EL-10-20-2299, 1107 NE 104th StT L fib- z6.221�
Date:
State of.�
County of CA l C'v Devot'o
Before me this day personally appeared KA eA 1v't ��� who, being duly sworn,
deposes and says:
That he or she will be the only person working on the project located at:
7 ti l 0 y 5 (7
Sworn to (or affirmed) and subscribed before me this _day of C , 20�
Personally known
OR Produced Identification
Type of Identification Produced
ype or Stamp game of Notary
��yiv"►� ••,, ALYSSA LARSON
Notary Public • State of Florida
Commission # GG 946940
of r+,•' My Comm. Expires May 9, 2024
Bonded through National Notary Assn.
l
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.
Signatur� , i
caner
State of Florida
County of Miami -Dade ,,
The foregoing was acknowledge before me this �� day of 6(41 i 120 2:0.
By KV ,of�/p w is ersonally kno n to me or has produced
as identification.
Notary: =oti�Y't%''••. JOHN M KORVICK
Notary Public - State of Florida
Commission K GG 909022
SEAL. '``oFF` My Comm. Expires Aug 29, 2023
Bonded through National Notary Assn.
Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address Parcel Number
1107 NE 104TH ST, Miami Shores, FL 33138 1122320290050
Contacts
H FRANK RUBIO Owner NEC ELECTRICAL CONTRACTOR INC Contractor t
1107 NE 104 ST, MIAMI SHORES, FL 331382657 MAIKEL GARCIA
rubiolaw@aol.com
Business: 7863898116
Inspection Re uests
Description: electrical for boatlift and lighting Valuation: $ 890.00 ^^
E 3 949';
Total Scl Feet: 225.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$0.60
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.20
Permit Fee
$50.00
Scanning Fee
$9.00
Technology Fee
$2.50
Tota I :
$116.30
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$116.30
Check # 1997
10/08/2020 $116.30
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 zoping. Futhermore, I authorize the above named contractor to do the work stated.
Authorized Signature: Owner / Applicant / Contractor / Agent Date
October 08, 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 ELECTRIC ❑ ROOFING
❑PLUMBING [--]MECHANICAL ❑PUBLICWORKS
JOB ADDRESS:
O(= ® i 2o2o
BY:
FBC 201--T
Master Permit No.2)Mk•-d&-19-/3`?A
Sub Permit No. F- l-�0- 2-0' 2-Zq9
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip: 33/c3ZS
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): / , f- ((." 1( 4)" LD
Address: 1l 0%• /JC 101L;) S 4 Yt c t
City: ✓ bafo►ll S�Dvls State: f7i Zip: 3JI3i
Tenant/Lessee Name: Phon
Email:
CONTRACTOR: Company Name: AlEC [. �CTtleltl / On�rQLDIr Phone#:
Address:!,, 70?b
City
_up:
Qualifier Name: 1/14/Ile / (�G11-d 1G Phone#:- ,),5� i��� ' V /--5—
State Certification or Registration #:4C 13dd 1-4S7 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Ad
Value of Work for this Permit: $ 8gz7 • oc Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteratign ❑ Ne/w/ ❑ R
)epair/Replace
Description of Work: t /� ��yI d / Toy &,) L IJ a, d �•a� rj ns1
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Permit Fee $ CCF $_
Radon Fee $ DBPR $
Technology Fee $ Training/Education Fee $
Structural Reviews $ _
State:
Zip:
❑ Demolition
CO/CC $
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 issued. In a absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of bd- 20 )Q by
Tj�C L�_ who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of _ rC' � 20 DO by
I 1 C�iLt' L� •L who is personally known to
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign: •....,.) U��Ca`l'�-�'�`'�-<
Print:
NOTARY PUBLIC NOTARY PUBLIC
Seal: STATE OF FLORIDA Seal: s STATE OF FLORIDA
Comm* GG233128 Comm# GG233128
1stD Expires 6/28/2022 Expires 6/28/2022
as
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)