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EL-06-21-1656, 10682 NE 11th CtMiami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Parcel Number 10682 NE 11TH CT, Miami Shores, FL 33138 1122320280500 Contacts SAMI SPRINGER Owner FRANCAR ELECTRICAL CORPORATION Contractor 10682 NE 11TH CT, Miami Shores, FL 33138 ISCANDER GARCIA 16012 SW 79 TER, MIAMI, FL 33193 Business: 3059154785 Inspection Requests: � Description: REMOVAL OF INTERIOR FINISH (KNOCK DOWN)ON Valuation: $ 800.00 CEILINGS & WALLS TO SMOOTH FINISH. REPLACING DAMAGED 4 EXISTING CABINETS (NO ELECTRICAL AND/OR PLUMBING) Total Sq Feet: 0.00 ,f r 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 $3.00 Technology Fee $2.50 Work Without Permit Fee $100.00 Work Without Permit Fee - Plus $100 $100.00 Total: $310.30 Building Department Copy Payments Date Paid Amt Paid Total Fees $310.30 Credit Card 06/24/2021 $310.30 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 \ 'f ation is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authori t e above named contractor to do the work stated. Authorized Signature: Owner / Applicant / / Agent Date June 24, 2021 1 Page 2 of 2 Miami Shores Village _RECFIVED Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 BY: LINE PHONE NUMBER: (305) 762-4949 FBC 20 BUILDING Master Permit No. RC-10-20-2226 PERMIT APPLICATION Sub Permit No.--,- 60S(o ❑ BUILDING 0 ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOBADDRESS: 10682 NE 11TH COURT City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-2232-028-0500 Is the Building Historically Designated: Yes NO XX Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): SAMI SPRINGER Phone#:7865971053 Address: 10682 NE 11TH COURT City: MIAMI SHORES State: FLORIDA Zip: 33138 Tenant/Lessee Name: N/A Phone#: n/a Email: springersam88@gmial.com CONTRACTOR: Company Name: Address: /,0o 12 ;5'cc City: OL/;tr A,ii Qualifier Name: Phone#• 3B5 `1 S �L Zip: 3-� Phone#: ?D S"Z/S State Certification or Registration #: "CC_ 1 'kOC� / Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: mo Value of Work for this Permit: $ OD X r, Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New 0 Repair/Replace ❑ Demolition Description of Work: Repair/replace instant water heater, recess light fixtures, GFI outlets. Specify color of color thru tile: Submittal Fee $ permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ DBPR $ Notary $ Double Fee $ Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ 3 (b - 3 Bonding Company's,Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State am 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 charaed. P. Signature / / CrNER VAGENT The foregoing instrument was acknowledged before me this L day of 30ne. 20 by titlQ&r ho is personally known to me or who has produced as identification and who did take an oath. NOT Signature CONTRACTOR The foregoing instrument was acknowledged before me this 2 day of l cr/l E 20 a/, by —r!5 nel�2 (4 who is personally known to me or who has duced as identification and who did take an oath. NOTARY PU Sig Sign: Print: Ill Print: Seal: ����` mUMIa Expea tr15,2o22 6aWWThu�dpKNawryeav�es Seal: FRANCISCA GIL State of Florida -Notary Public Commission # GG 938241 My Commission Expires Dec. 9, 2023 APPROVED BY Plans Examiner Zoning Structural Review (Revised02/24/2014) Clerk I bnda STATE OF FLORIDA DEPARTMENT IVr OF BUSINESS AND PROFESSIONAL REGULATION EC13009281 CERTIFIED ELECTRICAL CONTRACTOR +GARCIA, ISCANDER RANCAR tLtk., iRICAL C R0RATI - ED* /29/2021 nature LICENSED UNDER CH 489, FLORIDA STATUTES EXPIRATION DATE: AUGUST 31,2022 SE Dftl VER � *wNli%,,* 171 46610V 0&10 6 IP "A, 41 �-1 ® DATE (MM/DD/YYYY) AC ��.?RR�" CERTIFICATE OF LIABILITY INSURANCE 06i22r2021 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 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 endorsement(s). PRODUCER NAME: Arlenee Rodriguez Joy Insurance, Inc. (AIQ No.PHONEExth 305-809-8102 F'a No: 305-809-8028 12260 SW 8 St. Unit 155 nQ DRESS: loyinsuranceinc@gmail.com Miami, FL 33184 INSURER(S) AFFORDING COVERAGE NAIL # INSURED Francar Electrical Corporation 16012 SW 79 Ter INSURER A: Ategrity Special Insurance Company _i 16427 INSURER S INSURER C : INSURER D INSURER E : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 _ BR ADDL"SUPOLICY EFF POLICY EXP ,. TR TYPE OF INSURANCE I POLICY NUMBER M D YY DIYYY i LIMITS �COMMERCIAL GENERAL L EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR I DAMAGE TO RENTED $ 1 OO,000 PREMISES (Ea occurrence) A 1 x x - — 01-C-PK-P20025187-0 6/10/21 6/10/22 _ MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY i E o 1 LOC PRODUCTS •COMP/OP AGG $ 2,000,000 OTHER: Deductible $ 500 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _.... ;... _.... _. _ . ANY AUTO BODILY INJURY (Per person) $ OWNED 1 SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY _ AUTOS HIRED ­1 NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) i $ UMBRELLAUAB OCCUR I OCCURRENCE $ 7 EXCESS LIAB L� CLAIMS-MAD_E ;EACH AGGREGATE $ i DED RETENTION $ $ WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS' LIABILITY YIN XECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A; ❑ (Mandatoryin NHL. j E.DISEASE - EA EMPLOYEE; $ it yas describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ I i DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached F1 more space is required) "'Electrical Work— NGi?TICIr"ATC {dnl nap CANCFI 1 ATInN Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave. AUTHORIZED REPRESENTATIVE Miami Shores, Florida. 33138 (01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 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: 6/8/2021 PERSON: ISCANDER GARCIA FEIN: 863850719 BUSINESS NAME AND ADDRESS: FRANCAR ELECTRICAL CORPORATION 16012 SW 79 TER MIAMI, FL 33193 SCOPE OF BUSINESS OR TRADE: Electrical Wiring within Buildings and Drivers EXPIRATION DATE: 6/8/2023 EMAIL: JOYINSURANCEINC@GMAIL.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 ff, 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-262 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 E01363817 QUESTIONS? (860) 413-1609 Local Business Tax Receipt Miami —Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 7321343 BUSINESS NAME&OCATION FRANCAR ELECTRICAL CORPORATION 16012 SW 79TH TER MIAMI, FL 33193-3422 OWNER FRANCAR ELECTRICAL CORPORATION Worker(s) 2 RECEIPT NO. NEW BUSINESS 7612490 SEC. TYPE OF BUSINESS 196 ELECTRICAL CONTRACTOR EC13009281 EXPIRES SEPTEMBER 30, 2021 Must be displayed at place of business Pursuant to County Code Chapter SA - Art. 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR 75.00 06/10/2021 INT-21-315917 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec ga-276. MtAM For more information, visit Francar Electrical Corp. 16012 SW 79th Ter. Miami, FL 33193 EC-13009281 State §f Florida Coun of Miami -Dade Befor me, this day personally appeared Iscander Garcia who, being duly sworn deposes and says: That will be the only person working on the project located at: 91 Coud. Miami S r L 33138. for Signature Sworn Ito (or affirmed) and subscribeO befQree me this day of Type of Identification Prod ................:.... Personally Known Or ProducedideritIfi6ation Type or Stamp Name FRANCISCA GIL of Florida - Notary Public pt�mmission # GG 938241 My Commission Expires Dec. 9, 2023 Notice to Owner — Workers' Corn Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756,8972 nsation Insurance Exemption Florida Law requires \ orkers' 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. l . 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: _ wrier State of Florida Count\ of .\9iami-Dade 2 '�'` /� C The foregoing was ackn ledge before me this 2 3 day of J VP 200� By 'l ( 1' who is personally known o me or has produced I _1,i / I as identification. Notary: SEAL: �,.. LILL FERNANDEZ ,r . * COnttnl slon # GG 170880 80r*dTMn&*N*rik*N