EL-16-3400 I Permit No. EL-12-16-3400
`eH°REs P Miami Shores Village Permit Type:Electrical-Residential
Miami 12nd Avenue 00 Per i
Work ClassificafiOn:LOW Voltage
ami N.E.Shores,FL 3313&00000 Permit Status:APPROVED
Phone: (305)795-2204
�F[ORLDp'
issue Date: 12/20/2016 Expiration: 06!18!2017
Project Address Parcel Number Applicant
190 NW 100 Terrace 1131010230250
Miami Shores, FL 33150- Block: Lot: LUZ ELENA LERA
Owner Information Address Phone Cell
LUZ ELENA LERA 638 NE 97 Street
MIAMI SHORES FL 33138-2471
Contractor(s) Phone Cell'Phone Valuation=-
Total
DONE WRIGHT A/C AND ELECTRIC S
Sq
Type of Work:TV CAMERAS>LOW VOLTAGE Available Inspections:
Additional Info:TV CAMERAS>LOW VOLTAGE Inspection Type:
Classification:Residential
Review Electrical
Scanning: 1
i
r �
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60
DBPR Fee Invoice# EL-12-16-62392
$2.00 12/20/2016 Credit Card $ 108.60 $0.00
DCA Fee $2.00
Education Surcharge $0.20
Permit Fee-Additions/Alterations $100.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $108.60
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 z n Futhermore, I authorize the above-named contractor to do the work stated.
December 20, 2016
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
December 20,2016 1
2-)2-01 )
Miami Shores Village 7DEC711
Building Department 92016
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY:
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 201y-�
BUILDING Master Permit No. VC'lo '49
PERMIT AP PL ATION Sub Permit No. C_' L IZ- 16 _'-Y 00
F—]BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 190 NW 100th Terrace
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11-3101-023-0250 Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder):Luz Elena Lera Phone#:305-528-5552
Address: 190 NW 100th Terrace
City: Miami Shores State: Florida Zip: 33150
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name:-DOKt- r)6 �e one#:393- 9n, rel-of—
Address: 1671, S,LJ - A16-s� -
l �pD""
City: Yv�b 6-L i State: !r`i Zip: 3 3 0-2
Qualifier Name: W d WA rl, Phone#:
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
v
Value of Work for this Permit:$ In 0- Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
�—
Specify colamfcol r thru tile:
Submittal Fee$ hermit Fee$ U CCF$ Q `rte CO/CC$
Scanning Fee Radon Fee DBPR$C Notary$
Technology Fee$ Training/Education Fee$ (>• 20 Double Fee$
Structural Reviews$ Bond$ Plf
TOTAL FEE NOW DUE$
ns
(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 t be ap roved and a r inspection fee will be charged.
Signature Signature
OWNER or AGENT CONTRACTOR
The foreg ing instrumen s acknowledged before me this The foregoing instrument was acknowledged before me this
ffAday of 20�, by �day of De.U,Mb er 20 ho by
LIZ l Z who is personally known to �L1.V d WIrlg�l- who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
arii+1 ; GLADYS Q.PAZ Sign:
Notary PublicState of Florida � /Print: h 1-S gR
b 118,29117
Conimloslon N EE 863742 Seal: Ca E
' off Bonded Through National Notary Assn. EXION��
APPROVED BY., /���/oO Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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ACCPR" CERTIFICATE OF LIABILITY INSURANCE °08118;20°16'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
J 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 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 endomemen s.
PRODUCERALL CITY INSURANCE INC-ACI coNTACT CARMEN RODRIGUEZ
275 FONTAINEBLEAU BLVD. PHONE 305 463-9431 FA" 305 436-6797
SUITE 190 _ADDRESSL
GMAIL LLCITYINS.COM
MIAMI FL 33172 INSURER(S)AFFORDING COVERAE NAICB
N R A.WESTERN WORLD INSURANCE C
INSURED INSURER 8:
DONE WRIGHT A/C&ELECTRIC SERVICE INC.ID 710224 INSURER C
19532 SW 129TH CT. INSURER D:
MIAMI FL 33177 INSURER E;
-
COVERAGES CERTIFICATE NUMBER:01 REVISION NUMBER:00
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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
A GENERAL LIABILITY X Q 1147769-01 08/18/201608/18/2017 EACH OCCURRENCE $ 1,000,000
I X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000
CLAIMS-MADE a OCCUR MED EXP(Any oneperson) $ 5,000'
A PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE s 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000
X POLICY P1FrTRO- LOC I I $
A AUTOMOBILE LIABILITY X Q1 147769-01 8/18/2016 8/18/2017 Ea accident) E LIMIT 1,000,000
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS I
$
UMBRELLA LAB
HOLAIMS-MADE
CCUR EACH OCCURRENCE $
EXCESS LIAB AGGREGATE
DED I I RETENTIONS
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS LIABILITY YY 11 NN
ANY PROPRIETOR/PARTNER/EXECUTIVE(—
OFFICERIMEMBER EXCLUDED? u N/A E.L.EACH ACCIDENT
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE
If es,describe under
op E.L.DISEASE-POLI Y LIMIT
i
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,"more space Is required)
GENERAL CONTRACTOR
A/C AND ELECTRICAL CONTRACTOR
CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED
30 DAYS WRITTEN NOTICE SHALL BE GIVEN EXCEPT FOR NON-PAYMENT OF PREMIUM WHERE 10 DAYS SHALL
BE GIVEN ;
CERTIFICATE HOLDER CANCELLATION Al 003184
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
} MIAMI SHORES VILLAGE ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING DEPARTMENT '
10050 N.E. 2ND AVENUE AUTHORIZED REPRESENTATIVE
MIAMI SHORES FL 33138yGL('Qlrl
I
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
I
DONE WRIGHT A/C & ELECTRIC SERVICE, INC.
10711 SW 216TH STREET,SUITE 109•MIAMI,F1,,33170
(305)551-2137•FAX(305)278-9218
Date:
State of:
i Ap�
County of:. Nkl, LM t
11 `
Before me this day personally appeared Ll,1Z le�'t4 r� who, being duly sworn,4deposes
and says: _
f z
c
ThatGor she will be the only person working on the project located 190 NW 100"Terrace k
4
3
Sworn to(or affirmed)and subscribed before me this day of_0?_CeM6 ee 2016, by
Re rut Le rX4
Personally Known
OR Produced Identification L -60D—5 .25 7 7
A. ij
Type of Identification Produced r\Ver' A-Se-
SER _.:.. •.-, •
NOTARY PUBIC. �
STATE OF FLORM - 1 M ofe
Fbq*m
gym.."x
Print;Type of Stamp Name of Notary
E
SORES Gr!
s �► Miami shores Village
Building Department
10050 N.E.2nd Avenue
�IORiDp' 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 ACKNO LEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature: P1
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of -bezemLer 120 14,
.
By 2 P,e_na Le Ka— who is personally known to me or has produced
1P00-525'7-7-5f)
hl v : as idqntification.
Notary: PhAe_,�A� AMA& PR18CIU A ALEXANWR
A3916NOTARY PUBLIC
RUM 1h NATE OF FLORIDA
SEAL:
Ekins 4H5J20Z0