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EL-19-131Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 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 02/06/2019 $61.10 Credit Card 01/17/2019 $50.00 Amount Due: $0.00 Building Depa ment Copy In consideration of the issu nce to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in stict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this perrmit 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 Ortify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating �,onst�t n and zoning. Futhermore, I authorize the above named contractor to do the work stated. ature: Owned / Applicant / Contractor / Agent Date February 06, 2019 Page 2 of 2 Miami Shores Village RECEIVED BUILDING PERMIT APPL ❑BUILDING Building Department j N 17 20193 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 3y. . Tel: (305) 795-2204 Fax: (305) 756-8972 _,1 i_ INSPECTION LINE PHONE NUMBER: (305) 762-4949 TION IC ❑ ROOFING FBC 20 1 1 Master Permit No.�T_P \ 9 V 3� Sub Permit No. ��--1 q ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: i N /-) ?-.,/ a% 2 1 Occupancy Type: OWNER: Name (Fee Si Address:_-.. 01 A) City: Tenant/Lessee Name: Email: CONTRACTOR: Compa Address: t Li Z City: X ! &t--f / Qualifier Name: l State Certification or R DESIGNER: Architect/E Address: Value of Work for this Type of Work: ❑ Description of Work: _ ,6 q - d (C( - 06 2 0 Is the Building Historically Designated: Yes NO 'A'o-atl: Construction Type: Flood Zone: BFE: FFE: le Titleholder): GG� rJ7i'1'� -file, U) h4__ Phone#: 2 5 quo J 0 � 2 State: _fA_ Zip: /3 Phone#: Name: *i -1%UA-a Phone#: 706 Z S< < T St� K P�A:"k Z 2 State: Zip: Phone#: istration #: 3 0G b 3 f Certificate of Competency #: ineer: Phone#: City: State: Zip: !rmit: $ � � 0Square/Linear Footage of Work: dition ❑ Alteration New ❑ Repair/Replace ❑ Demolition Specify color of c#lor thru tile: Submittal Fee $ Scanning Fee $ _ Technology Fee $_ Structural Reviews Permit Fee IS Radon Fee $ DBPR $ _ Training/Education Fee $ CO/CC $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ I I 0 (Revised02/24/2014) y t Bonding Company's Nam (if applicable) Bonding Company's Addr ss City State Mortgage Lender's Name (if applicable) Mortgage Lender's Add City State Zip Zip Application is hereby ma a 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: Iertify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulatingconstruction and zoning. "WARNING TO NER: 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 4 1 condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith th t a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subjec to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection hich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be apiroved and a reinspection fee will be charged. Signatu NER or AGENT The foregoing instrument was acknowledged before me this a--01— day of LAA4� 20 � by who is p onal y knn to me or who has prod identification and M NOTARY P Sign: Print: Seal: did take an oath. COMMISSION II GG 159953 I•rF.�.F1�:°P••GwledThru EXPIRES: March 1Z, 2022 NoWy PLM WC #*n APPROVED BY as Signature CONTRACTOR The foregoing instrument was acknowledged before me this day/of ✓-'/ 20 by who is p rsonall wn to me or who has produced as identification and who did take an oath. NOTARY Sign: Prins MY COMMISSION # GG 159953 EXPIRES: March 12, 2022 Bonded Tivu Wary Pubk Under� Plans Examiner Zoning (Revised02/24/2014) Structural Review Clerk Miami shores Village Building Department CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY B. COPY )-COPY QUALIFIER'S STATE LICENCES LOCAL BUSINESS TAX RECEIPT LIABILITY INSURANCE* 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 D. COPY �F WORKERS COMPENSATION INSURANCE* (W rkers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR AS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY F CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY F LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CON RACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY BUSINESS NAME: BUSINESS BUSINESS PHON WORKERS COMPENSATION INSURANCE* Drs Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. �05eC4eJ/%C- Cori I (0 Z3 c i 5 9 1Valk CITY " � /-k / STATE ZIP 3 ( gyp ) I-q � I l S 4- • FAX NUMBER (-) CELL PHONE QUALIFIER'S NAME: 40s t QUALIFIER'S LIC UMBER: 0 3C-- ©O C) g 3 8' I RICK SCOTT. GOVERNOR JONATHAN ZACHEM. SECRETARY Fl di a opr STATE OF FLORIDA ARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL -CONTRACTORS -LICENSING BOARD THE ELECTRICAL CONTRACTOR HEREIN'15 CERRAED UNDER THE PROVISICAlS OF,CHAPTER 489, FLORIDA STATUTES 6' �., 1 Vk A, YOSEF `� �l YOSEFVAR ELECTRIC CORP. 14623 SW 158TH PATH MIAMI- FL 33196 ti Y 2 t J LICENSE NUMBER EC13006793 EXPIRATION DAT :`AUGUST 31, 2020 Always verify licenses online at MyFloridaLicense.com 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. OM39 Munic pal Contractor"sReceip M4 mI-Dade County, State of Florida -TH:S IS NOT A BILL - DO NOT PAY MCI 5084728 BUSINESS NAMEMOCATION RECEIPT NO. EXPIRES y� r YOSEFVAR ELECTRIC CORP NEW SEPTEMBER 30, 2019 14623 SVJ 158TH PATH 7550813 Must be displayed a; place of businc311 MIAMI FL 33196 Pursuant to County Code Chapter BA - Art. 9 & 10 SEC. TYPE OF BUSINESS OWNER MMC ELECTRICAL CONTRACTOR PAYMENT RECEIVED YOSEFVAR E ECTRIC CORP BY TAX COLLECTOR 03EO00438 $200.00 09/21/2018 Category() 1 FPPUIO-18-019045 Tt Is Local Business Tax Receipt only confirms payment of the local Business Tax. The Receipt is not a license, p rmit, Ora certification of the holder's qualificat.':ns, to do business. Hader Must comply with any governmental o nangovernmerrtai regulafarylaws aed nGuiremeMawhich apply to tha business. The RECEIPT NO, above must be displayed on all commercial vehicles- Miami -Dade Code Sac an-276. For more information, visit yyyq�v mi�iEgQttgcvPsxc311ac_�a 003MA Lora Business Tax Receipt Nl mi-Dade County, State of Florida -THIS IS NOT A 811. - DO NOT PAY 5084728 BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES YOSEFVAR ELECTRIC CORP RENEWAL SEPTEMBER 30, 2019 14623 SVI 158TH PATH 5311170 Must bo displayed tt F.;ace of business MIAMI FL 33196 Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED YOSEFVR.R ELECTRIC CORP 196 ELECTRICAL CONTRACTOR BY TAX COLLECTOR 03EO00438 S75.00 09/21/2018 Worker(s) 7 FPPUIO-18-019045 Th s Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, Fe -mit. er a certification of the holder's que2ications, to do business. Holder must comply wit.4 any goveramental at "governmental regu!atory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - M:3rei-Dade Code Sec 6a-276. For more information, visit mOq damillf. yoyfxx ^tc ac'ol .A� CERTIFICATE OF LIABILITY INSURANCE DAT10/08/D/18 10/08/2018 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()es) 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 INSUREOLOGIST, INC CONTACT tearina peralta NAME: FAX rN : 0 78-6241-2780 (A/C No): (786) 999 0909 E-MAIL Tinsureologist@gmail.com 14707 S DIXIE HWY #105 INSURERS AFFORDING COVERAGE NAICx Miami, FL 33176 INSURER A: ASCENDANT 13683 Phone (786) 241-2780 Fax (786) 999-0909 INSURED INSURER B : INSURER C : YosefVar Electric Corp' INSURER D : 14623 SW 158 Path MIAMI FL 33196- INSURER E : INSURERF: t'-AVFRAGFS CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE INDICATED. NOTWITHSTANDIIS CERTIFICATE MAY BE ISSUED EXCLUSIONS AND CONDITIONS POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD G ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCII ADDL INSR BR WVD POLICY NUMBER POLICY EFF MM/DD/YYY_ POLICY EXP MM/DD/YYY LIMITS q ❑/ COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE k OCCUR Y GL-539931-2 10/06/2018 10/06/2019 EACH OCCURRENCE $ 1,000,000.00 DAMAGE PREM SEa occ ES urrrrence $ 100,000.00 IVIED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 GENL AGGREGATE LIMIT APPLIES ❑ POLICY ❑ jE ❑ OTHER PER: LOC GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 1,OW,000.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ AALL UTOS OWNED ❑ SCHEDULED AUTOS NO ❑ HIRED AUTOS ❑ AUT ❑ ❑ -OWNED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ ❑ UMBRELLA UAB ❑ ❑ EXCESS LIAR ❑ ClIMS-MADE CUR EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTN OFFICEWMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N CUTIVE❑ kwv N/A ❑ STATUTE ❑ OTH- ER_ EL. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ EL. DISEASE -POLICY LIMIT g DESCRIPTION OF OPERATIONS/ LOCATIONS CC # 03E000438 EC # EC1300679 / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CFRTIFICATF H(N nFR I CANGELLA IIVN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Avenue Miami Shore, FL 3 138 AUTHORIZED REPRESENTATIVE T. Peralta ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) OF The ACORD name and logo are registered marks of ACORD WE JEFF ATWATER CHIEF FINANICAL OFFICE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * CONSTRUCTION IN This certifies that the EFFECTIVE DATE: 6/ PERSON: VARONA FEIN: 1342454� BUSINESS NAME ANI YOSEFVAR ELECTRI 14623 SW 158 PATH MIAMI SCOPE OF BUSINEc Licensed Electrical Contractor 'RY EXEMPTION dual listed below has elected to be exempt from Florida Workers' Compensation law. 17 EXPIRATION DATE: 6/5/2019 ADDRESS: CORP. L 33196 OR TRADE: Electrical Wiring Within Buildings and Drivers YOSEF 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 benefi s 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 o 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 ce ficate 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 he 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 County of: Before me this day and says: Swom to (or A rsonally appeared _ `/ i� S �° /— V Q who, being duly swom, deposes e onI erson working on a project located at subscribed before me this 15 day of T IL n t1 CL!! , 20_L� by ersonally know OR Produced Identification Type of Identification Produced EVia; AYLEEN CARRERA *: *_ MY COMMISSION # GG 159953 EXPIRES: March 12, 2022 '� gqR n Boded Th. Notary Public lhtd.,*Iea Print, Type or Stamp Name of Notary vjo� e F UQr'on� Notice tolOwner — Workers' Corn Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 nsation Insurance Exemption Florida Law requires orkers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate office s in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building pe mit. 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 empl yees, 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 exem t 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 alloy d 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 requ sting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor, part-time em loyees 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 BELACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of A) 0 �'t'Y , 20 By lA /i qi IL who i ersonall wn to me or has produced as identification. Notary: SEAL: _ • = MY COMMISSION # GG 159%3 o: EXPIRES: March 12. 2022 "�fF�.. °`�'� Bonded Tlxu Notary PubAc Underwriters