EL-17-2714 Permit NO. E L-11-17-2714
e�°RES� Miami Shores VillagePennit Type:Electrical-Residential
ut
F� 10050 N.E.2nd Avenue NE OVA a Work CiaSSt{cation:Addition/AlWaition
Miami Shores,FL 33138 0000 Pel i t
-atePermit Statin:APPROVED
Ep .i„�O Phone: (305)795-2204 -
F�ORiDr'` Issue Expiration: 07115/2018
Date: 1/16x/20113
Project Address Parcel Number Applicant
440 NE 91 Street 1132060190050 JEFFREY COOPER
Miami Shores, FL Block: Lot:
Owner Information Address Phone Cell
STEPHANIE LOPEZ GOMEZ 440 NE 91 Street
MIAMI SHORES FL 33138-
440 NE 91 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $,15,789.47
M.B. ELECTRIC SERVICE CORP (786)325-3383 Total Sq Feet: 0
Type of Work: INSTALL,REMOVE AND RELOCATE OUTLET Available Inspections:
Additional Info:
Inspection Type:
Classification:Residential
Final
Scanning: 1 Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Review Electrical
W.W.
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $9.60 Invoice# EL-11-17-65659
DBPR Fee $8.29 11/15/2017 Check#:2653 $50.00 $545.05
DCA Fee $5.53
Education Surcharge $3.20 01/16/2018 Credit Card $545.05 $0.00
Permit Fee-Additions/Alterations $552.63
Scanning Fee $3.00
Technology Fee $12.80
Total: $595.05
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: rtify th t a''IAAI the f regoing,information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zon' u eraut rize the above-named contractor to do the work stated.
January 16, 2018'
Authri ed Signatu :Owner / Applicant / Contractor / Agent Date
Buildl g Department Copy
January 16, 2018 1
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Miami Shores Village =1520V
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
FBC 201�P
BUILDING Master Permit No. -MI-4- 1
PERMIT APPLICATION Sub Permit No. (a-1-4 —Z9 I H
❑BUILDING dELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: AAX7 t-.j�' -X%, S
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: ik Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): Phone#: C3 —6'
Address: 444C'> " -N\
City: M%A.LA% 4EIk �� State: 'ZF-1_ Zip: 331,x(8
Tenant/Lessee Name: Phone#:
Email: Goty 4xN.- e-g�
CONTRACTOR:Company Name: Phone#:
Address: ON S
City: Stater Zip: SSS
Qualifier Name: ;2 Nkt- X --2- Phone#:
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ ,--,(�3; Square/Linear Footage of Work:
Type of Work: YI Addition ►y_J Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: k%nE;
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ P,71 CCF$ Q G CO/CC$
Scanning Fee$ Radon Fee$ C 53
2 DBPR$ Q ) Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ S r OS
(Revised02/24/2014)
k
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
i
Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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.....
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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."
i
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 not be approved and a reinspection fee will be charged.
Signature Signature
rkAz—
Z�OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
aJ day of O=V5F-Q 20 1- by day of t +TL. ,20 \-4_, by
Z)EfME'r 00011 who is personally known to &&3cx7Z 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:
-- �-- i
Sig Sign:
Print: i(- NVQ ) \IILLM1UEy,4 Print: 'QZCA�1�o dcl�-moo
Ricardo Dominguez
Seal: r�aaryPubNeSMedFbrid� Seal: -*'!P 'PI'��F; Commission # FF958686
Ignacio vftnuevs Z -
, ` My Commission
o oeianoiG 11M3 �� Expires:February 8,2020
aR %> X"' Bonded thru Aaron Notary
APPROVED BY wI Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
MB ELECTRIC SERVICE CORP.
October 3rd, 2017
State of Florida
County of Miami Dade
Before me this day personally appeared JUSEF MUNOZ who,being duly sworn,deposes and
says:
That he will be the only person working on the property located at 440 NE 91st Street
Miami Shores FL 33138.
Sworn to (or affirmed) and subscribed before me this day ofct::--G� . 20N:7-
by MZ
Personally Known
OR Produced Identification -'k>\-
Type
�LType of Identification Produced
Print,Type or Stamp Name of Notary
k'; 'J'd�/�o- Ricardo Dominguez
Commission # FF958686
. , Expires:February 8,2020
%' � Bonded tbru Aaron Notary
3955 NW 195 STREET MIAMI GARDENS FL 33055
• Miami Shore's Vi.11age
u. {
Building Department
7ve 10 ' 10050 N.E.2nd Avenue
OR 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
1 or members of a limited liability company (LLC) in the construction industry may elect to be
exempt i£
I. 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.
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Signature:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of cGta _ ,20 1-
Bye 'k ccs . =z54_3p&=A� ��who is personally known to me or has produced
as identification.
Notary: - --
`a �, Ricardo Dominguez
SEAL:
Commission # FF958686
�., Expires:February 8,2020