EL-17-2080Project Address
78 NE 101 Street
Miami Shores, FL
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit
Permit NO. EL -8-17-2080
Permit Type: Electrical - Residential
Work Classification: Addition/Alteration
Permit Status: APPROVED
Issue Date: 8/25/2017
Expiration: 02/21/2018
Parcel Number
1132060131330
Block: Lot:
Applicant
ROBERTO MAURICIO PALACIO
Owner Information
Address
Phone
Cell
ROBERTO MAURICIO PALACIO
78 NE 101 Street
MIAMI SHORES FL 33138-
(786)391-2280
78 NE 101 Street
MIAMI SHORES FL 33138-
Contractor(s)
R GOOD ELECTRIC INC
Phone
(954)432-2232
Cell Phone
Valuation:
Total Sq Feet:
$ 2,500.00
0
Type of Work: MOVE SERVICE LINE FOR NEW POOL
Additional Info: MOVE SERVICE LINE FOR NEW POOL
Classification: Residential
Scanning: 3
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$1.80
$2.25
$2.25
$0.60
$150.00
$9.00
$2.40
$168.30
Pay Date Pay Type
Invoice # EL -8-17-64905
08/17/2017 Credit Card
08/25/2017 Check #: 6365
Amt Paid Amt Due
$ 50.00 $ 118.30
$ 118.30 $ 0.00
Available Inspections:
Inspection Type:
Final
Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Review Electrical
W. W.
Underground
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 informatio
construction and zoning. Futhermore, I authorize the above-na
accurate and that al work will
ontractor to do,Che tk stated.
Authorized Signature: Owner / Applicant / Contractor /
Building Department Copy
done in compliance with all applicable laws regulating
August 25, 2017
Agent Date
August 25, 2017
1
0 00P
‘'N
BUILDING
PERMIT APPLIC TION
❑BUILDING LECTRIC ❑ ROOFING ❑ REVISION
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
Master Permit No.
Sub Permit No.
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: 7e /t). /o/d- s
t
RECEIVED
AUG 171017
S'h �
Fec 2oM
I--2_nA.`(i
❑ EXTENSION ❑ RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores
Folio/Parcel#:
Occupancy Type: Load:
County: Miami Dade
zip: "3"
Is the Building Historically Designated: Yes NO
Construction Type: Flood Zone:
OWNER: Name (Fee Simple Titleholder): .RO12-Q, (•-I ac_' v
Address: 7' /J l01s- S7-
City: ca State: �Lr
Tenant/Lessee Name:
BFE: FFE:
.j L i �•
Phone#:
Phone#:
Zip: 33/3Ci
Email:
CONTRACTOR: Company Namp:
Address:
Qualifier Name:
Dosc Phone#: / cJ Y' ;2/ y`'C 6- C/
Phone#:
State Certification or Registration #: - r 1 3t - 2 -qt) Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Gir
Value of Work for this Permit: $ c),,,17 -07f Square/Linear Footage of Work:
•
Type of Work: ❑ Addition ❑ Alteration ❑ New
Description of Work:
r-�.a-etc ,a te
epair/Replace ❑ Demo *tion
r
... ,,.45a.0W..iRs.+a1►sr. -..[T ^i�-'N�t"•t!4'' ,.+•�, +R
(ICU MiLfi' L
•
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
!:t:160LAl1 )c l:r.o •�
FICOL.41 Pi iro:zt+mrta^ µ
Permit Fee $ L.lo�De CCF $•-BAttelleyllntvr.!6/FfkNrLi:C:T ;"
Radon Fee $ DBPR $ Notary $
Training/Education Fee $ Double Fee $
Bond $
TOTAL FEE NOW DUE $ . so
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.
4-
/2(
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrumen as acknowle ged before me this The foregoing instrument was acknowledged before me this
day of fa s ! , by
dae e' , who is personally know to
��- day of// �V f , 20 �� , by
s
Buse 9
l 1 • %i• , who is personally known to
me or who has produced as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
4 �= Notary PubNlk-State of Florida
Commission I FF 230057
Teri !oa••'.,
Bonded th Comgphpir May
12, 2019
APPROVED BY
(Revised02/24/2014)
-t'_t I caySe . as
identification and who did take an oath.
NOTARY PUBLIC:
Seal:
rt."GIARARittK GONZALEZ
1. MY COMMISSION # GG 044602
EXPIRES: November 2, 2020
Bonded Thru Notary Public Underwriters
********************************************************************
Plans Examiner
Structural Review
Zoning
Clerk
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.
Signature:evezteei,,eiL,
Owner
State of Florida
County of Miami -Dade
The fore oing was ackno ledge before me this a/ day of
tiefitt4ihar
0°"� P' ,a CAROLINE *Op mann
,��¢ ; otary - VIM o1 Florida
Notary: . i ' r : ▪ 0'• IFF 230011
,
,_i"..omm. tzplias May 12. 2019
' adst.' Abad through National Notary Asan.
— —
By
4, /- ,20/7.
who is personally known to me or has produced
SEAL:
•
Date:
State .f Flo r da(�
County of 51/i -o -e -d
R. GOOD ELECTRIC, INC.
1730 NW 88TH WAY
Pembroke Pines, Florida 33024
Fax (954) 432-2232 CeII (954) 214-5899
Before me this day personally appeared Russell Good who, being duly sworn, deposes and says:
That he will be the only person working on the project located at: 78 NE 101 Street, Miami Shores
Village, Florida 33138.
Contractor Signature
Sworn to (or affirme and subscribed before this J day of 6 U ST. , 2017,
by vv 5c.�. G Cc
Personally know
Or Produced Identification
Type of Identification ProducedN
NINT>vz.
Ty.•e or . mp Name of Notary
Y Y Y. i! , Y til
• N Notary Public State of Florida
• ° �; Sindia Alvarez
• .t+ a My Commission FF 156750
or oo49 Expires 0910312018
03A13332I
R. GOOD ELECTRIC, INC.
1730 NW 88TH WAY
Pembroke Pines, Florida 33024
Fax (954) 432-2232 Cell (954) 214-5899
Rob, -,7; _
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SUBJECT TO CCMPUANCE WITH ALL FEDERAL
STATE AND CCUN'iY RULES AND REGULATIONS
°A
ZONING DEPT
APPROVED
-cl
rn
x
BY
Shcres Village
DATE
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