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EL-17-2891Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Permit NO. E L-12-172891 Permit Type: Electrical - Residential Work Classification: Pool - Private Permit Status: APPROVED Issue Date: 12/12/2017 Expiration: 06/10/2018 Parcel Number Applicant 12 NE 101 Street Miami Shores, FL 1132060131380 Block: Lot: DAVID AND JANICE SNOW Owner Information Address Phone Cell DAVID AND JANICE SNOW 12 NE 101 Street MIAMI SHORES FL 33138- 12 NE 101 Street MIAMI SHORES FL 33138- Contractor(s) Phone ON CALL ELECTRICAL CONTRACTOI (786)388-5880 Cell Phone Valuation: Total Sq Feet: $ 900.00 0 Type of Work: POOL ELECTRICAL Additional Info: POOL ELECTRICAL 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 $4.50 $3.00 $0.20 $300.00 $3.00 $0.80 $312.10 Pay Date Pay Type Invoice # EL-12-17-65848 12/12/2017 Credit Card 7I♦ Amt Paid Amt Due $ 312.10 $ 0.00 Available Inspections: Inspection Type: Final Light Niche Bonding Review Electrical Alarms 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.,. CHANVICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I cert. th. . l h, fp egoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. F ermo -, i, ' th .`r e the above -named contractor to do the work stated. Authorized Signature: f5w erj / Applicant / Contractor / Agent Building Depart ir - nt Copy December 12, 2017 Date December 12, 2017 1 BUILDING PERMIT APPLICATION ❑ BUILDING Miami Shores Village 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 20 Master Permit No. ���� - 2-cQc); Sub Permit NoLI T - ZeG l ELECTRIC EI ROOFING ❑ REVISION ❑ EXTENSION El RENEWAL PLUMBING 0 MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: N G. 101 S City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11" 30-b (g - 0 \ 3 - 1`3 $ 0 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 101J,i1 & S Y�.G W Phone#: (0)- ` 3 3 0 - Sit ?9 Address: ==' D- N C— nny City: Iv�A^A S VWYe--S State: FL Zip: 33 (3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Address:W -7j-bb � s/� City: ' " `/i a IkAn Qualifier Name: �Q 0 VA al- CALL aLEC LC, Phone#: --r26 -Scri 7 T I I ( State: F L Zip: �� a G G I I S Phone#: sus - State Certification or Registration #: DESIGNER: Architect/Engineer: Address: Certificate of Competency #: Phone#: City: State: Zip: Value of Work for this Permit: $ `P`%(JC7 • Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition Description of Work: Q®® I i (,e L'l-v I' cet ( Specify color of color thru tile: Submittal Fee $'- Q - Permit Fee $ ©6! 045 Scanning Fee $ .3 Technology Fee $ Structural Reviews $ (Revised02/24/2014) 0fi8 C� Radon Fee $ 3 • 6c Training/Education Fee $ CCF $ 0 • 0 CO/CC $ DBPR $ `t- • s 0 Notary $ 0'Zo Double Fee $ Bond $ 2 TOTAL FEE NOW DUE $ es 31a.1U 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 appiroved and a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this day of Or/1-0 b--Cy— , 20 b 1 � Y , who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: as Sign: �.L�C�GGj//��'�OG�Loi✓ Print: Seal: GLADYS BORGES MY COMM1ISSION # FF 177110 F� �a EXPIRES: December 17, 2018 rsonded Th. .r Notary Puh!ic ilnu; vr'e **********`►* ass. s e0*****s k* APPROVED BY Signature CONTRACTOR The foregoing instrument was acknowledged before me this ( 54 day of lOC e ! , 20 j i , by <J'i' Ni ("1 % ( t [ S , who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: as Sign: Print: erS Seal: -. L/)' Plans Examiner GL1t MY CC'. =177110 17, 2018 dares hers Zoning (Revised02/24/2014) Structural Review Clerk Local Business Tax Receipt Miami -Dade County, State of Florida -NIS IS NOT A BILL - DO NOT PAY 5308853 BUSINESS NAME/LOCATI• ON CALL ELECTRICAL CONTRACTORS INC 7400 NW 7 ST STE 111 MIAMI, FL 33126 OWNER ONCALL Wo(ker(s) RECEIPT NO. RENEWAL 2051613 SEC_ TYPE OF BUSINESS LECTRICAL C NTR INC 196 ELECTRICAL CONTRACTOR 2 EC 110947 EXPIRES SEPTEMBER 30, 2018 Must be tirspi eyed at place of business Pursuant to County Code Chapter 8A - Art 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR 82.50 10/03/2017 CREDITCARD-18.00071 7 This Local sinew Tie Receipt eitithress mewed of Ile total Besieges Tic Pis Receipt is eel *WO, permit or a mini:Scottie of tbe twilles goal &cations. to do besieges. Holder mast comply web any et nongovernmental revelator, Ism *et which apply te the business., The RECEIPT NO. abois west be &splayed ea all cconmere WI vehicles - let emi -0 see Cede See ler more est nineties, visit ACORO• ® DATE (MM/DD/YYYY) 10/30/2017 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. CERTIFICATE OF LIABILITY INSURANCE IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 endorsement(s). PRODUCER JVS Insurance Agency 9600 SW 8th St. Miami INSURED ON CALL ELECTRIC, INC. 325 CALUSA STREET LOT # 521 KEY LARGO COVERAGES FL 33174 FL 33037 NAME. SANDRA PEREZ PHONE 305 552-5250 1ALC�Lq Extl- (305) E-MAILDSS: SANDRA@JVSINS.COM INSURER(S) AFFORDING COVERAGE FAX JAIC No): (305) 552-5292 INSURER A : GRANADA INSURANCE COMPANY INSURER B NAIC C INSURER C : INSURER D INSURER E : INSURER F : 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 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 ADDL SUBR LTR INSD WVD A X TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I X OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC OTHER: 170015 POLICY NUMBER POLICY EFF (MM/DD/YYYY) 01/09/2017 POLICY EXP IMMIDD/YYYY) 01/09/2018 LIMITS EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL 8 ADV INJURY GENERAL AGGREGATE $ 1,000,000.00 $ 100,000.00 $ 5,000.00 $ 1,000,000.00 $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 2,000,000.00 AU OMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) $ $ $ PROPERTY DAMAGE (Per accident) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE DED RETENT ON $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below EACH OCCURRENCE AGGREGATE Y/N N!A STATUTE I I EERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Electrical Contractors. License #: EC0000947 Miami Shores Village Building Department, 10050 NE 2 AVE, Miami Shores, FL 33138. CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION t T EREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WIT THE PeCY PROVISIONS. AUTHORIZED REPR @ 19-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered ma s of ACORD JEFF A1WKIER CHIEF FI AN CIAL OFFICER • • CERTIFICATE OF ELECTION TO BE NSTRUC11CMN INDUSTRY EXEMPTION This c5e fire indivklu& listed below hes a t be exempt from Florida Workers' CompensationI EFFECTIVE iATE; 1J2,212O16 EXPIRAIION DATE: 1l21f q18 PERSON: C 1LLiS KEN FEIN: :l�IS72 �USNES$ NAME AND SS: ONGALL ELECTRICAL CONTRACTOR& INC STATE OF FLORIDA ENT OF FINANCIAL SERVICES WORKERS CrENSATION 1 ST., UNIT 111 i41IAMI FL SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR Pursuant b Chapter mey not meow banetls of oempelWtloll under Ns within Ole scope of the business of baba bled on v» nonce of to spt and corinnotos of election to be exempt ohal be oubiact to nwxsbn %t, at eny tai aboo ttno Ring ttlo potion named on the nolo orcaracole no tenger memo the nequiarnen $ rot Ns *Wm tot issuance et a osebbow Tito FLORIDA WORKERS' COMPENSATION LAW DFS-F2.D M -252 CERTIFICATE OF ELECTK)N TO BE EXEMPT REVISED 13 ILECTRICAIL 7400 NW 7 Si #111 M iami, Ft 331 26 786-345-800 1 jorre4onca Ilelecific.1 Date: 12-12-17 State of Florida County of Miami -Dade Before me this day personally appeared Kevin Gillis who being duly sworn. deposes and says: That he or she will be the only person working on the project loeatcd at: 12 NE 101 ST Miami Shores, FL Sworn to (or a fiTied) and: itbscribed befbra me this 12th day of December, 2017. by Kevin Gillis, Personally Known X, nt, T Siarnp Nrne of Notary CLAM ISSOt"# FF 17/110 S: December 17, 2,r 14 Pubk 1.11.04fieM4 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 Ow er State of Florida County of Miami -Dade The foregoing was acknowledge before me this / 0-- day of N ' G p 1r r , 20 () . a lie)c10 By Notary: SEAL: DCW _ MY GC (MISS ON ; FF 17'110 EXPIRES', 'Dec_s.nlbor 17, 2018 Bonded .. Net3rp POdic I;ndanvnte!s i o is personally kn to me or has produced as identification.