EL-17-1475 (2)RECE, VE0
Miami Shores Village JUN 0,9 1017
Building Department t�
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 7568972
INSPECTION LINE PHONE NUMBER. (305) 762-4949 FBC 20 11-1
BUILDING Master Permit No. LA —I
PERMIT APPLICATION Sub Permit No. I 1-i -I'S
F-1BUILDING � ELECTRIC F1 ROOFING ❑REVISION n EXTENSION []RENEWAL
MPLUMBING MMECHANICAL MPUBLICWORKS MCHANGE OF [:]CANCELLATION M SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 278 NE 1 03rd Street,
City: Miami Shores County: Miami Dade zip:
Folio/Parcel#: 11-3206-013-4860 Is the Building Historically Designated: Yes _ NO
Occupancy Type: _ Load: Construction Type: Flood Zone, — BFE: FFE:
OWNER: Name (Fee Simple Titleholder): HB GROWTH PROPERTIES LLLP Phone#: 954-774-4616
17071 W DIXIE HWY
City: MIAMI
State: FLORIDA zip: 33160
Tenant/Lessee Name: Vacant Phone#: -
Email:
CONTRACTOR: Company Name-, K & L Electrical Service Corp. Phone#: 305-380-0512
Address: 447 NW 61st Avenue
City: Miami State: Florida Zip: 33126
Qualifier Name: Jorge M. GrunPhone#: 786-354-6816
State Certification or Registration #.- E R 13014717 Certificate of Competency#: 12E000I 07
DESIGNER: Architect/Engineer: Phone#:
Address: —City: State: — Zip:
Value of Work for this Permit: 59 2200.00 Square/Linear Footage of Work:
Type of Work: D Addition HN Alteration F-1 New
Description of work: Ar- Work based on provided plans.
Specify color of color thru tile:
F-1 Repair/Replace 0 Demolition
Submittal Fee $ rmit Fee &I 14-�" cf CCF $ C cc$
Scanning Fee $ Zadon Fee $ DBPR $ Notary
Technology�Train' Training/Education Double Fee $
StruCtuReVlewc S_ Bond $
TOTAL FEE NOW DUE $
:_5 .07
(RevisedOZ124/2014)
Bonding Company's Name {if applicable}
Bonding Company's Address
City
State Zip
Mortgage Lender's Tame (if applicable)
Mortgage Lender's Address
City State 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.
Signatur Signature
CONTRACTOR
The foregoing instrume 11
was acknowledged before me this The foreg ' g instrument as ackr owledged before me this
day of 20 �� . by ay of 20 by
w s persona kno who ' p nna y know
me or who has produced as me or w o has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC:
Print:
w0o
nor l tJMMI5SI0N #FF991944
Seal EXPIRES: MAY 12, 2020
Bonded through 1st State Insurance
*s****s*s*•**ss**ss**sssss**ss**sssss**s******s*s**s*ss*�s***s**ss******ss********ss*s*s***s*ss*ss*ssssss**
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02124120141
�` yNOR �S `ItY
FLORtOp'
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit ivo. EL-6-17-1475
Permit Type: Electrical - Residential
t Per�',' Work Classification: Addition/Alteration
Permit Status: APPROVED
Issue Date: 12/20/2017 Expiration: 06/18/2018
Project Address Parcel Number Applicant
278 NE 103 Street 1132060134860
Miami Shores, FL 33138-2431 Block: Lot: HB GROWTH PROPERTIES LLLI
Owner Information Address Phone Cell
HB GROWTH PROPERTIES LLLP 17071 W DIXIE Highway
NORHT MIAMI BEACH FL 33160-
17071 W DIXIE Highway
NORHT MIAMI BEACH FL 33160-
Contractor(s) Phone Cell Phone
K&L ELECTRICAL SERVICES CORP (786)354-6816
e of Work: WORK BASED ON PROVIDED PLANS
itional Info:
>sification: Residential
nning: 1
Fees Due
Amount
CCF
$5.40
DBPR Fee
$3.38
DCA Fee
$2.25
Education Surcharge
$1.80
Penalty Fee
$100.00
Permit Fee - Additions/Alterations
$225.00
Scanning Fee
$3.00
Technology Fee
$7.20
Work without Permit Fee
$225.00
Total:
$573.03
Valuation: $ 8,200.00
Total Sq Feet: 0
Pay Date Pay Type Amt Paid Amt Due
Invoice # EL-6-17-64185
12/20/2017 Check #: 5141 $ 573.03 $ 0.00
Available Inspections:
Inspection Type:
Final
Meter Box
Alteration
nge
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, M ANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFI certify t all the foregoing m rmation is accurate and that all work will be done in compliance with all applicable laws regulating
constr n and zoning. F rmore, I authorize t ove-named contractor to do the work stated.
December 20, 2017
A orl Signature: Owner / Applicant / ractor / Agent
Buil ing Department Copy
December 20, 2017 1
FV(4qy"-e �' th
aJ
.- LJL 1l11,i 11 I ILI\L.
RICK SCOTT. GOVERNOR
KEN LAWSON. SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD
The ELECTRICAL CONTRACTOR
Named below HAS REGISTERED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2018
(INDIVIDUAL MUST MEET ALL LOCAL LICENSING
REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA)
CRUZ, JORGE MICHAEL
K & L ELECTRICAL SERVICES, CORP.e, ,
447 NW61AVEOWN
MIAMI FL33126
ISSUED 07i20i2016 DISPLAY AS REQUIRED BY LAW sEQ # L1607200001615
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
a"
DIVISION OF WORKERS' COMPENSATION
sy`�►':
CONSTRUCTION INDUSTRY
'
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW
--_
EFFECTIVE: 06/30/2015 EXPIRATION DATE:
06/29/2017
PERSON: JORGE M CRUZ
FEIN: 453662567
BUSINESS NAME AND ADDRESS:
K&L ELECTRICAL SERVICES CORP
447 NW 61 AVENUE
MIAMI, FL 33126
SCOPE OF BUSINESS OR TRADE:
1- LICENSED ELECTRICAL CONTRACTOR
IY
IMPORTANT
OPursuant to Chapter 440.0504i, F.S., an officer of a corporation who
elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chapter.
Pursuant to Chapter 440.0502), F.S., Certificates of election to be
H exempt... apply only within the scope of the business or trade listed on
E the notice of election to be exempt.
R
E Pursuant to Chapter 440.05031, 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.
CUT HERE
QUESTIONS? (850) 413-1609
* Carry bottom portion on the job, keep upper portion for your records.
OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
K & L ELECTRICAL SERVICES CORP.
447 NW 61 ST AVE
MIAMI, FL 33126
(786)-380-0512
License: 12E000107
Date: 1, _ ;!0 •- 1'k-
State of: -�
County of: �- Coa .`
Before me this day personally appeared who, being duly sworn, deposes and
says:
That he/she will be the only person working on the project located at:
c• I �� _ :cam.
17
Contractor Signature:
Sworn to (or affirmed)and subscribed before me this 9D day of 1 .20j7, by
abge- 4 ao . Cru -a
Personally known-0—IL r�._ o
OR Produced Identification -b G 'io20 ` q'33 _. 7i � O
Type of Identification Produced i
910ndld
MAYERSI FERNANDEZ
MY COMMISSION #FF991944
WIRIS: MAY 12,2020 tBtcugH 1st State Insurance
Print, Type or Stamp Name of Notary
Notice to Owner — Workers' Com
Miami hores Village
Building Department
10050 N.E.2nd Avenue
Miarni Shores, Florida 33138
Tel; (305; 795,2204
Fax: (305) 756-8972
nsation Insurance xec pjtlor,
I:Iorida Law requires Workers' Compensation insurance coverage` under Chapier 440 of the Florida Statutes. Ha, Sint. 441) G5
allows corporate officers in the construction indusiry to exempt themselves from this requircn.ent fol- ally corisiructiou project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure -
An employer in the consta;icticwn industry Who employs one or tttore part -lime of l all -tithe
employees, including the owner, must obtain workers^ compensation coverage. Corporate officers
or members of a limited liability company (LI,C) in the construction industry may elect to be
exempt f.
I _ The officer owns at lea t l0 percent ou the stock of [lie corporationi, or lit the case of
an LI.C, a statement attesting to the mirurnutn 0 percerwt ownershi p;
2- The officer is listed as an officer of the corporation in the records of the Florida
Departmeat of State, Division of Corporatiopt::; and
3. The corporation is registered and listed as active with the Florida Depariaterit of
State, Division of Corporations.
No more than three Corpporate off-icers per corporation Or lhltited liability conthany melnbcrs ;are
allowed to be exempt_ Construction exemptions are valid for a period of two years or until a
voluntary revocation is tiled or the exemption is rc vokut_i by the Division.
Your contractor is requesting a perrnit under this workers` compensation exemption and has acknowledgc tlsat lie- o - shti \sill nit ase
day labor, part-time employees or subcontractors tier your Ipi eject. The eontmcior has (-provided anaffidavit stating that ne or she will
be the only person allowed to work on your proiect, In tlic>e circumstance;. Miami Shures Village does riot require verification of
workers* compensation insurance coverage from the contractor's company for day- labor, part -brae employees or subcontractors.
BY SIGNING BLOW YOU ACKNOWLEDGE -1'i- M YOU RAVE READ THIS NOTICE AND UNDERSTAND ITS
C0NTET;\TS.
Signature:
_. Owner
State of Florida
County of Niliami-lade
The fore was acknoww�led e before ine th?,s \da ,olng
... ��`� wit c s aersonaliF_knciMn
.,tte or has ptoduced
Notarv:
SEAL: I ZERO V Conded iitrough 1st State Insurance