EL-16-1337 0I3 4 '� .:
Miami Shores Villagel�elTf7 � Rle�t#'� � ridtylliti8�
10050 N.E.2nd Avenue NE
F.1 f f s t on.,, •li.
Miami Shores,FL 33138-0000 �'�� �.
e � , # � ,
h— n Phone: (305)795-2204
ORR
Expiration: 11/1512016
Project Address Parcel Number Applicant
9350 NE 9 Place 1132060070040
LUIS ARTIEDA
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
LUIS ARTIEDA 9350 NE 9 Place
MIAMI SHORES FL 33138-2972
9350 NE 9 Place
MIAMI SHORES FL 33138-2972
Contractor(s) Phone Cell Phone Valuation: $ 800.00
VALDEN SERVICE SYSTEMS, LLC (786)253 7700 Total Sq Feet: 0
Type of Work:WIRE SWIMMING POOL Available Inspections:
Additional Info: Inspection Type:
Classification:Residential Final
Scanning:1 Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Review Electrical
Underground
W.W.
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60 invoice# EL-5-16-59808
DBPR Fee $4.50 05/19/2016 Check#:1873 $268.60 $50.00
DCA Fee $4.50
Education Surcharge $0.20 05/17/2016 Check#:1854 $50.00 $0.00
Notary Fee $5.00
Permit Fee-Additions/Alterations $300.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $318.60
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 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. Futhermore,I authorize the above-n a actor to do the work stated.
May 19, 2016
Authorized Signature:Owner / Applicant / Contr ctor / Agent Date
Building Department Copy
May 19,2016 1
a
Miami Shores Vill e �o �
9101 L 1 ON �
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
FBC 20
BUILDING Master Permit No. 6Pf - 3- 16 -F -L
PERMIT APPLICATION Sub Permit No. 1EL- - 13?)-�
❑BUILDING E&ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
r-1 PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
J CONTRACTOR DRAWINGS
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JOB ADDRESS: / 3 S0 � / 7� fL
City Miami Shores County: Miami Dade Zip: 3ji 3 e
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titigholder): 4 L/ S 4"T�C-0& Phone#: 3o r �-3d //Z-/
Address: j S� [V j�
City: i Avvv") 1 U State: FL Zip:
Tenant/Lessee Name: Phone#:
Email: (-
CONTRACTOR:Company Name: I/Uel cam'` `^ S"y Vi C e N Phond-W)_253—
Address: -6 CD 19/ -ST
City: M )r-- State: FL Zip:
Qualifier Name: @/1 ti--W' Te.v!� 1"s-V 4 Phone#� A
State Certification or Registration#: C D �-D 9 1 Certificate of Competency#: }96 2- —? �� 0 L
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ p Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration NewRepair/Replace F-1Demolition
Description of Work: 1 tez- -n�'Y'1 •+tee 9 ��
Specify color of color thru tile:
Submittal Fee$ v Permit Fee$ ®®o CCF$ CO/CC$ J0
Scanning Fee$ Radon Fee$ a"( DBPR$ Notary$ �•
Technology Fee$ " rU� Training/Education Fee$ rc) Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ G®
(Revised02/24/2014)
I
e
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
whose7property-issubject to-attachment..-Also,-a-certified copy of the recardL-d7wtice-of commencemnt-rust-se poned—aufhe job�-site
for the first inspection which occurs seven (7) days after the building permit is issued. e a of such posted notice, the
inspection will not be approved and reinspection fee will be charged.
Signature Signature W
OWNER or AGENT ""7CONTR,4CTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
CC., day of 20 16 by (C4 day of � 20 t(,,
t , by
*Ams" �� �''. `who is personally known to l l� ( w s ersofPally known to
me or who has produced T�DVWE� L��3 S9--as me or who has produced L i-f ls3
identification and who did take an oath. identification and who did take an oath.
NOTARY BLIC: NOTARY P LIC:
Sign: Sign: f 1 f
Print: '� Print: `'2
Seal aoti�0 Pya, Notary Public State of Fbrlda
Sindia Alvarez 1 Seal:
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y, gMy Commission cG 156750 � o�°�YNe� Notary Public State of Florida
9�ovt oe Expires 09/03/2018 ' at
^ Sindia Alvarez QOQ PflyCommission FF 156750
APPROVED BA'g� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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OR
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sS Miami shores Village
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11
01" Building Department
^ 10050 N.E.2nd Avenue
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�L0RIpP► 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 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 Y U 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 ,201L_.
By 1JU 0r� who is personally known to me or has produced
�Ir L I as identification.
Notary:
SEAL: ; ao��°`Y°ve, Notary Public State of Florida
Sindia Alvarez
oe My commission FF 156750
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JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
**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.
EFFECTIVE DATE: 8/5/2015 EXPIRATION DATE: 8!4/2017
PERSON: FERGUSON DENHAM j
FEIN: 141921254 j
I
BUSINESS NAME AND ADDRESS:
VALDEN SERVICE SYSTEMS LLC
2301 NW 191 ST j
MIAMI GARDENS FL 33056
4 SCOPES OF BUSINESS OR TRADE:
LICENSED ELECTRICAL
s � CONTRACTOR i
IPursuant w Chapter"0.05(14),F.S.,an ofdeer of a corporsom who elects exempdan from tivs chapter by Eling a cer.son t b e)eoeon�sder tivs section
R cati
maynotrecoe,benetxuinGsmtrade litedonthe nod�feledontobeexPvsuantto xrmptPusutamt Chap?'FS Cartd"0.5(13).�S..Notices ord ont.beceiteY
i exemthe pt and scope offhe etes of'lecdon to be exempt shall be subject to rwocallon it,at any time after the filing of the notice ar the issuance off Bhcwtiill a j
.ampthepeson named�t eno nodce er eerdficate no tenger meets the rewroments of this section for lssuance of s cerdfieata The deparun
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1 QUES-1p\S'�i850i413-1609
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08.13 i
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RICK SCOTT, GOVERNOR KEN LAWSON,SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD _
EC13007099
The ELECTRICALCONTRACTOR `�° `
r
Named-below IS CERT,f.FIED -
Under the provisions of Chapter.4.89 FS. .
Expiration date- AUG-31` 2016 = -
FERGUS.'W DEM.AM GEJ
VALDENSERVICE SYS C A
3Q1 IVW 19- ST STS: '
�`- z wr s 4
ISSUED: 10/25/2015 DISPLAY AS REQUIRED BY LAW SEQ# L1510250001077
Local Busi ness Tax Fecei pt
M iami-Dad e County, State of Florida
-THIS IS NOTA BILL-DO NOT PAY LBT
7201664 .10
BUSINESS NAM E/LOCATION RECEIPT NO, EXPIRES
VALDEN SERVICE SYSTEMS NEW BUSINESS SEPTEMBER 30, 2016
LLC 7484383
TERR Must be displayed at place of business
650 NW 100
MIAMI, FL TER Pursuant to County Code
Chapter BA-Art.9&10
OWNER SEC.TYPE OF BUSINESS PAYM ENT RECEIVED
VALDEN SERVICE SYSTEMS LLC 196 ELECTRICAL BY TAX COLLECTOR
C/O DENHAM G FERGUSON CONTRACTOR 75.00 05/17/2016
Worker(s) 1 EC13007099 0237-16-004852
This Local Business Tax Ilei pt only con"ms payment of the Local Business Tax.The Receipt is not a license,
permit,or a c:erti"cation of the,TOI der's qual i^cations,to do business.Holder nest comply with any governmental
or nongovemmental regulatory laws and n quirementswhich apply to the business.
The F8 PT NO.above met be displ eyed on all commercial vehicl es-Miami-Dade Code Sec Ba-276.
®DARE For more information,,isitwww niarridade goy/troccollector
__........................._...... ......._... ...... ..... ................ .............................. ..__................ - . ............ ...
A41-7®RO® CERTIFICATE Vi LIABILITY INSURANCE DATE(P9MIDOJYYY1)
®w/ 05/06/2016
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
BELLOW. 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 torms 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 lieu of such endorsement(s).
PRODUCER CONTACT DANIEL ROBINSON
Simplified Mortgage and Insurance Services,Inc. (AM Na.Eft954 583-1600 - _! N 954 583-6987
665 SW 27th Avenue,Suite#5 E"Man
DREG..
Ft.Lauderdale,Florida 33312 u�suRgN AFFORDING COVERAGE "aP
ISURERA WILSHIRE INSURANCE COMPANY
INSURED INSURER8: I
VALDEN SERVICE SYSTEMS,LLC ■ysuRERC
P.O.BOX 693533
INSURER D:
MIAMI,FLORIDA 33259 INSIIRERE:
Vann ER 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMIT'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
RT .. ...... _.. .. .._�A ....LUMTS-- ..
TYPE OF INSURANCE Mm vim POLICY NUMBER M ,
I GENERAL LIABILITY EACH OCCURRENCE §...._.__1,000,000.00
F iSATA' 2 M'ill,i0 M § 100,000.00
X COMMERCALGENERAL LIABILITY `_PRFS�U,S�F LE;x -
- -- -0
CLAIMS-MADE L]OCCUR MED EXP(Anp.orre Pelson}.....__.}S 5,000.00
A CLOO182534 01/1412016 01//412017 1 PERSONAL&ADV INJURY S 1 i000,000.00
GENERALAG-GREGATE__...._. 2000,000.00
—._
SPER: PRODUCTS-COMFiOPAGG §_ 2,000,000.00
GENLAGGREGATE LIMIT APPUE
r.-._._ __. .... 0
F_..f. POLICY Lac
AUTOMOSILE LIAMUTY i I COMBINED LIMIT S
AMY AUTOj BODILY INJURY(Par ice) S
ALL OWNED _}SCHEDULED ( --
AUTOS
1 i BODILY INJURY(Pei acctdertt) 5
__..
046PEW DAWIAGE"'-_._ _._.�...._._._.....
NON-OWNED
HIREDAUTCS AUTOS amderH..............._.._.......
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I I
't $
UMeRELLALWB1. OC I EACH OCCURRENCE S
EXCESS UA8 CUUM$-MADE AGGREGATE $
I DED RETENTIONS I i S
TH
WORKERS COMPENSATION
AND EMPLOYERSLIABILIY YIN
ANY PROPRIETOMPARTNERdEXECUMENIA' E.L EACHACCDEN7 S
OFFICER/MEMBEREXCLUDEDT ❑ El-DISEASE-EA E...-EA EAM_PLOYE $
_.�
(Mmdatory In NH)
�yyeess,,desa mer E.L.DISEASE-POLICY UMIT S
DESCRIPTION OF OPERATIONS br3bw
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DESCRIPTION OF OPgPAYMS I LOCATIONS I VEt S oft=h ACMW IOI,A<tMano Remarks Ste.S more space tsrequired}
ELECTRICAL SERVICES
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Mlomi Shores Village Building Department THE MaNRATION DA 7tiEREOF, NOTICE WILL BE DELIVERED IN
10050 NE 2 Avenue ACCORDANCE Wali E PROV18taNS.
Miami Shores,Florida 33318
A"101 12'ED A
ACORD 25(2010105) C 988-2010 RD CORPORATION. All rights reserved.
The ACORD name and logo are registered m of ACORD
Valden Service Systems LLC Contact: Denham Ferguson
ELECTRICAL CONTRACTOR Phone: 786 253 7700
P.O.BOX 69-3513 E-Mail:denny@valdenllc.com
MIAMI,FL,33269 State License#:13007099
Date: 05-19-2016
State Of Florida
County Of: Miami Dade
Before me this day personally appeared Denham Ferguson who,been duly
sworn.disposes and say.
That he or she will be the only person working on the project located at 9350 NE 9
Place.Miami Shores FL 33138.
Sworn to (or affirmed) and subscribed before me this 1 ^ day of � `�-2016 by
Personally known
OR Produced Identification
Type of identification Produced
E)�
otary Public State of Florida
sindia Alvarez
Ay Corrlmission FF 156750Expires 09/0312019
Print,Type or Stamp Name of Nota