ELC-19-107 (2)Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
P L�Dlfw-nj JR
Issue Date: 01/25/2019
Location Address Parcel Number
415 NE 105TH ST, Miami Shores, FL 33138 1122310430010
Contacts
Permit Ala. ELC-01-19-107
Permit Type: Electrical - Commercial
Work Classification: Alteration
Permit Status: Approved
Expiration: 07/ 15/2019
ED H OLLIE 1R &W & MARCIA OLLIE Owner
EDW MCCARTHY-ARCH BISHOP
9401 BISCAYNE BLVD, MIAMI, FL 331382970
Other:3057597750
G-3 ELECTRIC Contractor
GONZALO FERNANDEZ
8770 SW 72 ST, MIAMI, FL 33173
Description: SPECIAL EVENT Valuation: $ 400.00 Ins ection Requests:
TEMPORARY CHURCH CARNIVAL AT ST. ROSE C CHURCH L
j I
1305-762-4949
25 27 2019 Total Sq Feet: 0.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$0.60
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.20
Permit Fee
$50.00
Scanning Fee
$9.00
Technology Fee
$2.50
Total:
$116.30
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$116.30
Credit Card
01/25/2019 $116.30
Amount Due:
$0.00
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 zoning. Futhermore, I authorize the above named contractor to do the work stated.
1 - • .irn ' .A . , A 1 (1 1 - ' - - -
Signature: Owner
/ Applicant / Contractor / Agent
Date
January 25, 2019 Page 2 of 2
4
Miami Shores Village
Building Department BY:
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 j,LECTRIC ❑ ROOFING
CE V D
AN 1 2 9
FBC 20 L
Master Permit No. K I 0 v
Sub Permit No. F L 1 I — 10
❑ REVISION ❑ EXTENSION []RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: //jr /v6- 16!5— 0&1� f
City: Miami Shores County: Miami Dade Zip: 3�
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): ,�(�C%a�!/OBE' O// /8w Phone#:��0
Address: 9yao L��SCoy„e
City: / 7/ /"- State: A Zip:
Tenant/Lessee Name: O�2� Phone#: •SOS ,758 OS3p
Email:
CONTRACTOR: Company Name
Address: Z '
City: tA 1 Ja
Qualifier Name:
State Certification or Registration #: ;V& (�y f) 6?—flp Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address: City: State:
Value of Work for this Permit: $ �� do Square/Linear Footage of Work:
Zip:
Type of Work: ❑
Addition ❑ Alteration
❑ New
❑ Repair/Replace ❑ Demolition
Description of Work:
Y-'-to UY
C QL"(ZG-
Gfl{tr./i v►"
L,
C ; j�c,: i� ��
Ali` �►A,►y•
2S Z-7 , 7_01 G
Specify color of color thru the:
Submittal Fee $ Permit Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
CCF $ CO/CC $
DBPR $
Notary $
Double Fee $
Bond $ `
TOTAL FEE NOW DUE $ 1
(Revised02/24/2014)
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. 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 charged. W
Signature Signature
OW R or AGENT CONTRACT
The foregoing instrument was acknowledged before me this The foregoing instrument was ackno edged before me this
-� 1a day of :JA N V R f -�I,/20 J by I i day of ►vy v" ,20 1 by
Wu4-4+-G Y
r,,-1Sf6i2 E►r�Z rat3�` 1J who is personally known to Ga,,,ti.r+�o �c'R-t✓p"ncz who is personally known to
me or who has produced RtfAS0rj,.L2 X KA,6-)11/as me or who has produced as
identification and who did take an oath. iden
NOTARY PUBLIC: NO R CNotary Public State of Florida
Rita Baron-Wr issey
_ My Commission GG 13W2
Expires 12t27I2021
Sign: Sign. o!
Print: R n ... z L. M6X —tr C Print: it-%,rN 6jq-2byJ-
Seal: ,;,W , BRML"RIMY Seal:
Commisdott 0 00 26"
Expksa Jsmsty 4, 2023
c�Of fvo�@ eaa.a tlrvluep�t Nobar sewk.s
APPROVED BY 0 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
-ELECTRICG 3 Corp
8724 SW 72 Street #449 Maimi, FL 33173
EC130006290
Date: 01/09/19
State of Florida
County of Miami —Dade
Before me this day personally appeared 60rvZ '%'-D Fc P-P--N06Z who, being duly sworn,
deposes and says:
That he or she will be the only person working on the project located at:
S r) ros ig ar- Lim n z4icx vv c i v S s�'Y2( a
Sworn to (or affirmed and subscribed before me this 9T44 day of .209,
by 8�')� "
Personally know6
OR Produced Identification
Type of Identification Produced
BRIAN L MORRISM
CowAssion 0 GO 255855
EwVos,January4, 2023
Print, Type or Stamp of Notary
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
114011ce 1U owner — VVUrKers %..ompensauun insurance exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. y 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 'PHIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
O
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of ,"1 1_ (.t k.r' 20�.
By S{� �/ t z(1� Ulm' (eq who is personally known to me or has produced
nn as identification.
Notary:
KA`r'HLEE +i M BOST
SEAL: MY COMMISSION l: FF216826
EXPIRES April 02. 2019