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EL-05-19-1116, 1420 NE 101st St (2)REeEIVED Miami Shores Village 4 4 ,a+r Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795-2204 Fax: (305) 756-8972 6V INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION FBC 20 0-0 Master Permit No.2rQ - as ' kvt Sub Permit No.E 1l P ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSIONRENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE Cif ❑ CANCELLATION ❑ SHOP CONTRAC• OP% DRAWINGS JOB ADDRESS: 1420 NE 101 STREET 33 Folio/Parcel#:11-3205-023-0050 Is the Building Historically Designated: Yes NO _ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): MATTHEW & ELIZABETH ALLEN Phone#: Address:1420 NE 101 STREET City: MIAMI SHORES State: FL Zip: 33138 Tenant/Lessee Name: Phon Email: CONTRACTOR: Company Name: `�� C�C1�,�^ `i1 `��-• Phone#: �� �3t �-� O Address: 03AA e, �� `_\'4 City: Vy�\J�_ State: FL Zip: S39(DJ Qualifier Name: 9-Nq ✓ "O'L OSV--i Phone#: State Certification or Registration #: f— � 317� ��I S Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 1500 Square/Linear Footage of Work: Type of Work: ❑ Addition❑ Alteration New ❑ Repair/Replace ElDemolition Description of Work: `/1e\r(`/\\'��,,tCCj 1 `Ch�^1`'�Or T.0 wr\ Specify color of color thru the:, Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF $ CO/CC $ . DBPR $ Notary $ Double Fee $ _ - - Bond $ - (Revised02/24/2014) 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 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 ' s d. In the ence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. i Signature Sig re O�+or AGENT CONTR TOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of TH i4 20 LA by Q9 day of TLA 20 2t by MATTHEW & ELIZABETH ALLEN who is personally known to CAL 4' who is personally known to me or who has produced �C"S'e- as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: — Sign: v v Print: ae Print: s YP ' S 4 `SPY P(j'' ',.F.� Seal: ;=otr,....��, Seal: My My COMMISSION # GG 210408 ,* *_ MY COMMISSION # GG 210408 * ` EXPIRES: AP ril 23, 2022 A `o: EXPIRES: April 2022 yrc Public Underwriters I"''•'FodF�4Q' Bonded Thru Notary Public Underwriters BondedThruNotary ***************** *************************************************************************************** dqAPPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 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 i£ 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: wner State of Florida County of Miami -Dade The foregoing was acknowledge before me thi�� day of ByL4 �2 Q 1 = l who is personally known to me or has produced as identification. Notary: r� �_ 4P �1K Notary Samantha State of Flotainds ry � � Samantha ChambeAain 7 y� My Commission HH 0111oe SEAL: pia fu Expires 06/16/2024 Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. ..��\' \...�...0 ^• M■• ........................... BUSINESS NAME�,eC�'(1 BUSINESS ADDRESS: (0J('Q1 CITY TE F L—ZIP 334 BUSINESS PHONE: ( -4) G31- 59R5 FAX NUMBE / CELL PHONE (*Lk QUALIFIER'S NA QUALIFIER'S LIC NUMBER: Ec MC) 1315 Ran DeSantis. Governor STATE OF FLORIDA Halsey Beshears, Secretary DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD THE ELECTRICAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES MAJDOWSKI, RICHARD ANTHONY T.B.M. ELECTRICAL SERVICES INC 6361 GREBE CT LAKE WORTH FL 33463 LICENSE NUMBER: EC13001315 EXPIRATION DATE: AUGUST 31, 2022 Always verify licenses online at MyFloridaLicense.com Do not alter this document in any form. a\ C A L S C' • F�� ELECT AL : N CON CTOR — - STWF = ;. 00 q; M This is your license. It is unlawful for anyone other than the licensee to use this document. 11 i ANNE M. GANNON CONSTITUTIONAL TAX COLLECTOR Srruing Palm Beach County Serving you. P.O. Box 3353. West Palm Beach, FL 33402-3353 www.pbctax.com Tel: (561) 355-2264 "LOCATED AT•' 6361 GREBE CT LAKE WORTH, FL 33463 TYPE OF BUSINESS OWNER CERTIFICATION 8 RECEIPT #MTE PAID AMT PAID BILL 23D169ELECTRICALCONTRACTOR MAJDOMI(lRiCHARDANTHOM EC13001375 U20.578395-0826/!0 52750 W149978 This document Is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 202012021 LOCAL BUSINESS TAX RECEIPT TBM ELECTRICAL SERVICE INC LBTR Number: 201364669 TBM ELECTRICAL- SERVICE INC EXPIRES: SEPTEMBER 30, 2021 6361 GREBE CT LAKE WORTH, FL 33463 This receipt grants the privilegeengaging inof or managing any business profession or occupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. Florida i7R vv Lama tAE r ,i40 �±=j o1.t$" "toV It� .. ,,.....,- rrtas A ,may, yy� TBMELEC DATE(MM/DDNYYY) 09/16/2021 ACOROw CERTIFICATE OF LIABILITY INSURANCE 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(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER 561-487-6001 Global Insurance Services, Inc 21301 Powerline Road #211 NAOAJI CT Eric Klein PHONE 561-487-6001 FAx 561-451-9825 (AIC, No, Ext): (A/C, No): ADpRIE : e ei—n@giservices.net Boca Raton, FL 33433 Eric Klein INSURERS AFFORDING COVERAGE NAIC # INSURER A: Ohio SecurityIns. Co. 24082 1�$g ��I�p M Electrical Services Inc INSURER B : 6361 Grebe Ct Lake Worth, FL 33463 INSURER C : INSURER D INSURER E : INSURER F : CAVFRAnFC CFRTIFICOTF NIIMRFR- RFVISIAN NIIMRFR- 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 WITH 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. INSR LTR TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR BLS 22 56471770 ( ) 02/10/2021 02/10/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMI rr 300,000 $ MED EXP (Any oneperson) $ 15,000 PERSONAL & ADV INJURY 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECPROT - ❑ LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 29000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY AUUTOS ONLDY EOMBINED SINGLE LIMIT, accident) $ BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PerOacadent AMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ FFICER/MEMBER EXCLUDED? Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- T TLITE PR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) State License EC13001315 MIAMSHO Miami Shores Village 10050 N E 2nd Avenue Miami, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD WE JIMMY PATRONIS CHIEF FINANCIAL 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' Compensation law. EFFECTIVE DATE: 3/15/2021 PERSON: RICHARD A MAJDOWSKI FEIN: 650243669 BUSINESS NAME AND ADDRESS: T.B.M. ELECTRICAL SERVICES, INC. 6361 GREBE CT LAKE WORTH, FL 33463 SCOPE OF BUSINESS OR TRADE: Electrical Wiring Within Buildings and Drivers EXPIRATION DATE: 3/15/2023 EMAIL: RICKTBMELECCCGMAIL.COM IMPORTANT: Pursuant to subsection 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 subsection 440.05(12), F.S., Certificates of election to be exempt issued under subsection (3) shall apply only to the corporate officer named on the notice of election to be exempt and apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to subsection 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 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. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 E01274201 QUESTIONS? (850) 413-1609 July 27, 2021 Requested Change of Contractor Permit Number: Address:l��� Postal m DMAILPA RECEIPT ru M_ (Domestic Mail Only; No Insurance Coverage provided) N rru u7 Postage $ 0 Certified Fee O O Return Reclept Fee Postmark (Endorsement Required) Here C3 Restricted Delivery Fee co (Endorsement Required) Total Postage &Fees m O Sent To N- Sheet, Apt. No.: ---- ------•---------------•------•--'-----•---` or PO Box No. ----•--yf ..........a---------`-` City, State, ZIP+4 M. 11 I, C L� L KQW _ (Property Owner), have terminated my construction contract with: �1 _. i _ �AA G\�J17��[`�-" C- License number: Effective: -,, auktou I hereby request that my new Contractor: ar'( Y Cc 1 &A)1W Im, License number: �G NWk?`S be approved to take over the permit on my property and will assume the responsibility for the entire project. I have notified the current Contractor with a certified letter of the termination of my contract prior to the new Contractor taking over this permit. Attached is a copy of the certified mail receipt and termination letter for record. (Initial). Signature of Property wner Printed Name of Property Owner STATE OF FLORIDA COUNTY OF The fore oing instrument was acknowledged before me this �— day of T 20� by ` t�'� !�� who is personally known to me or has produced CW're— as identification and who did or did not take an oath. Seal: Notary Signature SASHOYCHAI [[,7." MY COMMISSION #GG 210408 EXPIRES: Aptil23,2022 FOF F °; Bonded Thw Notary Public Underwriters Nr��CA u� . �-003 TBM Electrical Services Date:9/22/2021 State of Florida County of�War��U7 Before me this day personally appeared, Richard Majdowski who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 1420 NE 101 Street, Miami Shores, FL. 33138 Sworn to (or affirmed) and subscribed before me this 22111 day of September 2021. Personally known ) A Print, type, or stamp name of notaryl /j 3r%')IO-n+kt'N m `" .ram Notary Public Stale of Florida ;p Samantha Chamberlain `,ia EExprees 06/1612 24 HH oft 106 6361 Grebe Court, Lake Worth 33463 (954) 931-5985