EL-15-1008Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL o�
Phone: (305)795-2204 Fax: (305)756-8972 �--
Inspection Number: INSP-234096
Scheduled Inspection Date: May 06, 2015
Inspector: Devaney, Michael
Owner: PETERSEN, CARSTEN
Job Address: 1209 NE 98 Street
Miami Shores, FL 33138-2562
Project: <NONE>
Contractor: WELL ELECTRIC TECHNOLOGY
tsmiamg uepartment comments
Permit Number: EL -4-15-1008
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Alteration
Phone Number (305)807-2221
Parcel Number 1132050090230
Phone: (305)726-7098
INSTALLATION OF 2 POLE 50 AM BREAKER FOR THE Infractio Passed Comments
A/C AIR HANDLER AND A 30 AMP CONDENSER WITH I
INSPECTOR COMMENTS False
DISCONNECT OF CONDENSER
Inspector Comments
Passed
Failed
/Y'
Correction ❑
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
May 05, 2015 For Inspections please call: (305)762-4949 Page 46 of 50
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Parcel Number Applicant
1209 NE 98 Street 1132050090230
CARSTEN PETERSEN
Miami Shores, FL 33138-2562 Block: Lot:
Owner Information Address Phone Cell
CARSTEN PETERSEN 1209 NE 98 Street (305)807-2221
MIAMI SHORES FL 33138-
1209 NE 98 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone
WELL ELECTRIC TECHNOLOGY (305)726-7098 (786)473-8455
of Work: INSTALLATION OF 2 POLE 50 AM BREAKE
ional Info:
Acation: Residential
ning: 3
Fees Due
Amount
CCF
$0.60
DBPR Fee
$2.25
DCA Fee
$2.25
Education Surcharge
$0.20
Permit Fee - Additions/Alterations
$150.00
Scanning Fee
$9.00
Technology Fee
$0.80
Total:
$165.10
Valuation: $ 650.00
Total Sq Feet: 00
Pav Date Pay Type Amt Paid Amt Due
Invoice# EL -4-15-55353
04/28/2015 Check* 3829
05/04/2015 Check #: 3837
$ 50.00 $ 115.10
$ 115.10 $ 0.00
Available Inspections:
Inspection Type:
Review Electrical
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 zoning. Futhermore, I authorize the above -napped cgfittactor to do the work stated.
May 04, 2015
Authorized Signature: Owner / Applicant / (tdntrlioYor / Agent
Building Department Copy
May 04, 2015 1
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 LECTRIC ❑ ROOFING
FBC 20 10
Master Permit No.&
Sub Permit No� �� s
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL []PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
QQ�t CONTRACTOR DRAWINGS
JOB ADDRESS: �D 7 1-4,� %D S�? %%//4r1/ .S'f��%I/��I AG .9
City: Miami Shores County Miami Dade Zip: 19tS
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: /Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): GNMARV tor: 1FV"d0-C:;1' Phone#: 1D. -S --,k ! 4?2Z/
j
Address:_ /.240 A�F, 40 '07,
City: 11109A!1 State: 464 Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: �(.$��wJ� Phone#:
Address: Al/w / % 67
City: /A,I A444 State: �� Zip: � /
ck—
Qualifier Name: I l Phone#:
State Certification or Regis at)on #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: ____._State: Zip:
Value of Work for this Permit: $ L5-01 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New
❑ Repair/Replace ED Demolition
Description of Work: � g l/4 n ,✓ !�' r 1 �. aS U f7m f3e-e -a,-
1 y
+
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ / CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revisedo2/24/2014)
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ t1�.
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
0
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'regukating construaioh 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 COMMENCEM,ENT." y
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500,, the applicant must
promise in goo# faith that a copy of the notice of commencement and construction lien law.'btgchure Wlll 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 app ro spection fee will be charged.
Signature Signature �—
OWNER or AGENT CORACTOR
The foregoing instrument was acknowledged before me this
day of, 20 /_5�_ , by
.CAl2_1;T_E�1/ /�,�—�s✓ ,io is personally kno to
die or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
The foregoing instrument was acknowledged before me this
7— day of A� [- ___,20./4— by
1,16 ho is personally known
or who has produced
identification and who did take an oath.
NOTARY �PUBLIC: 1
If n MEMO �Oe�� 2p16
Print:
Seal:
My
APPROVED BY Al /zi Plans Examiner Zoning
Structural Review Clerk
f Revised02/24/20141
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 �1 day of PYA , 20 15
By (Q4f-
5-le n who ispersonally known to me or has produced
as identification.
ODALMA M MEJ1A
MY COMMISSION # EE097160
EXPIRES May 31 2016
WELL ELECTRIC TECHNOLOGY INC.
4312 NW 11TH STREET, MIAMI, FL 33126
TEL. 754-245-1679
EC -13001181
04/28/15
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
- BEFORE ME THIS DAY PERSONALLY APPEARED MR. TONY WELL WHO, BEING
DULLY SWORN, DEPOSES AND SAYS:
THAT HE WILL BE THE ONLY PERSON WORKING ON THE PROJECT LOCATED AT:
/�V% 4J'5� 29 7-1 5
SWORN TO(OR AFFIRMED) BEFORE ME THIS 28TH DAY OF APRIL 2015 BY MR.
TONY WELL.
PERSONALLY KNOWN TO ME
WMAXIMO RODRIGUEZ
Notary Public - state of Florida
Comm. Expires Jul 5, 2016
MYCommission # EE 214350