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EL-17-18391 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Parcel Number Permit No. EL -7-17-1839 Permit Type: Electrical - Residential Work Classification: Alteration Permit Status: APPROVED Issue Date: 7/26/2017 Expiration: 01/22/2018 Applicant 157 NW 103 Street Miami Shores, FL 33150- 1121360131540 Block: Lot: CASSA GROUP LLC Owner Information Address Phone Cell CASSA GROUP LLC 18181 NE 31 Court AVENTURA FL 33160- (305)610-1905 Contractor(s) M&D ELECTRICAL SERVICE INC Phone (305)318-7005 Cell Phone Valuation: Total Sq Feet: $ 2,600.00 0 Type of Work: REPLACE SERVICE AND PANEL . DISCONN Additional Info: REPLACE SERVICE AND PANEL . DISCONN Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $1.80 $3.38 $3.38 $0.60 $225.00 $3.00 $2.40 $239.56 Pay Date Pay Type Amt Paid Amt Due Invoice # EL -7-17-64613 07/18/2017 Credit Card $ 50.00 $ 189.56 07/26/2017 Credit Card $ 189.56 $ 0.00 Available Inspections: Inspection Type: Review Electrical In consideration of pertaining thereto accepting this per required for ELEC e issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations trict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In ume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are UMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDA construction and zoni that all the .regoing information is accurate and that all work will be done in compliance with all applicable laws regulating ore, I - orize the above-named contractor to do the work stated. Authorized Si atur ner / Applicant / Contractor / Agent Building Depa "" ent Copy July 26, 2017 Date July 26, 2017 1 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 S-Fh FBC 2011 BUILDING Master Permit No.c., bIE Sub Permit No. -EL 11-1$3c1 c2 XVED JUL 18 2017 PERMIT APPLICATION ❑ BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL []PUBLIC WORKS ❑ CHANGE OF E CANCELLATION ❑ SHOP I "` CONTRACTOR ` DRAWINGS JOB ADDRESS: a '4- 4IA5 I O?, ST City: Miami Shores County: Miami Dade Zip: 3 ( S 0 I Folio/Parcel#: 1 I - 2'1 36 - 013 — /Sit() Is the Building Historically Designated: Yes NO IC !occupancy Type: 2.1T,S Load: --- Construction Type: -- Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): CA S 4 & .-Q p(t L < C Phone#:.3 OS. - 4/0 - /POI Of Address: 1$ 1 S 1 ) �c. 3 k G t Sc) 1 City: 1%V Y.KJ's 2.A State: C1- Zip: 33 1 6 0 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: AidZ9 £ /G'Zi ee:d c t V/Cly Phone#: _3 Os r•3!r 7c/os at � Address: 2//S 2 SGA% /2-.9" c / 8 te 1 44.3 5S Mi Cc4 r 10 S City: . 4.1Jr!/_� State: /r/G. Zip: 33/77 Qualifier Name:�1=yjO.rt/.41... s//U Phone#: 3'D s' -7/s-- Tevr !State Certification or Registration #: G C./500705 % Certificate of Competency #: EC /5dozes ,7 DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 2. 600 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: CG .$g vee .w/ �.S,u el; !� i 'e ' �coA,,Q A"- /PJy 4'4 /0, , 77 2 c9 /14.4/4/0 7 z 4) / ue, el�_�/* � / r e /vett) ( / c P ` 4 cf /06-iv/A- ,¢N d ot) . / /'(i T ,�.+J Specify color of color thru tile: /‘/-4.7. Submittal Fee $ i Permit Fee $ Z Ar/111° CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Edu ion Fee $ Double Fee $ 1 Bond $ TOTAL FEE NOW DUE $ (. C&::› Structural Reviews $ (Revised02/24/2014) Bonding Company's Name (if applicable) ' Bonding Company's Address City Zip i Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do thelwork 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 t.AIso,.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. I Signature T owledged befIr me this 20 ,by hq,(s pe %ally known to 11yp na as me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign' Print: Seal: RAYMOND A. DEQUARTO ilIttary Public, StztQgf, Fk riga: . ,comm, slon1 FF1`359/ th rvat ej 3e!'rt 2, 2tjt8 APPROVED BY (Revised02/24/2024) Signature CONTRACTOR The foregoing instrum was acknowledged before me this / r day of ,20__/,by Q41-0,:UAi7 M who is personally kn� togto me or who has produced identification and who.did take an oa NOTARY PUBLIC: Sign: Print: Seal: 1.4 Rio��.�� as ens, LUIS FERNANDEZ * t•R , MY COMMISSION # GG 041161 EXPIRES: November 7, 2020 of f E' botAid Nu Budget Notary Services A / 8..22 y CY Plans Examiner Structural Review Zoning Clerk STATE GF FLORIDA DEPARTMENT QF BUSINESS AND PROFESSIONAL REGULATION CERTIFIED ELECTRICAL CONT MORALES, IHOSV- M & D ELECTRCAi toc a Busi ness Tax Recei pt Mie. 'Dae County, State of Florida NO 1 A BILL Q•. OT • Y rt.QCA GALS T O. EXPTIRES SEPTEIVI5ER 30, 201 .° . I. yed at place of ban s U: nt to County Code A +ti 9 & 10 D E ECTRIC\1_ ER\'10E INC Sti.0 ' ' N EttISINLS4 193 ELECTRICAL CONTRACTOR 1 EC 13007057 pig Tax Rsetiipt or y corn rms payment of the ted Busi � a '<x% d the hd cur's gush "crone, to do hotness, tit:), story tawsandr+equlnanentawfi t#pplytothe mit be tisplayed Rx nue brio rrn PAYMt' RECEIYF,-":D Y TAX COLLECTOR 6,04 • 081/6/2010 HECK21.16.112 Tax. �i c.dptlsnot*n ' rI>Int �v,!rlth AC(JR/7 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 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(ies) must have ADDITIONAL INSURED provisions or 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 Ferrero Insurance Inc. 10637 SW 88th Street, Suite 71 Miami, FL 33176 6 Phone (305) 275-7572 Fax (305) 275-7572 CONTACT Marieta Ferrero NAME: taco No Ext. (786) 317-2073- FAX• No): E-MAIL ferreroinsurance©bellsouth.net _ADDRESS INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Seneca Specialty Insurance Co. BAG -1041106-1 / INSURED M & D Electrical Service Inc. 21152 SW 128 Ct Miami ' FL 33177-7425 INSURER B : EACH OCCURRENCE INSURER C : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER D : MED EXP (Any one person INSURER E : r ❑ INSURERF: S 1,000,000 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADD INSR N SUBR WVD N POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DDIYYYY), LIMITS A • V COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE LTJ OCCUR BAG -1041106-1 / 10/03/2016 10/03/2017 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) S 100,000 MED EXP (Any one person $ 5,000 ❑ PERSONAL & ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: • POLICY • JECOT ❑ LOC GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMP/OP AGG S 2,000,000 I ❑ OTHER S AUTOMOBILE LIABILITY • ANY AUTO OWNED • SCHEDULED ❑ AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ AUTOS ONLY "" HIRED • NON -OWNED AUTOS ONLY PROPERTY DAMAGE (Per accident) $ AUTOS ONLY ❑ ❑ S ❑ UMBRELLA LIAB ❑ OCCUR • EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ II DED • RETENTION $ $ WORKERS COMPENSATION..PER AND EMPLOYERS' LIABILITY Y 1 N ' ANY PROPRIETORIPARTNER/EXECUTIV N 1 A OTH- STATUTE ❑ ER E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS l VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Electrical Work - Electrical Apparatus " CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) QF © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 Northeast 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. ! AUTHORIZED REPRESENTATIVE / Miami Shores, FI 33138 1 (/ ACORD 25 (2016/03) QF © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD .� CF A1WATER CHIEF FINANCLLi_ OFFICER ,TATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSA CONSTRUCTION INDUSTRY EXEMPTION -Mi.,' certifies tha CCTIVE DATE: PERSON: FEI N : )e individual listed below has elected to be exempt from Florida Workers' Compensa EXPIRATION DATE: 11/1712017 IHOSVANY VORALES 204163102 11/18/2015 BUSINESS NAME AND ADDRESS: M a DELEC TICAL SERVICE INC 21 152 SVV 128TH CT 1 AMi CPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR o Cr pier 14), F S n c#i^ of a cot pora1ion W10 eicr is cornption front` tt> s Cha,xer byfiling a cortiAcatcc i demi r umIer ani$ H rOu;x Gen0 is cr Axa is . trc this chrpter. F'ursuru ft to ChaileT 44(),(6( 12), F,$, Cern eater ci duction to tc e,iPL, oap1Y only sco* cf tl_rs:r a or tr on tf0a rc 1Jcra of dation to bd, pt, Pursuant to Chapter 44005(13), F, S„ Notico cat ci ct on bStks ark: ttnc:atw of tobiu em/lvt subiEct to ro,cacation if, at any tinx, after rfka f to of the notice a tt irsuanc.a of rho con tificate, tsor>rrc r, rari on the rxAice cx cc�bfic<itrJl o long (yr nes the requrc w 4s o this se�ct.on k isstkux:e c24 a ceftiftcatu, The d partn>aca shi!(rcr�.c a �;- ,'-oWC-252 C FiTII ICATE OF ELECTION TO BE ENEWT REVISE) • EI Date:" //77 nc State of Florida Miami Dade County / / Before me this day personally appeared �' hJ b $ /Gv' c of (Who, being duly sworn, deposes and says: That he will be the only person working in the project located at: /5; Ai w /D3 s7' i 33/3 EP Contractor Siwature c�a subscribed before me this //- day of Personally know Produced Identification Type of Identification Produced 6,1sav Pu•,, LUIS FERNANDEZ COMMISSION # GG 1161 .` n '' MY 0 EXPIRES: November 7, 2020 d',. A of r`oe Bonded Thru Budget NearY S MOM Print, Type or Stamp Name of Notary 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 Exem 'tion 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 parttime or fall -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 it 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: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this 2 O day of -J v `a , 20 1'Z ByQk .,,Sse t..7o SEAL: who is personally known to me or has produced as identification. LUIS OLIVERA Notary Public. State of Florida Commission*s Jan. 2982020 My comm.