EL-19-2037Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
1250 NE 91ST TER, Miami Shores, FL 33138
r.,. +-t.
Issue Date:11/13/2019'
Parcel Number
1132050010550
Permit No.: EL-09-19-2037
Permit Type: Electrical - Residential
Work Classification: Pool
Permit status: Approved
Expiration: 05/11/2020
J Owner
GREG & JENNIFER BAUMANN
1250 NE 91 TER, MIAMI SHORES, FL 331383406
gbaumann@camdenlp.com
ONLY ELECTRIC CO INC Contractor
YOAV ADIKA
348 NW 102 TERR
Business:3057856059 onlyelectriccompany@gmail.com
Description: POOL BONDING AND GROUNDING HOOK UP POOL Valuation: $ 2,500.00 Requests:
Inspection 305-4949
PUMP AND POOL LIGHT
Total Sq Feet: 1,300.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$1.80
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.60
Permit Fee
$50.00
Scanning Fee
$3.00
Technology Fee
$2.50
Total:
$111.90
Building Department Copy
Payments Date Paid
Amt Paid
Total Fees
$111.90
Check # 315960 11/13/2019
$61.90
Check # 315943 09/03/2019
$50.00
Amount Due:
$0.00
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating construction and zoning. Futhermore, I authorize the above named contractor to do the work stated.
A
Authorized Signature: Owner / Applicant / Contractor / Agent Date
November 13, 2019 Page 2 of 2
% 6
BUILDING
PERMIT APPLICATION
Miami Shores Village RECEIVED
Building Department S P 03 2019
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 BY: --rr--
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 201 f
Master Permit No.12PP V�
Sub Permit No. FL_
❑ BUILDING X ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL
PLUMBING M MECHANICAL PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: I ZSV' NIr 4 / % 1MACr✓
City' Miami Shores County: Miami Dade Zip:
Folio/Parcel#: //- 3zv5 —co — 6_<:53 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): GaEG f71qUM4A/N Phone#:
Address: / L$ O /UC q ( _77a�F- 074GE
City: MzAMr- 54�ees State: 4:6 zip: 33/3�2
Tenant/Lessee Name:. Phone#:
Email: G�iW L*4APtJ(@ CAA06A/LPG' old+
CONTRACTOR`:' Company rNa/mef:
Address: `t t4 W j
city: '1'
Qualifier Name:
State Certificatic
If
. Phone#:
r—L zip: 33 2-Y
Phone#: C�oS) Z-
f 3 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State
Value of Work for this Permit: $ 2i �gCt)-c' o Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New . ❑ Repair/Replace
Description of Work: TD?y(, t LON oc( h
Zip:
❑ Demolition
Specify color of color thru tile: '
Submittal Fee $ r Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Technology Fee $,
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $ Notary
Double Fee $
Bond $
TOTAL FEE NOW DUE
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City State J Zip
Mortgage Lender's Name (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.
Signat le. t PNER or AGENT
The foregoing instrument was acknowledged beforemethis
day of �+1 20 / by
fLlri/► who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY P
Sign:_
Print:
Signature 7n7
CONTRACTOR
The foregoing instrument was acknowledged before me this
i I day of a.
20 Ic7 by
Ije `f c-#j Qp, 14 who ' personally- own to
me or who has produced as
identification and who did take an oath.
NOTARY P
`s MY COMMISSION 6 GO 249759
Seal: 0 al: v Pue CONN 10NA�'
'os EXPIRES: December 16, 2022 �,s , 18s�
•.Eof sRQ� BWIdld nn Notary PlbC WwMn t
i1Y18' ^ Meat
APPROVED BY 10 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Notice to Owner - Workers' Com
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 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 -
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;
The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
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
CONTENTS.
Signature:—Y::)— —
Owner
State of Flori a
County of Miami -Dade
The foregoing w`as acknowledge before me this r?� day of � 20�.
�tIAWII
ByQ&nwho is personally known to me or has produced
as identification.
Notary: ; v!.... , B1006 R"MONMW
MY COMMISSION IO(i 249759
�= EXPIRES: December 16, 2022
SEAL: :�osr+Q. BMW 71vuway Pd&Lk whits
ONLY ELECTRIC COMPANY, INC.
Florida State Certified Licensed Electrical Contractor
Residential, Commercial, Industrial
o, EC13002313
onlyeiectriccompany@gmail.com
t � 348 NW 102 Terrace Plantation, FL 33324
r Tel: (954) 476-5617 FAX: (954) 476-6189 Cell: (305) 785-6059
Date:
State of R Tt4
County of b_
Before me this day personally appeared YON him who, being duly sworn, deposes and says:
That he or she wiii be the only person working on the project located at:
1 Z5 0
Sworn to (or affirmed) and subscribed before me this AO G day of 20�, by
d*! tli'o
rE OF
Personally known
OR Produced Identification
IdentXtion Produced
Print, Type of Stamp Name of Notary