EL-18-998I 10\ Miami Shores Village
��45 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
BUILDING
PERMIT APPLICATION
El BUILDING d] ELECTRIC ❑ ROOFING
PLUMBING ❑ MECHANICAL [PUBLIC WORKS
JOB ADDRESS:
Master Permit No.
Sub Permit No.
❑ REVISION ❑ EXTENSION D RENEWAL
FBC 20
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR ": DRAWINGS
g-9--00S" NE B Aokt
City: Miami Shores
County:
Miami Dade
Zip:
Folio/Parcel#:
Occupancy Type:
Load:
OWNER: Name (Fee Simple Titleholder):
Address: 40 /J
City: / /t,vi,,l'
Is the Building Historically Designated: Yes
Construction Type: Flood Zone: BFE:
n /l )G
4/e
State:
Phone#:
NO
FFE:
ZIP: 53/ VO
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: 11/61G //T/d t/ ELECT/P/(4 e4A/TO-CrPhone#: eri "7/f d(C)
Address: //OP/
City: //4 '' 4 // State: % l Zip: 3 .? /..L.
Qualifier Name: .44/% ew/t 7/3 Phone#: " /e"d
State Certification or Registration #: Certificate of Competency #: /Q 40 762
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 3 SO - 0 Square/Linear F tage of Work:
Type of Work: ❑ Addition 0 Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: 'Z T rR r C/ '- /24 /t"4. /��- M
Specify color of color thru tile:
Submittal Fee $ SOIXI i d Permit Fee $ /5 04%7 CCF $
Scanning Fee $ Radon Fee $ Q • CC) DBPR $ a • 4ts-s
CO/CC $
Notary $
Technology Fee $ Training/Education Fee $ Double Fee S
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ 109 ' 8S
(Revised02/24/2014)
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address
Permit
Parcel Number
Permit Na. EL-4-18-998
Permit Type: Electrical - Residential
Work Classification: Service Change
Permit Status: APPROVED
!saw Dairs 411712018
Expiration: 10/14/2018
Applicant
8705 NE 4 Avenue Road
Miami Shores, FL
1132060460680
Block: Lot:
RAFAEL FELIZ
Owner Information
Address
Phone
Cell
RAFAEL FELIZ
6100 N BAY Road
MIAMI FL 33140-
6100 N BAY Road
MIAMI FL 33140-
Contractor(s) Phone
EVOLUTION ELECTRICAL CONTRAC1 (786)351-5784
Cell Phone
Valuation:
Total Sq Feet:
$ 350.00
0
Type of Work: ELECTRICAL PANEL CHANGE
Additional Info: ELECTRICAL PANEL CHANGE
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$0.60
$2.25
$2.00
$0.20
$150.00
$3.00
$0.80
$158.85
Pay Date Pay Type Amt Paid Amt Due
Invoice # EL-4-18-67178
04/16/2018 Credit Card $ 50.00 $ 108.85
04/17/2018 Credit Card $ 108.85 $ 0.00
Available Inspections:
Inspection Type:
Review Electrical
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 certi that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. rmore, I authorize the above -named contractor to do wo k stated.
Autho ' ed Signature: Owner / Applicant / Contractor / Agent
April 17, 2018
Date
Building Department Copy
April 17, 2018 1
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 not be a .ved and a reinspection fee will be charged.
Signature
OWN rRorAG+NT
The foregoing instrument was acknowledged before me this
day of , 20 , by
/z}r:„{ , who is ersonally knowto
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
APPROVED BY
,t, ,,,,,� MARIJAIR RAVELO
`o? Notary Public - State of Florida
Commission # FF 206163
ag**.11k;9111p; imiiRosi.May,i 1*119‘ `**:
Bonded through National Notary Assn.
/72.. /6,' Plans Examiner
Signature
The foregoing instrument was acknowledged before me this
13 day of P\ `,20 C�
by
G41,ry 1 � iek , who is ersonally to
as me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
*****************
Structural Review
,opY PU6
f' KARLA P. GARCIA
MY COMMISSION # FF140421
14.0
cFlI. EXPIRES: July 10, 2018
************
Zoning
Clerk
(Revised02/24/2014)
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 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 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 /lo day of i%2%(.- , 20 t
By EA; 4 Peal'o who i personally known t me or has produced
as identification.
Notary: aV
SEAL:
1i
My Comm. Expires May 5, 2019
° Bonded through National Notary Assn.
MARIJAIR RAVELO. — p
Notary Public - State of Florida
Commission # FF 206163 i
Date:
EVOLUTION ELECTRICAL CONTRACTORS INC.
11631 NW 58TH PL
HIALEAH, FL 33012
Telf: (786) 718 8562 — Fax: (305) 822 8211
ozoiX
State of --
Country of
Before me this day personally appeared Vbn 0 ke._oo who, being duly sworn,
deposes and says:
That he or she will be the only person working on the project located at:
Sworn to (or affirmed) and subscribed before me this 13 day of
Personally know
Or Produced Identification
Type of identification Produced
•
: KALA P. GARCIA
MY C MMISSION N FF140421
4471141raa0
J EXPIRES: July 10, 2018
Print, Type of Stamp Name of Notary