. tate STATE OF FLORIDA rt' OF—PARTMENT OF FINANCIAL SERVICES O MSION OF WORKERS'COMPENSATION 4 CONSTRUCTION INDUSTRY EXEMPTION CV"VW-ATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW EFFECTr4E DATE 2t 2"2016 EXPIRATION DATE, PERWO: NiEGRIN FELIX FEIN: 262362255 13USMESS NAME AND ADDRESS.- AV DDRESS:AV ELECTAICAL SERVICE INC - • t47* $04 SIN 120 AVE MIIAlM FL 33184 w SCOPES OF BUSINESS OR TRArpmy .. ours kcal x Receipt ' ,ate of Florida AIDMI�m1 �• T FAY 55701 EXP IRI- �d IK "EMBER 30, 2017 sae,PAC I op �. �a �•ro§„�'Far�d� �MI^.