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ELC-18-101Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. ELC-1-18-101 Permit Type: Electrical - Commercial Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date:/124/2018 Expiration: 07/23/2018 Parcel Number Applicant 415 NE 105 Street Number: CHURCH BLDG 1122310430010 Miami Shores, FL Block: Lot: ST ROSE OF LIMA CATHOLIC CI Owner Information Address Phone ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD MIAMI FL 33138-2970 (305)758-0539 Contractor(s) G3 ELECTRIC CORP Phone CeII Phone (305)322-2489 CeII Valuation: Total Sq Feet: $ 400.00 0 Type of Work: TEMPORARY CHURCH CARNIVAL Additional Info: TEMPORARY CHURCH CARNIVAL Classification: Commercial Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $o.00 $0.00 $0.00 $0.00 $1,000.00 $3.00 $0.00 $1,003.00 Pay Date Pay Type Amt Paid Amt Due Invoice # ELC-1-18-66120 01/24/2018 Check #: 1033 $ 1,003.00 $ 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 information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore; I authorize the above-named ontract9r to do the work stated. January 24, 2018 Authorized Signature: Owner / Applicant Building Department Copy / Contractor Agent Date January 24, 2018 1 t. Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION RECE!\7T AN 2 2018 BY:_akt th FBC 2011 Permit No. CLC -1-18-101 Master Permit No. Permit Type: Electrical 5 JOB ADDRESS: 41 (1 NE 105th Street City: Miami Shores County: Miami Dade zip: 33162 Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami Address: 9401 Biscayne Blvd. Phone#: (305) 727-6241 City: Miami Shores State: FL Tenant/Lessee Name: St. Rose of Lima Catholic Church zip: 33138 Phone#: (305) 758-0539 Email: CONTRACTOR: Company Name: V.vEtVUe/ _ Phone#: 30 3Z -/ El Address: 'Si 2' 5 W 81 Ail F a y� / 1 `� City: ,�, I -{! _ State: '(� Qualifier Name: ( IQ NI (9 T4 _iv,fih DLSL_ Zip: 33 7 3 Phone#: gZZ 2 TGj / State Certification or Re- gistration #: i3 00(02-90 Certificate of Competency #: 4 32 24 1 Email Address: '��F% � �D Contact Phone#: 3o DESIGNER: Architect/Engineer: Phone Value of Work for this Permit: $ 400.00 Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration New ❑Repair/Replace Description of Work: Temporary Church Carnival Jan. 26-28 2018 ❑Demolition **************************************Fees*****:x:x::x:x:x:x***** x********:x:x*********:x: ***** Submittal Fee $ Permit Fee $ ' CCF $ CO/CC $ Scanning Fee $ Radon Fee $ _ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ Heal 003 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 th absence of such posted notice, the inspection will not be approved a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this 1Z'10 day of n'irr»''zY , 20 1? by RC/. C- C( 101, C ti VG -7 7 rtir who i personal) know to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: as Print: 612.11), Seal: ***** *VA ***** rJu�++w r'„ate State of Florida Morrissey N+ .. • ..,poll FF 1b717a Exp.,t; utru4r2019 APPROVED BY (Revised02/24/2014) Signature RACTOR The foregoing instrum was acknowledged before me this d0714 day of IL(i) ,201? ,by Gns✓2.+�ti-v rdvt-NAnrvc7 who is (5ersonally kno me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ************************************************************* / L X;91(-11glans Examiner Zoning Structural Review Clerk G-3 ELECTRIC Corp EC 13006290 x(fit S#A�OTT HAA FL $3141S-351 nos Ii-01-19sr lea •►- Should you have any questions, please contact me at (305)322-2489 or G3electriccorp@hotmai1.com Respectfully. Gonzalo Fernandez President 8724 SW 72 Street #449 Miami, FI 33173 G-3 ELECTRIC Corp EC 13006290 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION EC 13006290 ISSUED: 07/28/2016 CERTIFIED ELECTRICAL CONTRACTOR FERNANDEZ, GONZALO G-3 ELECTRIC CORP IS CERTIFIED under the provisions of Ch 489 FS Expiration date AUG 31. 2015 L1607280002340 Should you have any questions, please contact me at (305)322-2489 or Respectfully. Gonzalo Fernandez President G3electrlccorp@hotmai1,com 8724 SW 72 Street #449 Miami, FI 33173 Local Business Tax Fbcei pt Miami --Dade County, State of Florida THIS IS NOTA BILL - DO NOT PAY 4983681 BUSINESS NAM E/LOCA TION G 3 ELECTRIC CORP 4151 SW 87 AVE MIAMI, FL 33165 OWNER G 3 ELECTRIC CORP Worker(s) MIAMIDADE RECEIPT NO RENEWAL 5204011 SEC TYPE OF BUSINESS LBII EX PIRES SEPTEMBER 30, 2018 Must be displayed at place of business Pursuant to County Code Chapter 8A Art. 9 & 10 PAYMENT RECEIVED 196 ELECTRICAL 6Y TAX COLLECTOR CONTRACTOR 75.00 07/10/2017 0210-17-004189 This Local Business Tax Receipt only con"rms payment of the Local Business Tax. The Recei pt is not a l icense, perm t, or a certi "cation of the holder's qual i "cations, to do business. Holder must correl y with any governmental or nongovernrrental regul atory laws and requirements w hi ch apply to the business. The RBS PT NO. above must be di splayed on all commercial vehicles - Miami --Dade Code Sec 8a--276. For more information, visit www,trrianjgedeaovLt _do lectq 1 EC13006290 ACoRD® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD V) 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: H the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the torms 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 Insurance Company PO Box 929 Oakland FL 34760 CONTACT NAME: JULIO JIMENEZ PHOAmple / Nye Ext. 305-264-9900 (a4 Nat: POLICY ECP (MM(DD)yvVV ADOREss, JJIMENEZ@AMPLEINS.COM INSURER(S) AFFORDING COVERAGE NAM 1 ENSURER A : GRANADA INSURANCE COMPANY 00334 INSURED G3 ELECTRIC CORP 8770 SUNSET DR 4 449 Miami FL 33173 INSURER s: METLIFE INSURANCE COMPANYY 03831 INSURER C : EACH OCCURRENCE INSURER O : INSURER E : CLAIMS•MADE X OCCUR INSURER F : 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS Wall I,TRINS!)WVD ttPE OF INSURANCE ADDL'SUBR POLICY NURSER PoE CTEFF R+M/DPITYYYI POLICY ECP (MM(DD)yvVV LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS•MADE X OCCUR FDAR MISES Ma GE TO RENTED S 100,000 MED EXP (Any one person) S 5,000 A 0185FL00030563-5 11/09/2017 11/09/2018 PERSONAL A ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY ( ! JPEROCT• LOC PRODUCTS • COMP/OP AGO S 2,000,000 QTHF.R: S AUTOMOBILE LIABIMTY COMBINED SINGLE LIMIT (Ea a$0,00a9 $ 300,000 X ANY AUTO BODILY :NJURY(Par person) S B ALL OWNED AUTOS — SCHEDULED AUTOS CA009577P2017 02/16/2017 02/16/2018 BODILY INJURY (Per ncddem) $ X HIRED AUTOS , X NON.OWNED AUTO$ PROPERTY DAMAGE (RV' #4414 nt PIP S $ 10,000 UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAe _ CLAIMS -MADE AGGREGATE $ DED RETENT ONS $ WORKERS COMPENSATION vER ATUTE ER AND EMPLOYERS' ABILITY LIY! N ANY PDOPRIETOR/PARTNER(ECUTIvE EX E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N / A E.L. DISEASE • EA EMPLOYEE $ DESCRIPTION Od RIPT Oo unF OPERATIONS ha10w do E.L DISEASE . POLICY LIMIT S DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Addmonsl Remarks Schedule, may be attached 0 more apace to required) Electrical Contractor NUMBER 11637 MCC 7040 PLAN & MCC 7360 PLAN Gonzalo Fernandez License No. EC13006290 VILLAGE OF MIAMI SHORES 10050 NE 2ND AVE MIAMI SHORES VILLAGE FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WrrH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ---. ) ACORD 25 (2014/01) 198&2014 ACORD COHh�HATION. Ail -- reserved. The ACORD name and logo aro registered marks of ACORD 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: 1/25/2016 PERSON: FEIN: FERNANDEZ 542082896 BUSINESS NAME AND ADDRESS: G 3 ELECTRIC CORP 8724 SW 72 ST #449 MIAMI FL 33173 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR EXPIRATION DATE: 1/24/2018 GONZALO Pursuant 10 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, al any lime after the riling 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 12/14/2017 G 3 Electric Corp EC 1306290 State of j2496G1%14-- County of M1,4441 1,416g___ Before me this day personally appeared 0fq,*Pao, being Duly sworn, deposes and says: That he or she will be the only person working on the project at: Village of Miami Shores 10050 NE 2nd Avenue Miami Shores, FL 33138 Sworn to (or affirmed) and subscribed before me this ft day of , 2017, by Notary public State of Florid Fy . Brian L Morrissey 1 My Commission FF 187178 d` Expires 01/04/2019 Per Produced ide of Identificati •l. • ';41464P '11441.4104-01111..M know 4 . . Print, Type or Stamp of Notary Should you have any questions, please contact me at (305)322-2489 or Resp $:: ly. Gonzof ernandez President G3electriccorp@hotmail.com 8724 SW 72 Street #449 Miami, FL 33173 farm pores Wage Buying Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Omer - Workers' ompensat ern; 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-titne employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LI.C') 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 ofCorporations;•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 notuse 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 y ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: State of Florida County of Miami -Dade The foregoing was acknowledge before me this S day of By Notai SEAL: , 2016 . Va.-. who is personally known to me or has produced as identification. CRISTINA M FRECHETTE ,-= State of Florida -Notary Public * Commission # GG 124808 ' My Commission Expires August 29, 2021 , Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-295374 Permit Number: ELC-1-18-101 Scheduled Inspection Date: January 25, 2018 Inspector: Devaney, Michael Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Job Address: 415 NE 105 Street CHURCH BLDG Miami Shores, FL Project: <NONE> Contractor: G3 ELECTRIC CORP Permit Type: Electrical - Commercial Inspection Type: Final Work Classification: Addition/Alteration Phone Number (305)758-0539 Parcel Number 1122310430010 Phone: (305)322-2489 Building Department Comments TEMPORARY CHURCH CARNIVAL JAN 26x28 2018 Infractio Passed Comments INSPECTOR COMMENTS False Passed Err Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments 3"/)--/./ January 24, 2018 For Inspections please call: (305)762-4949 Page 14 of 30