EL-15-7171
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
Phone: (305)795-2204
5 NW 106 Street
Miami Shores, FL 33150-
Owner Information
Permi•
Permit NO. EL -3-15-717
Permit Type: Electrical - Residential
Work Classification: Addition
Permit Status: APPROVED
Issue Date: 4/27/2016
Expiration: 10/24/2016
Parcel Number
Applicant
Address
1121360060240
Block: Lot:
ESTEBAN MATIAS STAVILE
Phone
Cell
ESTEBAN MATIAS STAVILE
2723 NE 6 Lane
WILTON MANORS FL 33334-
Contractor(s) Phone
CJ ELECTRICAL SERVICES INC (954)292-5711
CeII Phone
Valuation:
Total Sq Feet:
$ 3,500.00
0
Type of Work: ADDITION OF HOUSE, NEW ELECTRICAL A
Additional Info:
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$2.40
$3.38
$3.38
$0.80
$225.00
$3.00
$3.20
$241.16
Pay Date Pay Type
Invoice # EL -3-15-54986
03/30/2015 Check #: 1623
04/27/2016 Credit Card
Amt Paid Amt Due
$ 50.00 $ 191.16
$ 191.16 $ 0.00
Available Inspections:
Inspection Type:
Review Electrical
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 oning. Futhermore, I authorize the above-named contractor to do the work stated.
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
April 27, 2016
Date
April 27, 2016
1
BUILDING
PERMIT APPLATION
ElBUILDINGLECTRIC
❑ PLUMBING
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
WIC 1 N&fl P I AV rt
Master Permit No.
Sub Permit No
❑ ROOFING REVISION
❑ MECHANICAL El PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: (Jln.) /0614A Sff<e
City: Miami Shores
RECFTVED
MAR 30L015
Fsc Zo
PSC i5-�b55
❑ EXTENSION El RENEWAL
❑ CANCELLATION El SHOP
DRAWINGS
County:
Miami Dade Zip:
Folio/Parcel#:
Occupancy Type: 4ktAltb Load:
Is the Building Historically Designated: Yes NO
Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): cc, S 4-eoaV\ $1t*�
Address: S $ 4 1.0(04kA ST"r- e -T'
City: 11\k\a`(v.k 5 hp ,ref State: i -C
Tenant/Lessee Name: Phone#:
Email:
Fcl. 0:1p
Phone#:
Zip: 33 SSC)
CONTRACTOR: Company Name: G J b-7-- 6 L � � 7-' 4 //V(
Address: 3 7.-3 4 -
Phone#: 951-7— y 2- 9Z - 5 7i�
City: 6-6(o/c+u,/ (k State: moi, Zip: 3 3 073
Qualifier Name: 7;9-/A /'`/4/7/ Phone#: icy - f L — 5-711
State Certification or Registration #: �G / 3 o0 5-6/7 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ %G 0 • 00 Square/Linear Footage of Work:
Type of Work: Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolitionli
Description of Work: 'P- UGu 1e1 '1-ec i U4IAA tu' /co./CC6.010 /p �iAViA0,/�/
00 of,k-,:c veer Leci-vk-ol P(c1V►S 1012 642AGE. C6nik/ (Lf'l0(J
Specify color off\color ,tt hru tile:
Submittal Fee $ S v �W " Permiaffe '1414 c2-` co/Cc $
Scanning Fee $ 3 • Radon Fee $ c3 v DBPR $ 3 • 38 Notary $
Technology Fee $ 20 Training/Education Fee $ O ' CEJ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ I I 1 6
(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
OWNER or AGENT
The foregoing instrument was acknowledged before me this
I _04‘ day of i`Acrlrc(n , 20 lS
ark , who is personally known to
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
, by CGS day of Much , 201 c by
C7A4 54 '
, who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
,.:014‘.. KYLE C HAMBRICK
_'; MY COMMISSION # EE867056
EXPIRES January 22, 2017
•noridatiotaryServloe corn
identification and who did take an oath.
NOTARY PUBLIC:
Sign:,
Print:
Seal:
:;s+ KYLE C HAMBRICK
-•: MY COMMISSION # EE867056
,`'•• EXPIRES January 22, 2017
• ri.... .a tw@wlea Osla r+
01
*******s**s**********************************s*s*******************sssssss****************** **************
APPROVED BY
(Revised02/24/2014)
Z. eb/3
it/.01-2Plans Examiner00 . /S Zoning
Structural Review
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:
er
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this
By (S �COYI -too 1-G
n'• KYLE C HAMBRICK
MY COMMISSION # EE867056
t : � EXPIRES January 22, Y017
(407)398.0183
FicridallotaryService corn
114' day of /-t c1ych , 20 \5 .
who is personally known to me or has produced
as identification.
March 11, 2015
Re: Esteban Matias Stavile Residence
5 NW 106th Street Miami Shores, FI 33150
The letter is to make aware the owner and the Village of Miami Shores that CJ Electrical is exempt from
workers compensation and Jainarine Sing will be performing all of the electrical work.
Jai Sing
, /1:7YZ
t'�' KYLE C HAMBRICK
MY COMMISSION 8 EE887058
,p�, EXPIRES January 22, 2017
t+O? 9Yewtes Risndit4 _ Bfitvlee sem
rom:Carmen Orsini FaxID: Date:3/13/2015 02:25 PM Page: 2 of 2
AeoRLf CERTIFICATE OF LIABILITY INSURANCE
`-..---
DATE(MM/DD/YYYY)
3/13/2015
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
BELOW. 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 terms 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
BB Insurance Marketing Inc
10167 W Sunrise Blvd, 3rd Floor
Plantation FL 33322
CONTACT
NAME: Andrea Lopez Ext 314
(A/C, No, Exti:954-452-4900 (n/c, No):954-452-0450
E-MAIL .
ADDRESS:Andrea(1bbimi.COm
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A :Travelers Property & Casualty
25674
INSURED CJELE-1
CJ Electrical Services, Inc.
3753 Coral Tree Circle
Coconut Creek FL 33073
INSURER B :
660-9A501783
INSURER C :
12/20/2015
INSURER D
$1,000,000
INSURER E :
X
INSURER F :
REVISION NUMBER•
THIS 15 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 I5 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUER
WVD
POLICY NUMBER
POLICY EFF
(MM/DD/YYYYI
POLICY EXP
(MM/DD/YYYYI
LIMITS
A
GENERAL
LIABILITY -
660-9A501783
12/20/2014
12/20/2015
EACH OCCURRENCE
$1,000,000
X
COMMERCIAL GENERAL LIABILITY
I ED
PREMISES (Ea orccurrrence)
3100,000
CLAIMS -MADE
X
OCCUR
MED
EXP (Any one person)
$5,000
PERSONAL& ADV INJURY
$1,000,000
GENERAL AGGREGATE
GEN'LAGGREGATE
LIMIT APPLIES
PRO-
PER:
PRODUCTS - COMP/OP AGG
$2,000,000
$2,000,000
POLICY
JECT
JECT
LOC
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMI I -
(Ea accident)
$
ANY AUTO
ALL OWNED
SCHEDULED
BODILY INJURY (Per person)
$
AUTOS
AUTOS
NON -OWNED
BODILY INJURY (Per accident)
$
HIRED AUTOS
AUTOS$
PROPERTY DAMAGE
(Per accident)
$
UMBRELLA LIAR_
EXCESS LIAB
OCCUR
EACH OCCURRENCE
$
CLAIMS -MADE
AGGREGATE
$
DED
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y / N
WC STATU-
TORY LIMITS
OTH-
ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED'? ❑
N / A
E.L. EACH ACCIDENT
$
(Mandatory in NH)
If yesdescribe under
E.L. DISEASE - EA EMPLOYEE
$
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Electrical Contractor located at 3753 Coral Tree Circle, Coconut Creek, FL 33073.
CERTIFICATE Ianl nER _ - -.---
Miami Shores Village
Building Department
10050 NE 2nd Ave.
Miami Shores FL 33138
(
ACORD 25 (2010/05)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
O 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD