EL-11-19-2798, 27 NE 94th StMiami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
a
Issue Date: 03/03/2020
Parcel Number
27 NE 94TH ST, Miami Shores, FL 33138 1132060130540
Contaets
Permit NO.: EL-11-19-2798
Permit Type: Electrical - Residential
Work Ciassifrcation: Pool
Permit status: Aocroved
Expiration: 08/31/2020
KRISTINE A GEORGE TRS Owner FLORIDA ELECTRIC SOLUTIONS INC Contractor
27 NE 94 ST, MIAMI SHORES, FL 33138 YOISLANDY MARRERO
9115 BROAD MANOR RD, MIAMI, FL 33147
aquadesign1@bellsouth.net
Description: NEW SWIMMING POOL ELECTRICAL Valuation: $L578.00
Inspection Requ
ests:
Total Sq Feet: 305-762-4949
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 # 4996
03/03/2020 $111.10
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 for
regulating construction and zoning. Futhermore, I
ate and that all work will be done in compliance with all applicable laws
contractor to do the work stated.
Authorized Signature: Owner / Applicant / Contract&rf / Agent
Date
March 03, 2020 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 gELECTRIC F] ROOFING
RECETVEID
N V 2 2 019
BY:
C
FBC 20
Master Permit No.►,;j r
Sub Permit No. K�— �J ( � 2�
❑ REVISION E] EXTENSION []RENEWAL
[]PLUMBING [] MECHANICAL []PUBLIC WORKS ❑ SHOP
CHANGE OF ❑ CANCELLATION ❑DRAWINGS
JOB ADDRESS: A7 " " �� f reed'
Count Miami Dade Zi
Ci Miami Sh res NO
Folio/Parcel#: 3 20 U I?) — C) `C ��O Is the Building Historically Designated: Yes
n Flood Zone: BFE: FFE:
Occupancy Type: SF h Load: Construction Type: ��_ 4QQ/�� eDr � Phone#: 70c9 - 390 - g d?/
OWNER: Name (Fee Simple Titleholder): S fl e —
Address:
City: Y M< aYVI I a r�5 State:
Tenant/Lessee Name:
ne#:
Email: a V d+ Wu — d
CONTRACTOR: Company Name.
L_QR1 6 Gee Xx-IJ�v Phone#: 1__(Ar 2-1
Address: r Zi
L i State: FF • p
City: _/ 1 � � n phone#:
Qualifier Name: 6jj3Q F•grzko r 6666 1
Certificate of Competency #: I I G / a�
State Certification or Registration`#: Phone#: ?'J
DESIGNER: Architect/Engineer:`r l �AMLO �� A
l
Address: �d �dP�L- State rL, Zip:_r
1 v� Square/Linear Footage of Work:
Value of Work for this Permit: $ f [] Demolition
Alteration New Repair/Replace
Type of Work: Addition _ c i p.-A-r ► e,a,\,
Description of Work:
Specify color of color thru tile: Permit Fee CO/Cc $
$ CCF $
Submittal Fee $ Radon Fee $ Notary $
DBPR $
Scanning Fee $ Double Fee $
Technology Fee $ Training/Education Fee $
_ Bond $
Structural Reviews $ ) ,
TOTAL FEE NOW DUE $
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
he notice of commencement and construction lien law brochure will be delivered to the person
promise in good faith that a copy of t
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. 14
Signature
OWNER AGENT
The foreg ing instrument was ack owledged before me this
I $Lk day of ovew 20 191 , by
4? , who is pere known to
me or who has produced
ide
NOT
Print:
take an oath.
commie" JiGG 2WO
Seal: '' free Jenty 13, 2023
�y.,m;,"�'�BoldadflquTrgFelslnNua�eBOM38S-T019
as
Signatu
CONTRACTOR
Theforeringinstrument was acknowledged before me this
l (J day of /jV P VQL , 20 d q by
(�� ii� 'llf7 wtr� s°n�lly-known to
e or who has produced as
identification alylwho did take an oath.
NOTARY
I
Sign:_
Print:
`,J
Seal: . . Lamm
CWfiMW=0G9
BEqW 13, 6g0.185.101A
APPROVED BY Plans Examiner
Zoning
Clerk
Structural Review
In /)nl a)
FLORIDA ELECTRIC SOLUTIONS
9115 BROAD MANOR RD.
MIAMI, FL. 33147
MARCH 2, 2020
STATE OF FLORIDA
COUNTY OF DADE
BEFORE ME THIS DAY PERSONALLY APPEARED YOISLANDY MARRERO WHO,
BEING DULY SWORN, DEPOSES AND SAYS:
THAT HE OR SHE WILL BE THE ONLY PERSON WORKING ON THE PROJECT LOCATED
AT:
SWORN TO (OR AFFIRMED) AND SU SCRIB D BEF RE ME THIS O?AIDAY OF
2(-� , 2020 BY 015 LctncN�tErD
%4RSQN&LLY KNOWN TO ME.
ARYWIGNATURE
L0117 ll�e2rylbz--pk
PRINT NAME
+ir e LUIS ESP;OSA
NOTARY STAMP: Commisalon S GG 290679
Expka January 13, 2023
„t• •'' 6an0od Tiw Uoq Foln tneiunnco 800.3867019
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' Compensation 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
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 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:
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of G , 20
By k(J�Jlflen 6et01r4e_- who is�onally known to me or has produced
as identification.
1 11T T'1
SEAL:
l C ommission # GG 290679
Bonded Pru Troy Fein l uwm 8 oss.7olo
ACORD
Page 2 of 2
I AC RO - CERTIFICATE OF LIABILITY INSURANCE ATE
L.Ii 03r03n02o
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 have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsemem. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endow mem(s).
PRODUCER
SAMYINSURANCE
3855 SOUTHWEST 137 AVE SUITE B15
MIAMI FL 33175
Aimee Andino
PHONo EX1: 305-559-8855 (�. NO 305-555-6855
ADDRESS: semyinsumnce@prodigy.net
DISURER(B) AFFORDING COVEILIGE
NAIC 0
INSURER A: ABCO Insurance
0
INSURED
Florida Electric Solutions
51I S BROAD MANOR RD
Miaml FL 33147
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER P:
rn T`FRTIFIrATF NIIMRFR• nCvI*IUN NUMCCN:
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 WTH 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.
POLICYINSR F
POLICYUNITS
TYPE OF INSURANCE
INSO
vJw
POLICY NUMBER
(NMDDNYYY) I
@IMOOHYYY)
X
COMMERCIAL GENERAL UABUM
EACH OCCURRENCE
E 1,000,000
CLNNS-WADE OX OCCUR
DAMAGE TO HEWED
PREMISES(E—)
E IGo'000
MED EXP(AM —pmaonl
$ 5,000
CL 1883110
121222019
12222020
PERSONAL S ADV INJURY
S 1.000,000
GENT AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
S 2.000,000
PRODUCTS-CDMPW AGO
S 2,000,000
❑ PRO' O
Poucr JECT Loc
f
OTHER:
AUTOMOBILE LUU31LI1Y
COMBINED SINGLE LIMIT
S
BODILY INJURY (Pm p—)
$
ANY AUTO
BODILY INJURY (Pm aoklam)
$
OWRIED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON-0WNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE
(P dab)
S
E
a LOB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS IJAB
CLAIMS -MADE
LIED I I RETENnM $
$
WORKERS COMPENSATION
AND EMPR& LOYELIABILITY YIN
PER
R
STAME Er
ANY,ERIM MEERIPARTIIER/EXECIITiVE
EXCLUDED -I
IMim.demryb NH)
(M.d. YM NH)
NIA
E.L EACH ACCIDENT
$
E.L OLSEASE- EA EMPLOYEE
t
E.L DISEASE -POLICY LIMIT
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Oyes.e O
OESCRUMOIPRON OF � OPERATIONS babe
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addit aW R—I. Sd d.K may be e0eched Hmom epee G requlrcO
ELECTRICAL CONTRACTOR
LI CENSE011E000018 '
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
MIAMI SHORES VILLAGE BLD6 DEFT
ACCORDANCE WITH THE POLICY PROVISIONS,
10050 NE 2ND AVE
AUTHOR® REPRESENTATIVE
MIAMI SHORES FL 33138
ACORD 26 (2016/03)
The ACORD name and logo are registered marks of ACORD
https://api.accuagency.com/api/2.0/AcordFormsIPrint?acordFormId=ACORDG/`200025`/`2O... 3/3/2020