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EL-18-3034Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Permit NO.: EL-10-18-3034 Permit Type: Electrical - Residential Aj j Work Classification: Addition/Alteration 4 Permit status: Approved Issue Date:10/16/2018 I Expiration: 04/01/2019 Parcel Number Project 77 NE 105 ST, Miami Shores, FL 1121360060150 <NONE> Contacts JESSICA SCHILLING Owner 77 NE 105 ST, MIAMI SHORES, FL 33138 Other: 9546293012 EZEQUIEL ZYLBERBERG Owner 77 NE 105 ST, MIAMI SHORES, FL 33138 Mobile: 5617032510 SCHILLINGESI@GMAIL.COM JESSICA SCHILLING Applicant 77 NE 105 ST, MIAMI SHORES, FL 33138 Other:9546293012 RAVEN ELECTRIC INC Contractor OSCAR HERNANDEZ Business: 3059511210 Description: NEW LIGHT IN THE GARAGE SPACE AND KITCHEN Valuation: $ 2,000.00 Inspection Requests. AREA REPLACE ELECTRICAL SERVICE (150 AMP) 305-762-4949 Total Sq Feet: 230.00 Fees Amount Application Fee - Other $50.00 CCF $1.20 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.40 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $111.10 Payments Date Paid Amt Paid Total Fees $111.10 Credit Card 10/16/2018 $111.10 Amount Due: $0.00 Building Department Copy In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing inform ' in a curate and that all work will be done in compliance with all applicable laws regulating construction an oning. Futhermore, I authori a above named contractor to do the work stated. 6/2 - (W Authorized Signature: Owner / Contractor / Agent Date October 16, 2018 Page 2 of 2 . 'y PUblic U� de'writers Miami Shores Village RECFJVF. Building Department o T aj2o1$ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 BY: ''INSPECTION LINE PHONE NUMBER: (305) 762-4949 '' FBC 201�7 _ BUILDING Master Permit No. R(f — 2 — I o 2)I PERMIT APPLI ATION Sub Permit No. ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: _ -1 A45- 7 o S " City' Miami Shores County: -I"Z.I Miami Dade Zip: >2 / 361 Folio/Parcel#: 1 2 �'� CC G3 5 o Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 23 ay � Z t= % � D �' Phone#: 2Sj a Address: /l%C la's _ / K- 67-- City: N/ t$yl i State: Zip: Tenant/Lessee Name: Phone#: Email CONTRACTOR: Company Name: ti C i;V �Phone#:.3 0 S - �%_�5 l Address: 3l / S = Cs) `/ O 14 t/ City: 14 �r4// / 5 . �U �' / f7 /2 3 Qualifier Name: 0,S c A/AA/ � = Z Phone#: y c:) :c -- �� S / i ? r 0 State Certification or Registration #: /.3 DJ : 73 y` Certificate of Competency M DESIGNER: Architect/Engineer: ne#: Address: City: State: Value of Work for this Permit: $ "i000i C�� Square/linear�Fo(otage of Work: Type of Work: ❑ Addition El Alteration ❑ New LJ Repair/Replace Description of Work: —'! ( �, 7l� C� SO Specify color of color thru tile: Submittal Fee $ 9 Permit Fee $ Scanning Fee $ Technology Fee $ Radon Fee $ Training/Education Fee $ CCF $ DBPR $ Zip: ❑ Demolition iGlTCZi �L' CO/CC $ Notary $ Double Fee $ Structural Reviews $ Bond $ Bonding Comp?ny's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 approved and a reinspection fee will be Aw#eV--- OWNER or AGENT The foregoing instrument was acknowledged before this day of - 5, e. , 20 by L..! -7e� ZA J I Fs t ally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: MAHARAI K. GONZALEZ OSCC A 9- %)-.eWA hl-D '—=Z Signature CONTRACTOR The foregoing instrum t was ackn wledged before this 7V day of / 20 , by who is oersonagyjg wn to me or who has produced identification and who did take an oath. NOTARY PUBL Sign: r-4e� Print: Iq Z EXPIRES: November2,2020 Seal I F� „; Bonded Thru Notary Public Underwriters +� Seal: 2o�rgy Pup LUIS FERNANDEZ ■�■■ MY COMMISSION # GG 041161 wj o EXPIRES; November T, 2020 9lFOF FLOC Bonded Th. Budget Notary Servkes APPROVED BY Plans Examiner Zoning as (Revised02/24/2014) Structural Review Clerk RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY C4 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD THE ELECTRICAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES HERNANDEZ, OSCAR RAVEN ELECTRIC INC 3913 SW 90TH AVE MIAMI FL 33165-5313 LICENSE NUMBER: EC13005734 EXPIRATION DATE: AUGUST 31,2020 Always verify licenses online at My Florida License.corn Do not alter this document in any form. This is your license. It is unlawful for anyone other than the licensee to use this document. Ei ;M I 'm 13 i I Local Business Tax Receipt Miami —Dade County, State of Florida —THIS IS NOT A BILL — DO NOT PAY I4894722 LBT BUSINESS NAMEMOCATION RECEIPT NO. EXPIRES EXPIR RAVEN ELECTRIC INC RENEWAL SEPTEMB 2019 3913 SW 90TH AVE 510D061 MIAMI, FL 33165 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS RAVEN ELECTRIC INC 196 ELECTRICAL PAYMENT RECEIVED BY TAX COLLECTOR CONTRACTOR 75.00 07/1312018 Worker(s) 1 EC 13005734 CHECK21-18-067549 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commerclal vehicles —Miami—Dade Code Sec Its-276. MIS For more information, visit wwvv miamidade gov/taxcollector /AC.�QRU� CERTIFICATE OF LIABILITY INSURANCE FIDATE(MWDD/YYYY) 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 certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 CONTACT NAME: UNIVISTA INSURANCE UnIVISta Commercial PHONE ALC. No,_Ext)' () ( (A/C 305 228-8988- 305 228-8969 A/C No): ( ) 9880 SW 40th Street E-MAIL 9andecodes@gmail.com Miami, FL 33165 INSURES AFFORDING COVERAGE NAIC # Phone (305) 228-8988 Fax (305) 228-8969 INSURER A : FEDERATED NATIONAL INSURANCE CO INSURED INSURER B : Raven Electric Inc 3913 SW 90 Ave INSURER E : FL 33165 INSURERF: COVERAGES 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. TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE F,/1 OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: ❑ PRO - POLICY ❑ LOC ❑ OTHER AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS ❑ NON -OWNED HIRED AUTOS ❑ AUTOS ❑ UMBRELLA LIAR ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE ❑ DED ❑ RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A G L-0000036316-02 108/06/2018 108/0612019 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) STATE OF FLORIDA # EC 13005734 ELECTRICAL CONTRACTORS CERTIFICATE HOLDER Miami Shores Village Building Department 10050 NE 2nd Avenue Miami Shores, FI. 33138 I ACORD 25 (2014/01) QF CANCELLATION LIMITS EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES (Ea occurrence_ 100,000.00 $ —_ MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 2,000,000.00 BODILY INJURY (Per person) 1 $ BODILY INJURY (Per accident) $ EACH OCCUF AGGREGATE E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE E.L. DISEASE - POLICY LIMIT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PLEASE OUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE r-zv., zz; - - - - - - - - - - - --- - - - - - - - - - - - - - - - - - - - - - - - - - - DEPAWnWElff OF FINANCLAL SERVI= Dr#VUM OF V10FOOMW COMPENSATM IMPORTANT CONSTRUCTM lIKKISTRY EXEnnM F CERYV!r-J= OF WICTION TO aE 0=01r RM FLOMA •wno emu waffoor, mm OC- rilapter by Ong o certificate of *00AXERS' COMPEN"7M LAW election under tau zectior mpy not recover beneft or L camp on wxjw iris dopter. 8:FE:TtVEDATft MMMS EXPIRAYM DATE: 727/D PUMuent to Chapter "O-W12� F-S.. Cerlificateg or eWoftn to PER' 50ft: 03GAR HERNANDEZ ENAL= cAmmammocalra woacom be —npL- apply only QJmn 2A 300pG Of #16 hisiness or tads FWt 46IM518 sled an the notice of election to be exempt.StMUM NAM AND ADDRESS: 1H liE pwwj" to Chapler 44005(1 3} F.&, Notices of election to be and cerfificabas of election to be "mnpt ma be RAVEN ErCr= WC R st 10 MvDcabm ff. at any *no afWr On Ming of V* notice E Gr "m bsuanca of '-w cereficam' Um person na"Ad an r* notice or certificate no kmW rmkm tha rsqA-ww*. of Vft section for il- of cwffmmta. The depam"d 4ia es,,oim MLAA& FL Wledi a certificate at my Urre for fail" of the psfsw. named on the certficate to rneet te raquire"Hwks of this sec1 n. SCOPE Or MOKESS OR TRAM - - - - - - - - - - - - - - - - - - -- - - - - - - - - - -- - - - - - - - - - DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO SE EXEMPT REVISED.G8-13 QUESTIONS? RAVEN ELECTRIC, Inc. Miami October 16, 2018 City Of Miami Shores Village Building Department State Of Florida County Of Miami -Dade Before me this day personally appeared Mr. Oscar Hernandez who, being duly sworn, deposes and says. That he will be the only person working on the project located at: 77 NE 105 street. ectric, inc.d Sworn to and subscribed before me this 16 day of October 2018, By Mr. Oscar Hernandez. SILVIA LEON MY COMMISSION N F 917f17 EXPIRES: FaDruety 17. 3913 SW 90"' Avenue — Miami, Florida 33165-5313 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 �...�•� ,.11 5* • If State of Florida County of Miami -Dade /� The foregoing was acknowledge before me this I(0 day of l�� , 20 18 personally known to me or has produced