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EL-16-2443Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Pe 'mit Permit NO. EL -9-16-2443 Permit Type: Electrical - Residential Work Classification: Pool - Private Permit Status: APPROVED Issue Date: 11128/2016 Expiration: 05/27/2017 Parcel Number Applicant 1551 NE 103 Street Miami Shores, FL 33138- Owner Information 1132050310210 Block: Lot: Address 1216 NE 93 ST MIAMI SHORES FL 33138-2941 KURT GUSTINGER Phone Cell Contractor(s) RAVEN ELECTRIC INC Phone 305-221-3339 Cell Phone Valuation: Total Sq Feet: $ 950.00 0 Type of Work: ELECTRICAL TO SWIMMING POOL MOTOR A Additional Info: ELECTRICAL TO SWIMMING POOL MOTOR A Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $0.60 $4.50 $4.50 $0.20 $300.00 $3.00 $0.80 $313.60 Pay Date Pay Type Invoice # EL -9-16-61196 11/28/2016 Check #: 3227 09/02/2016 Credit Card Amt Paid Amt Due $ 263.60 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final Light Niche Bonding Review Electrical Alarms 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 ei her myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDO /►ORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing infor ,, I /. 1 .nd that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -a, ; t. to do the work stated. Authorized Signature: Owner / Applicant Co tract,r / Agent ate Building Department Copy November 28, 2016 Date November 28, 2016 1 A 4C4OPRC, CERTIFICATE OF LIABILITY INSURANCE r DATEIMM/DDIYYYYi _1111 10n4r16 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 POUCIES 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the term$ 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 G & E insurance Consultants,inc. 9880 SW 40th Street Miami, FL 33165 Phone (305) 228-8988 Fax (305) 228-8969 NAOMNEACT MARINA SANTOS c PfK)No Ext): (305) 228-8988- ?C, No): , (305) 228-8969 ADDRESS; MSANTOSOUNNMSTAINSURANCE.COM PRODUCER _G.USIDMER ID- _-,. 'NSUREi) RAVEN ELECTRIC INC 3913 SW 90 AVE MIAMI FL 33165 COVERAGES INSURERS) AFFORDING COVERAGE NAM INSURER A: FEDERATED NATIONAL INSURANCE COMPAN INSURER B INSURERC : INSURER D : INSURER E : INSURER F 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INV( !ADM -sag L���.��� LTR TYPE OF INSURANCE IIna YAW POLICY NUMBER –POLICY (MM/DLXY\rYY)^ GENERAL LIABILITY • COMMERCIAL GENERAL LIABILITY Cj CLAIMS -MADE NZ OCCUR GENT. AGGREGATE LIMIT APPLES PER POLICY ❑ PRO- ElLOC ,IEGT AUTOMOBILE LIABIUTY ANY AUTO ALL OWNED AUTOS [1 SCHEDULED AUTOS Li HIRED AUTOS NON -OWNED AUTOS UMBRELLA UAB OCCUR 1 EXCESS UAB DEDUCTIBLE. Li RETENTION CLAIMS -MADE GL -0000036316-00 WORKERS COMPENSATION 1 1 AND EMPLOYERS' LIABILITY y / d i ANY PROPRIETOR/PARTNER/EXECUTIVE`` OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) i If yes, describe under ()ESCRIPTION OF OPERATIONS below 08/06/2016 08/06/2017 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I OSCAR HERNANDEZ ELECTRICAL CONTRACTOR LICENSE # EC13005734 LIMITS EACH OCCURRENCE ( $ 1,000,000 ►AMAGE 70"RENTED PREMISEL(Ea occurrence).,_ $ ..,... 1,00,000 ` MED EXP (Any one person) $ 5,000 PERSONAL & AIN INJURYj $ 1,000.000 GENERAL AGGREGATE $ 2,000,0001 PRODUCTS - COMP/OP AGG, S 2,000.000 IS , COMBINED SINGLE LIMIT (Ea accident) 3 BODILY INJURY (Per person),„ % $ BODILY INJURY (Per accident ) $ PROPERTY DAMAGE $ (Per eccdent) EACH OCCURRENCE AGGREGATE WC STATU- TORY LIM1T$,,,_,_I—I. ER E L. EACH ACCIDENT $ E L DISEASE - EA EMPLOYE I $ E L. DISEASE - POLICY LIMIT; $ $ $ more apace Is required) CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES FL, 33138 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 ACORD 25 (2009/09) OF X71988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Miami Shores Village Building. Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel:, (305) 795-2204 Fax: (305) 756-897 INSPECTION LINE PHONENUMBER~(305) 762.=494%, BUILDING PERMIT APPLICATION ❑BUILDING XELECTRIC ❑ ROOFING PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS 4 1- F 1 I SEP 2 2016 q•-•"( FBC AYH Master Permit No. "111 -!co—1 'cI%a ;Sub Permit No. k.,••\ " 14 4 ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: I 5 GI K.) 2i 103 JA1ee 1GIY iSiloYea • 33) 3E City: Miami Shores. County: i� Miami Dade Zip: Folio%Parcel#c 1k 3' 2.1� 1� — O3 — 02-1 t.15the•BuildingHisttorically; Designated: lies NOQ Occupancy Type: s t\ Load; Construction, Type: Floud 2cme: BFE: FFE: OWNER: Name (Fee Simple Titleholder): KQi 1 V l nq er Phone#: � ^ S 1.., ria ID3 Stree r L 1 i &ThI S11Q1(4.0 State: P1 Zip: 3 3 13,S Address: City: Tenant/Lessee Name: Monet Email: CONTRACTOR: Company Name: R k C. Address: 7)al 3 t© e\\) City: o'N 1 1• State: I— Zip: 3 (D S OSC � (�- GZ�1PIyv O 2 Phone#:3oS se), 12I 0 1 �J© o5")1/41 -certificate of Competency #: f> Phone#: 3 )SG9 Qualifier Name: State Certification or Registration #: DESIGNER: Architect/Engineer: ICL l nee ili'ioci Address: c� ••�� ��,, Phone#: 30G 2101-0-S2./ BBS SU c 4 City: w/► L I State: R Zip: • 33 5. Value of Work for this Perrnit:$ $ -/S 0 ,'Square/Linear Footage #'Work: Type>ofWork: ❑ Addition ❑ Alteration (g New ❑ Repair/RReplace ❑ Demolition Description cif Work: .IZ \eGAY IC. -0.)► to SVJtrnml i1(a 7e 1 m t -f tis Specify color of color thru tile: Submittal Feer$::' J%Permit fee .7©O• OG Scanning Fee $ Radon Fee $ u. 50 CCF $.. CoO cofcc $„ DBPR $ 4.50 Notary $ 0 Technology Fee $ • 8 0 Training/Education Fee $ • 2 0 Structural Reviews $ (Revised(32/24/2014) Double Fee $ Bond $ TOTAL FEE NOW DUE $ 7 CO 3 • `Q • 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 Zr`R Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has 'oo r:nerreed:prior to the issuance ''of -a=permit ..and that .all .work will be 'perforrned to meet the standards of ail :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: .1 certify that all the foregoing information. is --accurate and that all work will be ,done .incompliance 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 ' subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first ins ection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection: :will pthe ppproved and o reinrpect.op ee'will :be:chwged. Signature 'Signature OWNER or AGENT Cscax..kkerOaNiletIRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowled.ed before me this 24 day of a a9 LA sr , Za. 1 (o , by <Z day a vv 1 y , 20( I G by 1eurfi &U -i1 T. Y' , who_is personally known to. OSCeer ffer ('&1ezwho'is personallykpown.te me or when has produced as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: aa n- Q 1 Print: ,61e.nQ tit J Q c► er Sea * ELENA A SADLER Mary Public - State of Floods Commission I FF 924095 Bondedtlro �tatwatt 2019 APPROVED BY (Revised02/24/2014) identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ******************** ai--13/4 ELENA A $ADUR Notary Milt • Sia of Florida My Comm. hobos Doc 13, 2019 Bondeners4 Naomi Noisy Assn. Plans Examiner _ _ _ willooip- wet. Zoning, Structural Review Clerk 4 STATE OF FLORIDA DEPARTMENT -OF BUSINESS AND PROFESSIONAL REGULATION z EC 13005734 74- .UED:' 08/21/2016 CERTIFIED ELEC1TRICAL CONTRACTOR HERNANDEZ, OSCAR.. RAVEN ELECTRIGING,, '1$ CERTIFIED under the provisions of Ch.489 FS. expiration date . AUG 31, 2018 11608210004032 _._ _.tea t _• 1 11 100% 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 * * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 9/23/2015 PERSON: HERNANDEZ FEIN: 481261518 BUSINESS NAME AND ADDRESS: RAVEN ELECTRIC, INC 3913 SW 90 AVE MIAMI EXPIRATION DATE: OSCAR FL 33165 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR 9/22/2017 Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate. the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 002692 ATA - 1,77 4 ei 5109061 Must 644U..,aye�dsmess Pursuaret'_to F uaty Code . ;d .: Chapter87''-AxS�c30k., _> OWN E€TRIC INC W 1, xto h14 SEC. TYe;,, OF BUSINESS 1:96 ELECTRICAL CONTRACTOR; EC13005i34 =w, • PAYMENt'RECEIQED -r... SY TAX COLLECTOR ''t $75.00 09/15/201 REDITCARD-15-046148- 2,,' This a1 Businesst Receipt only confirms paym'lit ofthe Local The Recegitis not a license, ons pet�etiter,,acertificatw„4tt.oftheholdersqualificatitodohosiness. Holder must comply with any governmental �,orO ngover mental regulatory laws as quirementswhich'applyto the business. The RECEHtT.NO. abdvphnust be dis iNiedd on all commercial vehicles Miam-Da ide-Cede�See`;8a-276. ;_ For mort.iitfo cation,vis www. miamidade.aov/taxcollecxor, .T RAVEN ELECTRIC INC 3913 SW 90 AVE Miami, FI. 33165 305 300-7559 July 30,2016 State of Florida County of Miami -Dade Before me this day personally appeared Oscar Hernandez who being duly sworn, deposes and says: That he and Fiorentino Hernandez will be the only person working on the project located at: 1551 1.3E 103 Streea- Sworn to (or affirmed) and subscribed before me this �-2.---day of J �1 ,2016, by 0SCa..r na.ndeZ • ELENAASADLER Notary Public - State of FIo116 CommK1ion . FF 924095 ss/My Comm. Elmira Doc 13, 2019 Bonded Wm. MIMI Noisy Asia ianli S h•o.res Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Ower — Worms Compensation. Insurance Exemptions 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, waist 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 ar3=: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 idled or the .exemption is revoked by the Division. Your contraetor.is,requestirrg a permitunder 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. inn=these ciroemstamces, Miami Shores Village does Itat re -quire verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGN G BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS Signature: Owner. State ofF1'orid'a County of Miami -Dade The foregoing was acknowledge before me this i day of Pn q (L0 t ,20 1 (o By f Adi + V Vsktl� eC who personally known to me or has produced as identification. Notary: SEAL: ELENA A saw Notary Public • Stilt of Nodes Coo m sie 114016 Ills COMM. ltrin s Doe *10111 ldlMMro�Misul Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT A BILL — DO NOT PAY 4894722 BUSINESS NAME/LOCATION RAVEN ELECTRIC INC 3913 SW 90 AVE MIAMI, FL 33165 OWNER RAVEN ELECTRIC INC Worker(s) MI RECEIPT NO. RENEWAL 5109061 SEC. TYPE OF BUSINESS 196 ELECTRICAL CONTRACTOR 1 EC13005734 LBT EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR 75.00 07/14/2016 CREDITCARD-16-040514 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles — Miami—Dade Code Sec 8a-276. For more information, visit www.miamidade.nov/taxcollector