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EL-18-1667Permit No. EL-6-18-1667 `gµOREs yt Miami Shores Village Permit Type: Electrical - Residential 10050 N.E. 2nd Avenue NE Per �It Work Classification: Alteration Miami Shores, FL 33138-0000 l Permit Status APPROVED Phone: (305)795-2204 't�oRi"vA Issue Date: 6122/2018 1 Expiration: 12/19/2018 Project Address Parcel Number Applicant 1280 NE 102 Street 1132050220030 Miami Shores, FL 33138-2618 Block: Lot: MARK & DENISE JUANICO Owner Information Address Phone Cell MARK & DENISE JUANICO 1280 NE 102 Street MIAMI SHORES FL 33138-2618 1280 NE 102 Street MIAMI SHORES FL 33138-2618 Contractor(s) Phone Cell Phone LG4 INC (954)681-5866 e of Work: INSTALL NEW SOCKETS IN KITCHEN TO C itional Info: INSTALL NEW SOCKETS IN KITCHEN TO C ,sification: Residential nning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $1.20 $2.25 $2.00 $0.40 $150.00 $3.00 $1.60 $160.45 Valuation: $ 1,950.00 Total Sq Feet: p Pay Date Pay Type Amt Paid Amt Due Invoice # EL-6-18-67965 06/18/2018 Credit Card $ 50.00 $ 110.45 06/22/2018 Credit Card $ 110.45 $ 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 certV that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Fu rmore authorize the above -named contractor to do the work stated. i June 22, 2018 AuthorizVC gnature:Owner / Applicant / Contractor / Agent Date Buildingpartment Copy June 22, 2018 1 Miami Shores Village j JUN 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 ❑BUILDING ETfLECTRIC ❑ ROOFING FBC 200 Master Permit No. rc `U—Ut Sub Permit No.ZUS I� I ❑ REVISION ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CONTRACTOR JOB ADDRESS: ( 7_ NJ 11-7 `y7— h k SV ❑ EXTENSION [—]RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Miami Dade Zip: !�\3,6 Folio/Parcel#: Is the Building Historically Designated: Yes NO - Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: nWNFR• Alama Iran Cimnla TitlahnlrlarL• MC'il(+ Phone#: V S51', Address: 12, Of 0 1114:' A) Z Sb`ems City: ,5Aa,,-es State: Zip: 33�38 Tenant/Lessee Name: Phone#: 7,r6 -Z 2- 3J'Y 01 Email: id4 41 1 Ve-I C?Gi.60 CONTRACTOR: Company Name: 116 4 �Phone#: Address: 7 � Clet44"� t'a'11 � City: Qualifier Name L —bal.l State Certification or Registration #: � 4-6gl - S-.f6( Ft" Zip: 3a- / 11(1 !a/ Phone#: a/S` - 6?10 - 1116� Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address City: State: Zip: Value of Work for this Permit: $ l 9.r0, U Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New l / ❑ Repair/Replace ❑ Demolition Description of Work: I bl5) .lt I�ecr/ Sd 6,GeA //�-r le-ITA en /v JG0� a [�� per. L✓✓Q.�/ I°'1 i s �� 11 6h2t11C �sG�Cri J.�j �G Gce L e , Qj%C GZ-1 h-G`r✓�� L Specify color ofcolorthru tile: Submittal Fee $ So a I 4 Permit Fee $ Scanning Fee $ Technology Fee $ Radon Fee $ 3 o" 0 0 CCF Training/Education Fee $ DBPR $ CO/CC $ Notary $ Double Fee $ Structural Reviews $, (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $__ _I l0. `-S Bonding Company'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. 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..... 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 charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this day of U>rre 20 10 by Mo%r T. Aq q O '''jj��who is personally known to me or who has duced — iy`Q r I C�.>r� 'e as did take"Ian oath. Print: U LAAhQS� T 1 Seal: gDYPRIETO Y�c vYgN ` MY COMMISSION # FF214031 -As EXPIRES: March 25, 2019 Bonded Thru Notary Public Undervolo,s ************** The foregoing instrument was acknowledged before me this �^^ day of 1 C 1n it , 20 ) Y by II L1� �AreY , who is ersonally known me or who has produced as identification and who did take an oath. NOTARY PUBLIC: ;g�iV%.,,�, Andrea Perez �r= Commission # GG179W �z Expires: January 28, 2022 Sign: '�; c`'Bonded thru Aaron Notary Print: r Yc) � Z Seal: ************************************************************* APPROVED BY J21a /6 Plans Examiner Zoning Structural Review (Revised02/24/2014) Clerk STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD ,� 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 GARTNER, LOUIS WINTER IV LG4 INC. 7 EASTLAND LANE PALM COAST FL 32164 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the -regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! (850) 487-1395 STATE OF FLORIDA F DEPARTMENT,'OE BUSINESS AND y `• - ' PROFESSIONAL REGULATION +f EC13006863 .: +- �;isSUED: '12/01/2016 , { CERTIFIED ELEGTRICA .COkl FZACTOR GARTNER, LOUIS'WINs ER-IV�: -`•: LG4 INC. { IS'CERTIFIED uriderthe-provisions of Ch.489 FS. _ t Expiration date : AUG 31, 2018 L1612010001526 — v - r4kf�.• .� DFTn(G.". ER F -- -- RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD EC13006863 The ELECTRICAL -CONTRACTOR `- Nanied,below IS CERTIFIED- ,-Under.th&'.provisions of Chapter 489 FS. Expiration date:'-AUG 31, 2018 ` GARTNER,-.LO.UIS IN NTER'IV, o-- ^ � - 7 EASTLAIVD LANE' -PALM`COAST ,, - FL32-164.: ''.air .r`.+! .r� � l i '' ♦ � �, h '� I(• '� f� �}, y+ � t �� .� q4i �. �-tw...�.....c.�,.0 - �"'� �!'� — _ ._--... +— ��j.�_.—.....��.f:.-.r ..-..i21..... �". i..^.. - �.-�.--�.� .»�1.�`\4� la,.s..��".s....>• ISSUED: 12/01/2016 DISPLAY AS REQUIRED BY LAW SEQ # L1612010001526 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2017 THROUGH SEPTEMBER 30, 2018 DBA: 7815 LG4 INC Receipt #:EL CTRI CAL/ALARMS/CONTRACTOR Business Name: Business Type: (CERTIFIED ELECTRICAL CONTRACTORI Owner Name: LOUIS WINTER GARTNER IV Business Opened:12/04/2017 Business Location: 7 EASTLAND LN State/County/Cert/Reg:EC13006863 OUT OF COUNTY Exemption Code: Business Phone: Rooms Seats Number of Machines: Employees 1 For Vending Business Only Machines Vending Tvoe: Professionals Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: LG4 INC 7 EASTLAND LN PALM COAST, FL 32164 2017 -2018 Receipt #20C-17-00000444 Paid 12/04/2017 27.00 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2017 THROUGH SEPTEMBER 30, 2018 DBA: LG4 INC Receipt #: 181-287815 Business Name: Business Type: ELECTRICAL/ALARMS/CONTRACTOR (CERTIFIED ELECTRICAL CONTRACTOR) Owner Name: LOUIS WINTER GARTNER IV Business Opened: 12/04/2017 Business Location: 7 EASTLAND LN State/County/Cert/Reg: EC 13 0 0 6 8 6 3 OUT OF COUNTY Exemption Code: Business Phone: Rooms Seats Employees Machines Professionals 1 Signature For Vending Business Only Numlx,r of Machines' Uanrlinn Tvrw• Tax Amount I Transfer Fee I NSF Fee I Penalty Prior Years Collection Cost I Total Paid 27.001 0.001 0.001 0.00 0.00F 0.00 27.00 Receipt #20C-17-00000444 Paid 12/04/2017 27.00 Client#: 27619 LG41NC ACORV,,, CERTIFICATE OF LIABILITY INSURANCE DIYYYY) =01 8 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: 0RTAf: if - thi . e certificate holder is an ADDITIONAL INSURED, the policy(ies) must . be endorsed. If SUBROGATION IS WAIVED, subject t I o 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 enclorsement(s). PRODUCER Jeanne Bender NAME: Cypress Insurance Group (COM) . FPHONE ... ........ . . . ....... .. . .. . ........... . — - F . AX - --- . ........ . ... ........ . . ....... LAIC, No, ,,,1: 954 771-0300 [AJC No,: 954 772 9424 .. ...... ...... . ....... PO Box 9328 E-MAI L Fort Lauderdale, FL 33310-9328 ADDRESS: certs@cypressinsurance.com - ----------- - INSURER(S) ............... ... ..... . .. .. ................ ................................. 954 771-0300 AFFORDING COVERAGE NAIC # Ohl. Security Insurance Company A INSURED LG4, Inc. 7 Eastland Lane Palm Coast, FL 32164 INSURER B i INSURER C: INSURER E: 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 CONTRACTOR 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 TYPE OF I SUM LTR INSURANCE ADDL . ...... JNSR WVD POLICY NUMBER ........... 1-1---.111-1-1 .................. ............. POLICY EFF POLICY EXP LIMITS (MM/DDfYYYY). IMMID ................ - .......... A X COMMERCIAL GENERAL LIABILITY BLS57282880 04/18/2018 04/18/2019 EACH OCCURRENCE $1,000,000 CLAIMS-10ADE X. OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) j300,090 10ED EXP (Any me person) $15,000 PERSONAL.& ADV INJURY $1,000,000 ............ ................... GEN1. AGGREGATE. LIMIT APPLIES PER'. GENERAL AGGREGATE s2,000,000 PRO - POLICY JECT LOC ........... . PAGG I RODUC TS -COMPiO ............ - .................... ............... ..... . ............ ..... - .................................... - ............. - 52,000,000 OTHER AUTOMOBILE LIABILITY ........ .... . . CONIBINED SINGLE LIMIT Ea accident)ti BODILY INJURY (Per person) ANY AUTO ALL OWNED SCHEDULED S BODILY INJURY Per acodent) S AUTOS OS NON -OWNED PROPERTY bAmm;ff $ HIRED AUTOS [ : .(Peraccident) .......... .... ........ . .... . .............. .......... ........ ........... ..... UMBRELLA LIAR i OCCUR ................. .................................. .......... ........ ..................... .......... 11.1 ............ EA.. I OCCURRENCE $ AGGREGATE EXCESS LIAR CLAIMS-NIADEi DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN .... . ......................................... ANY PROPRIETORIPARTNERIEXECJTIVE.---i E.L.'PACHACCIDENT S 0 'ERIMEMBER EXCLUDED? N/A FFIC ................ (Mandatory in NH) I-E.L. Fr, EMPLOYEE $ If yes, describe tinder DESCRIPTION OF OPERATIONS beluw E.L. DISEASE - POUCYLIM.-IT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Electrical Contractor - Louis Gartner - License #EC13006863 Village of Miami Shores Bldg Dept. 10050 NE 2nd Avenue Miami, FL 33138 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 REPRESENTATIVE @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) 1 of I The ACORD name and logo are registered marks of ACORD #S266348/M263662 JBB JIMMY PATRONIS CHIEF FINANICAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 3/21/2018 PERSON: LOUIS W GARTNER FEIN: 550898505 BUSINESS NAME AND ADDRESS: LG4 INC. 7 EASTLAND PALM COAST, FL 32164 SCOPE OF BUSINESS OR TRADE: Licensed Electrical Contractor EXPIRATION DATE: 3/20/2020 EMAIL: ELECTRIKONE299AOL.COM IMPORTANT: Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 LG4 Inc. Electrical Contractors 7 Eastland Lane Palm Coast, FI.32164 EC #13006863 June 5th, 2018 State of Florida County of Broward Before me this day personally appeared Louis Winter Gartner IV, who, being duly sworn, deposes and says: That he will be the only person working on the project located at 1280 NE 102"d St. Miami Shores, FI. 33138. SworMtoo�r affirme ) and subscribed before me this 6th day of June, 2018 by: S � �� _ey Personally know 1V ft, Andrea Rem , 0, Commission I GG179W Expires: January 28, 2022 ...... Bonded thru Aaron Notary Print, Type or Stamp Name of Notary Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 1vUL1ce LU owner — worKers Compensation insurance txemption 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 CONTENWer Signature: State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of , 20D_. BY � ► 5 q �YACY who is �o me or has produced as identification. O Notary: �.�i�s;�d��, Andrea Perez SEAL: I `1 C, C� !� • Commission # GG179644 1 ; �•,, Expires: January 28, 2022 �0',4'�Fl.d�;�. Bonded thru Aaron Notary