EL-14-2699 Miami Shores Village
Building Department -
10050 N.E.2nd Avenue, Miami Shores,Florida 33138 - r
Tel:(305)795-2204 Fax:(305)756-8972 - -
INSPECTION LINE PHONE NUMBER:(305)762-4949
C 20
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No. G
❑BUILDING (!$ELECTRIC ❑ ROOFINGIallt ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
�
r5S /n CONTRACTOR DRAWINGS
U
JOB ADDRESS: IVE, q&_ SL-
City: Miami Shores �i County: Miami Dade Zip:
Folio/Parcel#: /1 3 2_061)/y ,4�k Is the Building Historically Designated:Yes NO 1p<6
Occupancy Typeow ;;Coad: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): L.-M-
Address: (Ny__ ':No �T
�/►/J _
City: `►"! 1 SJ�L&��� State: Zip: � P
Tenant/Lessee Name: 6" JA— Phone#:
Email: 111 C le C't'wn C%f-L-7— v° I;
CONTRACTOR:Compa6
ny Name: ° n -/
Address: 10
City: State: Zip:
Qualifier Name: / Phone#:
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ e OW CO Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration F-1New ❑ Repair/Replace ❑ Demolition
Description of Work: (A l Zz__ A2_
73
00
Specify color of color thru tile: r-71 IE
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ I �9, I
(Revised02/24/2014)
/ kr
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$25W, 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 reins ction fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The for oing instrument was acknowledged before e t is The for oing instru ent was acknoledged before me is
/VzAay of 20 ,by day of 20 by
/ <.
whois personally known to - who is personally known to
me or who has produced a as me or who has produced as
Identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY el00yj0
CASign: .�� � R9� r
Sigs
Prins �° ' s Prig
'
e
SeaF�;• 9EE885143 ��Q Sea ..Qpa
46,
APPROVED BY 3PZ c��°QC Plans Examiner Zoning
Structural Review Clerk
(Re Ased02/24/2014)
a
RICK SCOTT,GOVERNOR
KEN LAWSON,SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD
rEC1300"5618!�_
The ELECTRICAL CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2016
MARTIN, MAXIMO ERNESTO, u f Q y'a'Q
MAXIMO ELECTRIC, INC •
16931 SW 141 CQURT
MIAMI FL 33177
Y �.
ISSUED: 0622/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1406220001607
Local Business Tax Receipt
Miami—Dade County,State of Florida
-THIS IS NOT ABILL-DO NOT PAY %. LBTool
5618744
BUSWESS NAMEILOCATION RECEIPT NO. EXPIRES
MAXIMO ELECTRIC INC RENEWAL SEPTEMBER 30, 2016
16931 SW 141 CT 588189
MIAMI,FL 33177 Must be displayed at place of business
Pursuant to County Code
Chapter RA-Art.9&10
OWNER SEC.TYPE OF BUSINESS pAYMENT RECEIVED
MAXIMO ELECTRIC INC 196 ELECTRICAL BY TAX COLLECTOR
CONTRACTOR 75.00 07/152015
Warker(s) 1 EC13005618 CHECK21-15-094335
This local Business Ta:Receiptonly ff, psymemolthe Loral Bast STm0ho Receipt isada li+ense,
permit or a cm0cattoa ofthe bM&s pdfflcations todo I IMss Holder most comply wish any lunar mnenisi
or nongavermnead regulatory laws and requimments vAdch apply to th businew
Tice ww"Naabm stat be displayed on an commercial vel toles Miami-Bade Code Sec Ba-m
141000 Formore lnoa,vistt
DATE(MMIDDIYYYY)
Aco p® CERTIFICATE OF LIABILITY INSURANCE 01/21/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
HE POLICIES
CERTIFICATE DOES NOT AFFIR"TiVEI-Y OR NEGATIVELY AMEND' EXTEND OR ALTER THE COVERAGE AFFORDED ( AAUTHORIZEDBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S).
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER-
IMPORT—ANT:
OLDERIMPORTANT:If the aerttltoate holder is an ADDITIONAL INSURED,the polil:T►(tes) must be endorsed. N SUBROGATION IS WAIVED, subject to
the terms and conditions of the Politer,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
cerdficate holier in Heu of such endorsement(s).
Cower PRODUCER David Gil,Sr.
G17 8,Associates Inde anoe PHONE (305)279 7665 FAx Not (305)279-9705
9485 S.w 72 St Suite A-120 ADDRESS.. wm p y
PISURERIAS AFFORDING COVERAGE
Miami FL 33173ra.MOtER.: AMTRUST INSURANCE
POURED PISlRER B
Maxbm Electric Inc C:
16931 SW 141 Ct POWER 0:
99SUREt E:
Miami FL 33177- 01SURER 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,
rA
XCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID L IM �Tg
TYPE OF 01SUIMCE POLICY NUMBER EACH OCCURRENCE $ 1,000.000
X COMMERCIAL GENERAL UABILITY per$ TED $ 100,000
CLAIMS-MADE D OCCUR PREMISES a o rtence
MED EXP(AIRI wte Pm�) $ 5.000
VVPPI389385 07129/2015 07129/2016 PERsoNAL s ADV INJURY $ 1,000.000
GENERAL AGGREGATE $ 2,000,000
GEN)AGGREGATE LIMIT APPLIES PER
X POLICY EJ MC�Loc -coMp�P Acac S 2.0 .000
O�� SI UMR $
AUTO l6OB8 E UABtI TTY
BODILY INJURY(Par PMW) $
ANYAUTO BODILYIWIJRY(Per acddmd) $
SC
ALL OWNED AUTOS A HEDULED PROPERTY DAMAGE $
HIREDAUTOS AUTOS $
EACH OCCURRENCE $
{"MUMMA^LIAB SUR
AGGREGATE $
EXCESS LIAR CLAIMS-MADE $
D RETENnON$
WORKERS COMPEMATM TATAE9ER
AND EMPLOYERS'LUIBMY YINI ELL EACH ACCIDENT $
ANY PROPRMTORIPARTNERO(ECUME ❑
OFFlCERASEM�R EXCLUDED? N/A E.L.D15EASE-EA EMPLO $
(ATarttMtmy In Nlq
ELDISEASE-POLICY LIMIT $
M.MTIONS Wow
DESCRIPTWN OF OPERATRu1SI LOCATIONS I VE1=C ES(ACORD 101,Ardlonal Remade Schedult,may be allRdt u9 R more apace ho wgldred)
LICENSE#EC13005618
CERTIFICATE HOLDER CANCELLATION
`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 MOBS
Building Depafterd AWHORIZED REPRESENTATIVE
10050 NE 2nd Avenue --
Miami Shores FL 33138
®1888-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
MIAMI INVOICE
ELECTRIC
SUPPLY Pa e
ASSOC. 1
5742 SW 7th Street, Miami, FL 33144
18640 SW 104th Ave, Perrine, FL 33157
Bill To: MAXIMO Ship To: MAXIMO
MAXIMO MARTIN MAXIMO MARTIN
16931 SW 141 CT 16931 SW 141 CT
MIAMI FL 33177 MIAMI FL 33177 �s
Date Customer PO# Wh# SP# Alt# Ship Via Order # Slip # Invoice #
12/22/15 2 008 008 PICK UP 673213.00 1034688
UANTITY PRODUCT ID DESCRIPTION U/MUNIT PRICEEXT. PRICE
ORDERED SHIPPED BACKORDER
14 14 FBPP FIRE BARRIER PUTTY PADS EA 5.00 70.00
1 1 FBIC FIRE BARRIER INTUMESCENT CAULK EA 12.00 12.00
4 4 BRDC " BOX COMB, DEEP EA 1.1659 4.66
4 4 BRCS 4X4 BLK BOX COVER 112 KO EA 0.41 1.64
1 1 WG ROLL GALV TIE WIRE EA 5.75 5.75
SUB-TOTAL 94.05
SALES TAX 6.58
TERMS: DISCOUNT TERMS IF PAID BY DEDUCT TOTAL DUE
NET DUE ON 01/25/16 01/10/16 1.88 100.63
All sales subject to terms on back
RECEIVED THE ABOVE IN GOOD ORDER
BY
- --- - ---- ------ CUSTOMER COPY
Miami shores Village
11 mass n:1 91
Building Department
LpR ► 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305)756.8972
Notice to Owner - Workers' Compensation Insurance Exem tion
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 subcgntractors 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 20__�_
By - �� t a9� who rsonally kno to me or has produced
Notary.
�o �` '•�ti'
SEAL. -a� "•�
+�0
JEFF ATWATER
CHIEF FINANCIAL.OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW a"
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 6/1/2015 EXPIRATION DA'L'E: 5131/2017
PERSON: MARTIN MAXIMO
FEIN: 201480521
BUSINESS NAME AND ADDRESS:
MAXIMO ELECTRIC INC
16931 SW 141 CT
MIAMI FL 33177
SCOPES OF BUSINESS OR TRADE:
LICENSED ELECTRICAL
CONTRACTOR
Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by fling a certificate of election under this section
may not receeer berherds or wmpmmftn ureter this chapter.Pursuant to Ch aper 440.05(12),F.S.,Certificates;of ele0m to be exempt..,apply only within
the scope of the bustrhess or trade!!sled on to notice of election to be exempt Purward to Chapter 440.0.5(13),F.S.,Notices of election to be exempt and
certificates of eleWon to be exempt shall be subject to revocation ti,at any time after the firing of the notice or the issuance of the certificate.the person
named an the notice or certificate no longer meets the requvemenfs of this section for issuance of a cerrrlice4e.The department shall revoke a cert at
DFS-F24DVVC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609