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ELC-19-1566Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Issue Date: 07/25/2019 Permit NO.: ELC-07-19-1566 Permit Type: Electrical - Commercial Work Classification: Alteration Permit Status: Approved Expiration: 01/06/2020 Location Address Parcel Number Project 9723 NE 2 AVE, Miami Shores, FL 33138 1132060134210 NE 2 AVE SEWER CONNECTION Contacts GATOR 9723 NE 2ND AVE, LLC Owner GATOR 9723 NE 2ND AVE, LLC Applicant 1595 NE 163 ST 1595 NE 163 ST GOLDEN ELECTRICAL CONTRACTOR LLC Contractor GLAUBERT REGALADO 19407 NW 82 CT, MIAMI, FL 33015 Business: 9545123848 Inspection Requests: Description: INSTALLATION OF NEW SERVICE 100 AMP, NEW Valuation: $ 4,000.00 Inspec ion Re METER, NEW MAIN AND DEDICATED LINE FOR LIFT STATION 49 REMOTE. Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $2.40 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.80 Permit Fee $70.00 Scanning Fee $3.00 Technology Fee $3.00 Total: $133.20 Payments Date Paid Amt Paid Total Fees $133.20 Credit Card 07/25/2019 $83.20 Credit Card 07/09/2019 $50.00 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 information is accurate and that all work will be done in compliance with all applicable laws regula oning. Futhermore, I authorize the above named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Date July 25, 2019 Page 2 of 2 Miami Shores Village 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 X ELECTRIC ❑ ROOFING RECEIVED ik 0 9 2019 BY: (0 k FBC 20 1=i Master Permit No. C�jT �I oce Sub Permit NO.En o� G I t-1 9do ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: aT 2S 0 E 2 AoF- City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): (iA'1-01L gZ25 0E 2 AUE Phone#: Address: `IW"�,O K)W l4(0 4j City: IMLCuOK ( LA (LDS State: 14:L. Zip: !1301(o Tenant/Lessee Name: Phone#: Email: M4/AJL62 0E—L- 94 _ ciR7V %L1 t4 U . CC.+rt/^._ U/� CONTRACTOR: Company Name: 6O! q�&1,C &eJ21) a ft1A',6(9,A ✓Phone#: O O (E � d Address: 9a City: State: Zip: 3 3 O AF Qualifier Name: Q o—o r3.ewt Rg::�) c, Phone#: �� 2 3 7 Y State Certification or Registration #: IFM % 3 DESIGNER: Architect/Engineer: Certificate of Competency #: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ I�0�� Square/Linear Footage of Work: Type of Work: ❑ Addition r) ❑/ /Alteration ES New ❑ Repair/Replace ❑ Demolition Descriptionof.Work: 1s�0.lCt�L�?'t- �'¢vt7W( r'�lQ0'i��J'' Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ e-3' ZQ (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: that Asa co flition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection w ich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be b roved and a reinspection fee will be charged. Signatu OWNER or AGENT The foregoing instill ment was acknowledged before me this day of �C r 20 1 -5 by me or who has produced identification and who did take an oath. NOTARY PU Sign: Pri nt: Seal: Mike Vazquez Bonded Thru Alaw Notary as 'A Signature CONTRACTOR The foregoing instrument was�cknowledged before me this _day of r`,.�,( 20 12 by �-� i G� � W- ho i c n ersonaIIy known tQ� me or who has produced as identification and who did take an oath. NOTARY PUBLIC: ike Vazquez Sign:M� Print: EM15,�. Seal: ****�s��:s***��*��**»***�s**ss*+�s*****��«*.*«���ss►********r******�.*�*********s***.*****s*s**.*****.*sr*.** APPROVED � ld ,rUl V/ Z?Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ACORV CERTIFICATE OF LIABILITY INSURANCE 11I,a/ DATE(MMIDD/YYYY) 1 06/19/2019 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(les) 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 (786) 573-4485 (786) 573-4486 Insurance NOW Agency 12915 SW 132 Street suite 4-13 Miami, FL 33015 NAMEA T Stephanie Garcia °Hc°N o 786 573-4485 FAX No): 786 573-4486 n o less: stephanie@insurancenowagency.com PRODUCCUSTOMER R ID INSURERS AFFORDING COVERAGE NAIC # INSURED Golden Electrical Contractor, LLC 19407 NW 82nd Court Hialeah, FL 33015 INSURER A: Western World Insurance Company INSURER B : INSURER C: INSURERD: INSURER E : INSURER F : 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. INSR LTR TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $300.000 A COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $100,000 MED EXP (Any one person) $5,000 CLAIMS -MADE F✓ OCCUR I PERSONAL & ADV INJURY 000,000 PLLDQ-G 6/5/2019 6/5/2020 GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $300,000 ✓POLICY PRO- LOC BI/PD Deductible $ 500 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Pet accident) $ SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) $ F $ NON -OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HEXCESS AGGREGATE $ LIAB CLAIMS -MADE DEDUCTIBLE $ $ RETENTION S WORKERS COMPENSATION I WC STATU- DER EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) License #.EC13008451 _cM r rrwn r V_ nvLvcrt ODU r UU OU f L VPIIYVCLLA I IUIY Miami Shores Village Building Department 10050 NE 2nd Ave 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 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD GOLDEN ELECTRICAL CONTRACTOR, LLC 19407 NW 82 CT. MIAMI, FL. 33015 W 954-512-3848 glaubertregalad ojr«gmail.com 6/25/2019 State of Florida County of Miami Dade Before me this day personally appeared Glaubert Regalado Jr. who being duly sworn depose and says from Golden Electric Contractor, LLC. That he will be the only person working on the project located at 9723 NE 2 ave, Miami Shores, Fl. Contractor Signature Sworn to (or affirmed and subscribed before me this _25_ day of dune , 2019 Personally kt / or Produced Id =�-t4 ary Public State o' Florida lye ChirinoPrint, Type or stamp of Notary Commission CG +35?ires 00113124'tn 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" L;omaensation Insurance txemation 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 -rime 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 staring 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 AC WLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. II Si CaCp ur 6(112 $Z State of Florida J ­Scw" County of Miami -Dade Y The foregoing was acknowledge before me this day of 0,0_ , 20-ft_. By -N_rAA" %. ( who isRersonally known to me or has produced as identification. Notary: Notary Public State of Florida +� SEAL: Leslye Chirino My Cort Tliftion GG 1357 4 Expires O6/13/2020