EL-19-2052Permit No.: L-09-19-2052
Miami Shores a Villa ")'-L
g I� -g- Permit Type: Electrical- Residential
10050 NE 2 Ave
Miami Shores FL 33138 "yam ISWork Classification: Pool
305-795-2204 Permit Status: Approved
Issue Date:10/17/2019 Expiration: 04/15/2020
Location Address Parcel Number
83 NE 100TH ST, Miami Shores, FL 33138 1132060131440
Contacts
MATTHEW AULTON Owner
83 NE 100 ST, MIAMI SHORES, FL 33138
Other:3054523074
ON CALL ELECTRICAL CONTRACTORS INC Contractor
KEVIN GILLIS
Business: 7863885880
Mobile: 7863458001
r
Description: NEW POOL ELECTRICAL WORK Valuation: $1,800.00 tion Re uests:
2-4949
Total Sq Feet: 338.00
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
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$111.10
Check # 5705
09/04/2019 $50.00
Credit Card
10/18/2019 $61.10
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.
Authorized Signature: Owner / Applicant / Contractor / Agent Date
October 18, 2019 Page 2 of 2
Sh Village
Miami 0' hares s jff
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner —Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
C>
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 (LLQ 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 LI-C, 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 nietribers 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 TIIA:T' YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:.z��__
L-6wner
State of lorida
County of Miami -Dade
Aa
The fore goipg was acknowledge before me this day of,, ")o
B who _ IS to me or has produced
as identification.
I GG 27ing
EXPIRES. DOMMI)W 17,2M
amw 71vu N01mv PLO,& I
�3f�t;
Miami Shores VillageqEP
Building Department10050 N.E.2nd Avenue, Miami Shores, Florida 33138Tel: (305) 795-2204 Fax: (305) 756-8972 B
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING ELECTRIC ❑ ROOFING
FBC 20
Master Permit No. ?;i_`—d --11 —2.4yS
Sub Permit No. LL CAI-1 I ZDSZ,
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
M CONTRACTOR DRAWINGS
JOB ADDRESS: -43 NE lW �
City: Miami Shores County: Miami Dade Zip: ?�13C(
Folio/Parcel#: 115?,0 mr?)1 *40 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): H04htw Au Ruin Phone#:
Address: 14?J 1\iFi 1W
City: miaYV11 �i��:e5 State: Zip:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: OA 1LL1) V tC YI l Phone#: -NU • 51S Qt
Address: -11-M Nw -RY) !�}. 11
City: Miak State: Zip: Z3 Ilu
Qualifier Name: Ww"I i &'i l l7j 1 �Phone#:
State Certification or Registration #: eW=C1.,K 1 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ u`' Square/Linear Footage of Work:
Type of Work: .k Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition
Description of Work: Mtw A T 8Q �
Specify color of color thru tile:
Submittal Fee $ (::;2t' C Permit Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
CCF $ CO/CC $
DBPR $
Notary $
Double Fee $
Bond $
(Revised02/24/2014)
TOTAL FEE NOW DUE $ �O 1. lb
Bonding
Bonding
Name (if applicable)
Address
City f State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
Zi
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 priorito the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in thfis jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILEI,S, 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 notibe approved and a reinspection fee will be charged.
I
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
—(—Q day of 20 (9 , by
(Aho is personally known to
r v
i
me or who has produced as
identification and who did take an oath.
NOTARY PU
Sign:_
Print:
Seal:
r°`is�✓tq�c i GLADYS BOPOES
MY COMMISSIGr! # GG 271799
"_• ,o' EXPIRES: D,:cer, er t i. 2G22
Signature iv,,
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of _Clwho
20 ,� a . by
R U is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal: GLADYSBOROES
'rR mY COMMISSION # GG 271799
'_p_• �.�,;' E:t ;ZES: December 17, 2022
r ,c�
APPROVED 6Y Y k �j�'Q� l Plans Examiner
Structural Review
*************
Zoning
Clerk
(Revised02/24/2014)