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EL-17-2645Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit No. EL-11-17-2645 Permit Type: Electrical - Residential ram' Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 1/212018 1 Expiration: 07101/2018 Project Address Parcel Number Applicant 129 NW 96 Street 1131010250100 Miami Shores, FL 33138- Block: Lot: ERIK SACCOMANI ERIK SACCOMANI 129 NW 96 Street MIAMI SHORES FL 33150- 129 NW 96 Street MIAMI SHORES FL 33150- Contractor(s) Phone Cell Phone JJ ELECTRICAL OF DORAL LL (305)305-1620 of Work: NEW CIRCUITS FOR LIGHTS AND OUTLETS onal Info: NEW CIRCUITS FOR LIGHTS AND OUTLETS ification: Residential ling: 1 Fees Due Amount CCF $2.40 DBPR Fee $2.10 DCA Fee $2.00 Education Surcharge $0.80 Permit Fee - Additions/Alterations $140.00 Scanning Fee $3.00 Technology Fee $3.20 Total: $153.50 Phone Cell Valuation: $ 4,000.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # EL-11-17-66678 01/02/2018 Credit Card $ 153.50 $ 0.00 Avaliame Inspection Type: Final Meter Box Aiteranon Relocation Fire Alarm Service Change Review Electrical W. W. Underground 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 and ning. Futhermore, I authorize the above -named contractor to do the work stated. January 02, 2018 Authorized Signatgre: Owner / Applicant / Contractor / Agent Building Department Copy January 02, 2018 Miami Shores Village RECEIVED Building Department Nov 06 2017 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4%9 FBC 20 t-A BUILDING Master Permit No. JZG q - 46_3 PERMIT APPLICATION Sub Permit No. E i f�--1— z_(yL S - ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: Io 16 Is A . r'ity Miami ChnrPc rnunty- Miami Dade 7in- ) v Folio/Parcel#: 3 I D S - D (o C) Is the Building Historically Designated: Yes NO Occupancy Type: Load: OWNER: Name (Fee Simple Titleholder):, Address: 1 2 c) t'j u-) de16 Construction Type: Flood Zone: K SQ CCyvYta n 1 BFE: FFE: _ *: ­? o ro -q 75 3 J City: -tia'm i sm r-e S State: 'j Zip:-33 (' C) Tenant/Lessee Name: Phone#: ` & Gl 1, 7 3 A Email: CONTRACTOR: Company Name: J-J 1� G dl" +D06P-�, 41C Phone#: Z!P5" Address: �290 N� '4v� 7-4: 00-7. City: AtXD*LL� State: fL Zip: 3�( Qualifier Name: ���- cT'y/n'� Phone#: State Certification or Registration M 130 Certificate of Competency #: J,?Fo000 6 $^ DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $tUfl J Square/Linear Footage of Work: Type of Work: ❑ Addition El Alteration ❑ New ElRepair/Replace ❑ Demolition Description of Work: �,, L' Ir'� �'' 4, /'i�;b` ay oailnif kr r lealyL:4 Parr,/ Z&_ /ycu�ot- Specify color of color thru tile: No -on Submittal Fee $ Scanning Fee $ Permit Fee $CCF $ CO/CC $ Radon Fee $ 2, c)o DBPR $ 2. 1 Notary $ Technology Fee $ Training/Education Fee $ Structural Reviews $ Double Fee $ Bond $ _.._.. ___ ....... _.._ . I E3, 5D Bond:,n&Company's Name (if applicable) Bonding Company's Address City State Mortgage Lenders 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. 1 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 promise in good faith that a copy of the notice of commencement and construction lien law bra whose property is subject to attachment. Also, a certified copy of the recorded notice of commenc for the first inspection which occurs seven (7) days after the building permit is issued. /hQ the inspection will not be approved and a rein5pection fee will be charged. v, Signature Signature \/ WNER or AGENT CO,I The foregoing instrument w s acknowledged before me this L day of Vim`! I�`V 20�� by who is personally known to meoriwhohas produced � L"��_- 2�J`J'7sJlJ� as identification and who did take an oath. The foregoing inst ling $2500, the applicant must will be delivered to the person 'must be posted at the job site ice of such posted notice, the before me this 6.9 ,, day yoff., '�z 20 1-7 by zisiJl1_`�-�►�� �"a —who is personally nown to (:3moor who has produced as n and ."I Pie, ROMMEL L. UZCATEGUI NOT IC: NO Y PUBLIC: ;r° Nptu Public •State of Florida ®. Commission I FF 96951 _ 4 My Comm. Eapinl Mar 9. 2020 Sign: Sig ��'" , �dadthr NatlortalNotar y Assn Print: � V 1 . �� �� -y�V l J 1� Pr Y�A-C" tc ZCJ��C$Q Seal: 9 PalkAl>tft J 'ero""^ al: •' 11\1 • Mph 12, 2021 APPROVED BY ��%� Plans Examiner Zoning Structural Review Clerk 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: 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. Signature: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this C—\./ day of QQAK , 20 `� . By �� l��Cfi �_1y 1 who is personally known to me or produced r l--QL- — 0�dentilication. Notary: 1�)Ab 5 rn �� �\�0 W N SEAL: �Bn7Mrtt �� r� Ruth =�,1----��b My Commission Explrea __ 2624 �N'r Com,nisslon No. Ga 81599 JJ ELECTRIC OF DORAL, LLC LIC 13014851 Date: to /!$% State of ;C.1o/1-b4 County of D-nze- Before me this day personally appeared �/avc-�2 J�,�,a who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: A11-V q&711 � ✓Vz Sworn to (or affirmed) and subscri ed before me this 19 day of 0Ct6r-�-1G�2 . 20—U, by �2 c.c.a-4�-4D p . Personally know r OR Produced Identification Type of Identification Produced ROMMEL L. UICATEGUI ¢y Notuy Public - State of Florida Commission N FF 969514 My Comm. Expires Mar 9.2020 Bondldthrough National Notary Assn Print,/f ype or Stamp Name of Notary 7290 NW 114th AVE SUITE 207- MIAMI, FL - 33178 Pmnil - ii PlPntrin llrrnhntmnil rnm - nhnnP Rqn