EL-17-1951r
! RECEIVEDMiami Shores Village JUL 311017
Building Department 041
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FE� OILS
CANCEL -LED a� � �-Ig5o
BUILDING Master Permit No. �
PERMIT APPLICATION Sub Permit Noft —Lot Is �
❑BUILDING 'ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: _] 0%7 N 15- 9 ( Tpr-rr, §--
City: Miami Shores County: Miami Dade Zip: 3�31
Folio/Parcel#: r i — — Is the Building Historically Designated: Yes NO
Occupancy Type: r-,FP, Load: Construction Type: _Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): L-w-we /\ Phone#:
Address: tp-,,:Y NJ r
City: _Y'r State: -�L Zip: '33iAet
Tenant/Lessee Name:
Email:
Phone#:
CONTRACTOR: Company Name: _'Rije,6i o o& �r -,tra ���,. h r-{r„ C.,,j Phone#: C-1n5)
Address: 1200 A -
City: ti a" -,A t State: Zip:
Qualifier Name: m(l,-16vrtD P c 0. Phone#: �`Z�uAS _� e
State Certification or Registration #: EG — I-.�flcn'saa 7 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address: City: State:
Value of Work for this Permit: $ I'TGO , (0 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace
Description of Work:
Specify color of color thru the:
Submittal Fee $
Scanning Fee $
Permit Fee $ !] CCF $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
DBPR $
Zip:
❑ Demolition
CO/CC $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ j?,G'
(Revised02/24/2014)
.41
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: 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.
Signature
OWN E rAGENT
The foregoing instrument was acknowledged before me this
day of,' l/ u- h t 120 17 by
04 b'5O h WLf- L -L , who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
as
Signatur
CONTRACTOR
The foregoing instrument was acknowledged before me this
day o / --� by
av, in On rho is �k�nown
me or who has duced as
identification and who did take
NOTARY PU
Sign: Lt�..� C%� Sign:_
Pri . : _ d-�i.h �� f K OL Print:
Seal: Seal:
SANDI PENA
Ad My COMMISSION #FFt63783
(407) Tki 0 1 ❑3 1 i,!f-0aN,]IaryService.com
APPROVED BY Plans Examiner _
MICHELLE ESPINOSA-CLARK
r° �n MY COMMISSION #F1F126847
EXPIRES: MAY 28, 2018
O°"� Bonded through 1st State Insurance
********
Zoning
Structural Review
(Revised02/24/2014)
Clerk
goo rc �`
JEFF ATWATER
CHEF FINANICAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compen ption law.
EFFECTIVE DATE: 7/16/2017 EXPIRATION DATE: 7/16/2019
PERSON: SANTIESTEBAN MARIANO J
FEIN: 651009473
BUSINESS NAME AND ADDRESS:
SUNSHINE ELECTRICAL CONTRACTORS CORP
1300 SW 85 COURT 4
MIAMI FL 33144
SCOPE OF BUSINESS OR TRADE:
Licensed Electrical Ccntractor
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 benefits 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 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 r+o 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.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609
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