EL-17-2598Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Pe
it
Permit NO. EL -10-17-2598
Permit Type: Electrical - Residential
Work Classification: Alteration
Permit Status: APPROVED
Issue Date: 10/31/2017
Expiration: 04/29/2018
Parcel Number
Applicant
165 NW 96 Street
Miami Shores, FL 33138-0000
1131010250130
Block: Lot:
PROVIDENT FUNDING ASSOCIA
Owner Information
Address
Phone
Cell
PROVIDENT FUNDING ASSOCIATES L P165 NW 96 Street
MIAMI SHORES FL 33150-
165 NW 96 Street
MIAMI SHORES FL 33150-
Contractor(s) Phone CeII Phone
A-1 FLORIDA ELECTRIC CONTRACTC (786)316-3158
Valuation:
Total Sq Feet:
$ 1,020.00
0
Type of Work: ALL ELECTRIC WORK FOR A/C
Additional Info: ALL ELECTRIC WORK FOR A/C
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Notary Fee
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Amount
$1.20
$2.25
$2.00
$0.40
$5.00
$150.00
$3.00
$1.60
Total: $165.45
Pay Date Pay Type
Invoice # EL -10-17-65518
10/31/2017 Credit Card $ 50.00 $ 115.45
10/31/2017 Credit Card $ 115.45 $ 0.00
Amt Paid Amt Due
Available Inspections:
Inspection Type:
Review Electrical
1
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`� DAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction a 1. zoning. Futhermore, I authorize the above-named contractor to do the work stated.
October 31, 2017
Aut orSignature: Owner / Applicant / Contractor / Agent
Building epartment Copy
Date
October 31, 2017 1
36%1 7P‘ .0./D
BUILDING
PERMIT APPLICATION
Miami Shores Village
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
RC
OCT 12017
BY:—
stt,
FBC 20i fi
Master Permit No. �L ii—' ZS 98
Sub Permit No.
❑ BUILDING Q ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 165 NW 96th Street
City: Miami Shores
County:
Miami Dade Zip:
Folio/Parcel#: 11-3101-025-0130 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Provident Funding Associates, L.P.
Address: 851 Traeger Avenue
Phone#: 650-652-1300
City: San BrunoState: CA Zip: 94066
Tenant/Lessee Name: n/a Phone#:
Email: rbrede@provident.com
CONTRACTOR: Company Name:/9-7/C7c7/Zi.S/9� %N72AeAofc Phone#: 23/6-3J53
Address: 2030 A/ w ) 5 S7
City: /4 A4 / State: 1::-/ Zip: 311-/2..
Qualifier
Qualifier Name: P/0S/4I 1/011/d.4/2.15 Phone#: 2 --0235
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
,Value.of.Work. or.this Permit:.$, /621) . Square/Linear Footage of Work:
•Typek: ❑ Addition ❑ Alteration ❑ New /Repair/Replace ❑ Demolition
State Certification or Registration #: / G -%3O060 e
Description•of.Workrn c rffli
t4/0 f- 4/c6'
Specify color of color thru tile: -
Submittal Fee $ SJR► d Permit Fee $ 13-25'0 v CCF $ 1 •Za CO/CC $
Scanning Fee $ 3 Radon Fee $ 2 _ e'" DBPR $ Z • ZS Notary $ S
. /
Technology Fee $ 1 • 60 Training/Education Fee $ 0 g 0 Double Fee $ 6\
Structural Reviews $ �Q Bond $ N
TOTAL FEE NOW DUE $ `15 .i S
(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 4w ` /2(1`e. Signature
OWNER or AGENT
The foreeggo''nng instrument wasacknowledgedbefore me this The foregoing instrument was acknowledged before me this
St day of odtVono, 20 1-1 , by 2-4 day of GC.TU'5. , 20 , by
YY YIC6t- CJS , who is personally known to 'I.105Ll N -1.40 who is�pe�rsonSY-known to
me or who has produced (....e.i - li r)
identification and who did take an oath.
NOTARY PUBLIC:
CONTRACTOR
me or who has produced 6 LACCfSar----'as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
Sign:
Print:
Commission # 2095221 Seal:
Notary Public - California
San Mateo County
M Comm. Ex fres Jan 25, 2019
*******************
APPROVED BY
(Revised02/24/2014)
Nrc)iA AWo� p
e SM'4.V'Y Y'a v . - ..r
:esMY ""t<„ Notary Public State of Florida
4 Sindia Alvarez
if My Commission FF 156750
e'
of, Expires 09103/2018
***********4 ` `'*t***'*z**A*s**********"s**************
/ ?-3/t,"4-z Plans Examiner Zoning
Structural Review Clerk
Corporate Resolution
I, Michelle C. Blake, Secretary of Provident Funding Group, Inc., a corporation duly organized
and existing under the laws of the State of California, and General Partner of Provident Funding
Associates, L.P., do hereby certify that the following is a true and correct copy of a resolution of
the Board of Directors of said corporation, adopted at a special meeting held on the 6th day of
January in the year 2016:
RESOLVED, that any one of the following:
• Ernest Brede, Assistant Vice President
• Rebecca Brede, Assistant Vice President
• Minn Patel, Assistant Vice President
is authorized and directed to cause the Company to take all steps necessary to effect the sale of
any real property pursuant to a notice of time and place of a foreclosure sale; to bargain, sell,
transfer, assign, set over and deliver the real property; and to sign the name of Provident
Funding Associates, L.P., to all deeds, contracts of sale or other instruments necessary to carry
out this resolution, all of the acts in the premises undertaken by each of these individuals being
ratified as the act and deed of this corporation.
FURTHER RESOLVED, that any and all actions taken these individuals in connection with the
matters contemplated by this resolution be, and are hereby, approved, ratified and confirmed
in all respects as full as if such actions had been presented to the Board of Directors for its
approval prior to such actions being taken.
Dated: 1/28/16
MeAeglalaik,
Michelle C. Blake, Secretary
PLOttIDA DEPART ENT L11E
I C.ORI'ORATIONS
DIVISION of
CORPORATIONS
an official Siau i>f.1 !arida irc'hsiue
Department of State / prviston of Corporations / Search Records / Detail By Document Number /
Detail by Entity Name
Foreign Profit Corporation
PFG LOANS, INC.
Cross Reference Name
PROVIDENT FUNDING GROUP, INC.
Filing Information
Document Number F98000004548
FEI/EIN Number 77-0293745
Date Filed 07/30/1998
State CA
Status ACTIVE
Last Event CANCEL ADM DISS/REV
Event Date Filed 10/27/2008
Event Effective Date NONE
Principal Address
851 TRAEGER AVENUE
SUITE 100
SAN BRUNO, CA 94066
Changed: 02/21/2012
Nailing Address
851 TRAEGER AVENUE
SUITE 100
SAN BRUNO, CA 94066
Changed: 02/21/2012
Registered Agent Name & Address
CORPORATION SERVICE COMPANY
1201 HAYS STREET
TALLAHASSEE, FL 32301-2525
Officer/Director Detail
Name & Address
Title PDVC
http://search.sunbiz ore/'aquiry/CorporationSearch!SearchResu...dinIistNameOrder=PROV,DENTLUND,NG%20F990000022710
10/25/17, 2:43 PM
Page 1 of 3
14,
•
PICA, R. CRAIG
851 TRAEGER AVENUE, SUITE 100
SAN BRUNO, CA 94066
Title DSVP
PICA, DOUGLAS
851 TRAEGER AVENUE, SUITE 100
SAN BRUNO, CA 94066
Title DSVS
BLAKE, MICHELLE
851 TRAEGER AVENUE, SUITE 100
SAN BRUNO, CA 94066
Annual Reports
Report Year Filed Date
2015 04/13/2015
2016 04/29/2016
2017 04/24/2017
Document Imaq4l.
04/24/2017 -- ANNUAL REPORT
04/29/2016 — ANNUAL REPORT
04/13/2015 -- ANNUAL REPORT
05/01/2014 -- ANNUAL REPORT
04/16/2013 -- ANNUAL REPORT
02/21/2012 -- ANNUAL REPORT
94/04/2011 -- ANNUAL REPORT
04/21/2010 -• ANNUAL REPORT
04/24/2009 -- ANNUAL REPORT
10/2712008 -- REINSTATEMENT
V t / image in PDF format
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04/30/2007 -- ANNUAL REPORT View I. raga in PDF format
04/24/2006 -- ANNUAL REPORT
04/06/2005 -- ANNUAL REPORT
0/03/2004 -- ANNUAL REPORT
02/17/2003 -- ANNUAL REPORT
05/29/2002 -- ANNUAL RcPORT
09/06/2001 -- ANNUAL REPORT
05/06/2000 -- ANNUAL REPORT
07/30/1999 -- ANNUAL REPORT
07/30/1990 -- Foreign Pro it
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Page 2 of 3
• 2017 FOREIGN PROFIT CORPORATION ANNUAL REPORT
DOCUMENT# F98000004548
Entity Name: PFG LOANS, INC.
Current Principal Place of Business:
851 TRAEGER AVENUE
SUITE 100
SAN BRUNO, CA 94086
Current Mailing Address:
851 TRAEGER AVENUE
SUITE 100
SAN BRUNO, CA 94066
PEI Number: 77-0293745
Name and Address of Current Registered Agent:
CORPORATION SERVICE COMPANY
1201 HAYS STREET
TALLAHASSEE, FL 32301-2525 US
FILED
Apr 24, 2017
Secretary of State
CC5588344593
Certificate of Status Desired: No
The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both, in the State of Florida.
SIGNATURE:
Electronic Signature of Registered Agent
Officer/Director Detail :
Title PDVC Title DSVP
Name PICA, R. CRAIG Name PICA, DOUGLAS
Address 851 TRAEGER AVENUE, SUITE 100 Address 851 TRAEGER AVENUE, SUITE 100
City -State -Zip: SAN BRUNO CA 94066 City -State -Zip: SAN BRUNO CA 94066
Title DSVS
Name BLAKE, MICHELLE
Address 851 TRAEGER AVENUE, SUITE 100
City -State -Zip: SAN BRUNO CA 94066
Date
I hereby certify that the Information Indicated on this report or supplemental report Is true and accurate and that my electronic signature shall have the same legal effect as If made under
oath; that 1 am an officer or director of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 607, Florida Statutes; and that my name appears
above, or on an attachment with all otter like empowered.
SIGNATURE: MICHELLE C. BLAKE
SECRETARY 04/24/2017
Electronic Signature of Signing Officer/Director Detail
Date
This
c',§fate Erf California
Fiurck1cff nn Fu
ecrrtart; afc*tats
CERTIFICATE OF LIMITED PARTNERSHIP
IMPORTANT—Read instructions on back before completing this form
Certificate Is presented for filing pursuant to Section 15621, California Corporations
Code.
Form LP -1
1. NAME OF LIMITED PARTNERSHIP
Provident Funding Associates, L.P.
2. STREET ADDRESS OF PRINCIPAL EXECUTIVE OFFICE
1050 East Evelyn Avenue
CRY AND STATE
Sunnyvale, CA
11P CODE
94086
3. STREET ADDRESS OF CALIFORNIA OFFICE IF EXECUTIVE OFFICE IS IN ANOTHER STATE CITY
4. COMPLETE IF LIMITED PARTNERSHIP WAS FORMED PRIOR TO JULY I.
ZIP CODE
CA
>r�
1984 AND 15 IN EXISTENCE ON DATE THIS CERTIFICATE IS EXECUTED.
THE ORIGINAL LIMITED PARTNERSHIP CERTIFICATE WAS RECORDED ON 19
RECORDER OF COUNTY.
WITH THE
FILE OR RECORDATION NUMBER
5. NAMES AND ADDRESSES OF ALL GENERAL PARTNERS: (CONTINUE ON SECOND PAGE. IF NECESSARY)
A. NAME: Provident Funding Group, Inc.
ADDRESS: 1050 East Evelyn Avenue
cirv: Sunnyvale STATE: CA ZIP CODE: 94086
C. NAME:
ADDRESS:
CITY: STATE:
ZIP CODE:
8. NAME:
ADDRESS:
CITY: STATE: ZIP CODE:
O. NAME:
ADORESS:
CITY:
STATE: ZIP CODE:
E. NAME AND ADORES -5 OF AGENT FOR SERVICE OF PROCESS:
NAME: Ralph A. Pica
ADDRESS: 1050 East Evelyn Avenue
Crre; Sunnyvale
STATE: CA
ZIP CODE:94086
7. ANY OTHER MATTERS TO BE INCLUDED IN THISCERTIFICATEMAY 8. INDICATE THE NUMBER OF GENERAL PARTNERS SIGNATURES
BE NOTED ON SEPARATE PAGES AND BY REFERENCE HEREIN ARE REQUIRED FOR FILING CERTIFICATES OF AMENDMENT,
ix. ON, CONTINUATION AND CANCELLATION.
A PART OF THIS CERTIFICATE.
NUMBER OF PAGES ATTACHED:
0
OF GENERAL PARTNER(S) SIGNATURE(5) IS/ARE:
a.MMSNFKRMOMIMC1ar...s
9_ IT 15 HEREBY DECLARED THAT I AM (WE ARE) THE PERSON(S) WHO EXECUTED THIS CERTIFICATE
OF UNITED PARTNERSHIP WHICH EXECUTION IS MY (OUR) ACT AND DEED. (SEE INSTRUCTIONS
Provident Fuming
Eyze
SIGNATURE
President 11/6/92
POSITION OR TITLE
SIGNATURE
DATE POSITION OR TITLE
SIGNATURE
POSITION OR TITLE
DATE
SIGNATURE
DATE POSITION OR TITLE
DATE
10. RETURN ACKNOWLEDGEMENT TO:
NAME
ADDRESS Steven K. Denebeim., Esq.
Feldman, Waldman & Kline, APC
235 Montgomery St., '2700
zlPcooE I San Francisco, CA 94104-3160
CITY
STATE
7
J
5961.0000
SEC/STATE REV 1 88
FORM 15 -1 --FILING RI' I7O
Appror.d by Soo bury of Slate
1
(PLEASE LNDICATE NUMBER ONLY.
THIS SPACE FOR FILING OFFICER USE
C1).3\.1CCCC1
FILED
In the Off r.a Of she Srtrvltm/ O( Stella
of /Nle Stem Of California
NOV 1 O 192?
MARCH FONG Eu
SECRETMY OF STATE
Miami Shores Village
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
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 ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
r ig'�iatut'e:1
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this 35# day of
By bat-11cl PonC e
QCT-obt r
, 20 17 .
who is personally known to me or has produced
as identification.
Notary:
SEAL:
°Ne` YANADY PRIETO
.yR �'
d ' MY COMMISSION # FF 214031
EXPIRES: March 25, 2019
q ; , , Bended Thru Notary Public Underwriters
AnsIMIldisibmir
COMPANY:A-1 FLORIDA ELECTRIC CONTRACTOR CORP
Date: 10/30/2017
State of FLORIDA
County of MIAMI DADE
Before me this day personally appeared DIOSLAYHONDARES MORENO who, being duly sworn, deposes
and says
That he or she will be only person working on the project located at 165 NW 96th Stree Miami Shores
FL 33150.
Sworn to (or affirmed) and subscribed before me this 3 -day of 0 Ccx w 20 11 , by
--NOSIA“a 1-toc)(krar-cs i11'14ekto
Signature .
Personally
OR Produced Identification V
Type of Identification Produced �.J Vi 'J' Y \1C'NS'
Q2,xi) 1.\1 -Z1 -ZO2'
Print, type or Stamp Name of Notary
YANADY PRIETO
MY COMMISSION # FF 214031
EXPIRES: March 25, 2019
Bonded Thru Notary Puo'ic Underwriters
./...71.260W4r.+:.vmfOKn