EL-17-762 (2) Miami Shores Village
- -
Building De �� ' ' '�i'
Department
._ g p .MAR.,24 20p,
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
-- -
-.Tel:(305)795-2204 Fax:(305)756-8972• i BY.—
INSPECTION
Y._INSPECTION LINE PHONE NUMBER:(305)762-4949 77 J
FBC 20 }
BUILDING . , t Master Permit No.. C I I _A&C,
PERMIT APPLICATION Sub Permit No. 17 — qC0 2 -
,, ,.f 19' " 4 f 4 ._ ♦ i �-1_ _ .— .V` s tt f 4 •� � . s1 )! .W
❑BUILDING ELECTRIC_ t, ❑.ROOFING _+ , ❑ REVISION F1 EXTENSION .❑RENEWAL + r:
+
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE CF ❑ CANCELLATION ❑ SHOP
CONTRACTOR' DRAWINGS
JOB ADDRESS:2l�3".y� 9ZS1f" + •�
City:. : ,r A iami Shores ,r. _ ,,County:-,. ;_ -7 ,>'Miami Dade, , + , ^Zia`- 1 22!E? L;STC il t'
Folio'/,Parcel# p = Is the Building Historically Designated:Yes^ }e a' NO, .#
Occupancy"'Type:, ' `-t-"Z1oad: ",s '' Construe#ion'Type: a rt},'',j 4Flood Zone: _. `*i BFE° n V Ld .'FFE.-a A "4 e ,
a , a P
OWNER:Name(Fee Simple Titleholder): `Z(0 5 NL �� S� �fl Phone#:�1$6 ?-3� 6J?qt &f `
Address:_!5C1 00 ` Colll�►"�'
}. ._ ,., r.S s• ',�.. .. . .. `i '.1 1. .. .. �i,.
City:�}�C Aril l PJ�iOIC`� State: ( Zip:53I
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Phone#:.3Q��.yz
Address:
City: &/-� 0/ State: AL Zip:
Qualifier Name: Ll/ �61/�i/` Phone#. ��J .�.9Z
State Cer'tificat'ion or Registration#: Certificate-of Competency#:
DESIGNER:Architect/Engineer: Phone : '
k .J,I . . • t
Address: City: State: Zip:
Value.of,#ork;for,this Permit:$ r Square/Linear Footage of Work:
t. „ � r -•rya ` s���x
TypetoftWork ❑ Addition•;;f1M�� Alteration -❑ New ❑ Repair/Replace i ❑ Demolition
Description of Work: 2
lvi
t
Specify color of color thru tile:
Submittal Fee S� Permit Fee /b0. ,rq' + f5j} .t ?
rs'f k
$ �� � ,CCF$ �_ ,rC0/.CC$ •�..
Scanning Fee$ Radon Fee$ DBPR$ �-1 � Notary$
Technology Feb Training/Education Fee$ Double Fee$ ^
Structural Reviews$ Bond$
I e y.. .. r •, �I
TOTAL FEE NOW DUE$_-
(Revised02/24/2014) +
t". a pn., `i�r e¢- ,.1 d�• y.tf• I'n ,�`,Ir J
Bonding Company's Name(if applicable)
0 i«a 9 . •r F LSF 4.
Bonding Company's Address
CityState Zip
^4- p.t7
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address-f
City , r , State_..�r` 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:pri& to the issuance.of a permit and that.all work will be performed to meet the`standards'of all lawsrregulating
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...... ••
L ..3 .. S,°` ,.ti• ,�'lt .r "t .° ` ,
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. T _ *^ Sr *' " .
"WARNING TO OWNER: YOUR,FAILURE`T0 RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING'TWICEFOR 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 anestimatedvalue 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 su 'ect to attachment.Also;a certified copy of the recorded ndtice of commencement must be posted at the job site
for the first inspectio which curs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be and a reinspection fee will be charged.
Signature Signature y
WNER or AGENT ., '_CONTRACTOR 6
The foregoing instrument was acknowledged'before me this The foregoing instrument was acknowledged before me this
t /. s i
SI- ` =< < a �F g "0' .
~a'0 day of ._MI.Cly; 20 11.. by 2! dyay of r 1,` �,, `20 ' i,by
_ � _ N t i'. I'• <'..Y._ `, ,C.. 1 l.. \ 6••ti , -�e�rsonarCy
S t eC!S I►CM who is personally known to �O��%A� 0 '� I��V� who i n to
me or who has produced �Ye�rS ' 1%Ccv%St 'as me or h has roduced 3 as
N P
identification and who did take an oath. identification and who did take,,44i. AILYNRIVERO
* WCOMMISSION#FF 940071'
NOTARY PUBLIC: NOTARY PUBLIC:
EXPIRES:December
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Print:H` two.,k�,. L �.3 ; —• � -� •, Print: �� �<.I'in- ive—f�`�r
Seal: µre ANDY WDUEW Seal: 1 _.
. t *MY COMMISSION AI GG 081818
e� EXPIRES:March 12;2021 ^
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APPROVED BY ?/M& ! 'Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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EloorTHm 000.000.00
0 MProP AGG s 2,000.000.00
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AUTAAIOM.E LIiSM.IfY SfNGIE LIMIT
❑ 'SOS tNID DAUSCHEDUM BODILYWAW(Parparson) $ ..�.--
rBODILYRL $❑ Auop
DAMAGE :
❑ mm"UA ° p $
p etcps un cW EACH OCCURRENCE s
DED. AGGREGATE :
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CANCELLATION
3"'ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE"RAT"DATE THEREOF,NOTICE WILL BE DELIVERED IN
108 N ACCORDANCE WITH THE
POLICY PROVISIONS.
ASD N3'I+ESENrAmE —
®198&2014 ACORD COR '-
PORAT�pN' All rights reserved.
The ACORD name and 1090 are registered marks of ACORD
tobe exempt fi3rn Florida Workers'Compensation taw.
10/14/2015 EXPIRATION DATE: 10/13f2017
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CORPE1 Ets11Rl Ik RVICEs
FL 33016
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ELECTRICAL WIRING FOOROUfRT CONSTRUCTION BURGLAR AND FIRE
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TPD17 TO BE EXEMPT REVISED 0&13
DUESTIONS?tasoN13-IW9 a
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�58�R�•S�t
.1nm 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 i£
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 in juraqpe coverage from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNINGBELOW U ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Owner
State of Florida
County of Miami-Dade 1 �i
The for$Wing was ac owledge before me this day of ay ,20
B 0 � is
By
who personally known to me orroduced
as identification.
(�Notary: 'C
NANCY GOLDRING
SEAL:
MY COMMISSION#GG 059069
1^. c' EXPIRES:February 15,2021
OF F�aP` Banded Thr,Budget Notary S&-vkeS
1
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1 (MMND/YYY'I)
CERTIFICATE OF LIABILITY INSURANCE I DATE 04,29,2017
I 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 certlf)cate holder is an ADDITIONAL INSURED,the otic les must be endorsed.If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endo e(ment.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s)-
PRQOUCER
----- -----
Automatic Data Processing Insurance Agency,Inc. (�I�1gEXtl: �nuc,No): ___
1 Adp Boulevard t --
Roseland,NJ 07068 ADDRESS:
WSURER(S)AFFORDWG COVERAGE NAIL t
- INsuRERA: HnUnrd underarrlars Insurance Company 30104
INSURED
AABAA ELECTRICAL SERVICES CORP INSURER 8:
--
5951 NW 201ST LN IMSURERC:
Hialeah,FL 33015 INSURER D:
----------------- ---------
INSURER E:
INSURBt F:
COVERAGES CERTIFICATE NUMBER: 667079 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.
nNSR—__.._.___.._.____._ L$UBR _—____ __ —_.___._ POLICY�Ff`POITCY EXP__—._______._._._..__—____—__._
LTR TYPE OF INSURANCE MSD yyyp POLICY NUMBER MAUD MIItID UNIT
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
--_.—_
CIAIMS-MADE T OCCUR
PREMISES(Ea o¢urenoe I S
MED EXP(Any one person) �S
PERSONAL d ADV INJURY S
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AUTOMOBILE LIABILITY ) N L LIMIT S
1 ANY AUTO BODILY INJURY(Per pomm) i$
ALL OWNED SCHEDULED BODILY INJURY(Per soxford) E
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UMBRELLA LIAR OCCUR I EACH OCCURRENCE E
EXCESS LUIS CLAIMSA40DE AGGREGATE E
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I pFp I RETENTION s S
MIOR"Its COMPENSATION X
AND EMPLOYERS'UABIUTY YIN I _ STATUTEER _
ANY PROPRIETMPARTNER(EXECUTIVE E.L.EACH ACCIDENT !E 1,0001000
A .nEl.
NLA N 76WEGER8229 01101!2017 01f01/20f8
I(MuWatory In NH) �E.L DISEASE-EA EMPLOY_ 1rtI00,000
If yes describe under
DESCRIPTION OF OPERATIONS below I El.DISEASE.-POLICY LIMIT S 1,000.000
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional RemaAca ScAsduN,may be athchad I mon space iorequired)
Contractor License:EC13006533
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
VIIIMp of Miami Shores Building Department ACCORDANCE WITH THE POLICY PROVISIONS,
10050 NE 2nd Ave.
Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE
®1988-2014 ACORD CORPORATION.All rights reservad.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD