EL-14-2293 )�)PP /4`�/- 2227Z
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-221831 Permit Number: EL-10-14-2293
Scheduled Inspection Date: May 08, 2015 Permit Type: Electrical - Residential
Inspector: Devaney, Michael Inspection Type: Final
Owner: GUGUEN,ALICE Work Classification: Pool - Private
Job Address: 10601 NE 6 Avenue
Miami Shores, FL 33138- Phone Number
Parcel Number 1122310120020
Project: <NONE>
Contractor: YORK ELECTRIC CORP Phone: (786)287-7380
Building Department Comments
ELECTRICAL FOR NEW POOL Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
p =
Passed
Failed
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
May 07, 2015 For Inspections please call: (305)762-4949 Page 4 of 33
Miami Shores Village
I j
OCT 1 7 2014
Building Department i
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
- - -
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
rFBC 201
BUILDING Master Permit No. il- 1p ILA
PERMIT APPLICATION Sub Permit No. f,L4 `i— ZZ 3
❑BUILDING 0 ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 10401 AV&
City: Miami Shores County: Miami Dade Zip: 3313 1;
Folio/Parcel#:11 - Z2-31 -- 012. -ooZO Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): 4AklC (7-OLVAIS Phone#: X96 2-41 5112
Address: 1I//10601 06 Gp Avg
City: fl Apf I S,*W 3 State: 'F 0)e'DA Zip: 33/30
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: yo264 LTxAC, (�aP Phone#:A,S '1 3Y S12 2C
Address: ZSR 1 7 S W/ 13 `�sr
City: M/an 1 State: -7iQ21514 Zip: 3 31 ys
Qualifier Name: 40irf-0 Phone#: -305 "OV V22-6
State Certification or Registration#: C-C 133C L/4 9 7 Certificate of Competency#:
DESIGNER:Architect/Engineer. V,CCArrE �2AA)Cly Phone#: 30S 3DB 563
Address: I U7? 6 lU\0 o V Lam, -95 City: /7i-441 State: (-_Zip: 31 6
Value of Work for this Permit:$ 'Sn Square/Linear Footage of Work:
Type of Work: ® Addition ❑ Alteration ❑ New ❑ /Re lace
Re air
p p ❑ Demolition
Description of Work: rony- 0-CCT,n I c.
Specify color of color t ru tile:
Submittal Fee$_ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revise d02/24/2014)
Bonding Company's Name(if applicable)
Bonding Company's Address _
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State 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 charged.
G I
Signature Signature
OWNER or AGENT O RA TOR
The foregoing instrument was acknowledged before me this The foregoing instrument s a owledged before me this
2`( day of 120 by day of _,20 by
who is k I wis pe��j o
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PU C: NOT*PC.,
Sign: Sign-
t_
Print: Prin
Seal: akY
A� .P\,.^oF,.^s a..Aa SealLsanchez Iorida P ra o'rhiuiarPRa °fi, iia r7c7�'1i ' m 043995M �:vC°R n5,,o r , r4
, y
APPROVED BY '�}� / �'c,r Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
S�Oxc Iva
logo ,,,,, Miami shores Village
Building Department
OR 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. In these circumstances,Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore,you may be
personally liable for the worker compensation injuries of any person allowed to work under this permit. Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner rac r
Print Name: Print Name: l l
Signature: JQ1rl - clG Signature:
State of Florida) State of Florida)
County of Miami-Dade) County of Miami-Dade)
Swornto and ubscribed before me thh Sworn to subscribed before me this
day of day of
ar ale Notary P blic State of Florida o' e� Noiary blic State of Florida
"� Roberto Sanchez
BB Roberto Sanchez B
y_ y .��- Q MY Commi s' n -�n
'of e°� Expires 12/0512014
FOF c.o Expires.2/05,'2014
(SEAL) %.01V (SEAL) `'
Type of Ideritification produced Type of Identification produced
RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION a`
ELECTRICAL CONTRACTORS LICENSING BOARD
EC13p04787 I
The ELECTRICAL CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.,
Expiration dates AUG 81,2016
0
MORENO, ROBERTO
YORK ELECTRIC CORP
- 25!7.SW 13 STREET`"'._.
,1<i11Xi�llt �'
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ISSUED: OB/05/2014 DISPLAY AS REQUIRED BY LAW SEC)# L1408050002134
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10/6/2014 09:21 3054458153 QUINTANA & ASSOC PAGE 01/01
DATE(MMIDDIY1 YY)
CERTIFICATE OF LIABILITY INSURANCE 10/16/2014
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 1NSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER-
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must 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
AM12: MARIA REYES
ME• _
QUINTANA S ASSOCIATES OF MIAMI INC. PHONE M5.446-506Y_ FAx 305 446 8153
A/C N0:
5200 S W 8 ST SUITE 250 •MAIL ----
MIAMI FLA 33134 ADPRESS: -- •--......._..-
INSURER S AFFORDING COVERAGE
INSURER A•NAUTILUS INSURANCE COMPANY ^�
INSURED INSURER 0; ---_
YORK ELECTRIC CORP INSURER 0:
2517 S W 13 STREET INSURER D;
MIAMI, FL 33145 INSURER E:
(NSURSR F:
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,
I TSR TYPE OF IN5URANC2 ADDL SU POLICY NUMBER POLICY EFF
PO on Ml LIMITS
OENERALLIABILITY NN412691 6/05/2014 6/05/2015 EACHOCCIJRRENCE S 1,000,000
COMMERCIAL GENERAL LIABILITY PREMISES Me N D a 8 100,000
A CLAIMS-MADE,OCCUR MED EXP(Any ono arson) 3 $000
PERSONAL$ADV INJURY E 1,600:000
GENERAL AGGREGATE S 2,000,000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMP/OP AGG S 2�0(ZQ,0
POLICY F1 TeT LOC S
AUTOMOBILE LUURRM EO aBINED SIN LJMIT
—
ANYAUTO BODILY INJURY(Per parson) S
ALL
AUTOS
OWNED SCHEDULED 800I4Y INJURY(Perecadenl) b _- ---
HIRED AUT03 NON-OWNED
AUTO
_ S M . . ...... .. .. ..
UMBRELLA UAB OCCUR EACH OCCVRRENCE
EXCESS UAB HCLAIMS-MADE AGGREGATE
DED I I RETENTION S S —
WORKERS COMPENSATION WC STATU- OTW
AND EMPLOYERW LIABILITY Y I N
ANY PROPRIEYORIPARTNER/EXECUTNE
OFFICERRdEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S
ifea,desalDa under
DESCRIPTION Of OPERATIONS below I-L.DISEASE•POLICY LIMIT S
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICI.:S(Attach ACORD 901,A44191ona1 Remarks Soltedulo,If more apace is required)
ELECTRICAL WORK WITHIN BUILDING
POLICY SUBJECT TO POLICY TERMS AND CONDITIONS
CERTIFICATE HOLDER CANCELLATION
VILLAGE OF MIAMI SHORES ZHOULD ANY OF THE ABOVE DF30RIINED POLICIES BE CANCELLED BEFORE
10050 NE 2 AVENUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIV1=REo IN
MIAMI SHORES,FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED R RESENTATIVE
FAX:(305)756-8972 ��
9)1988-200 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
4
JEFF ATWATER
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: 5/11/2013 EXPIRATION DATE: 5/11/2015
PERSON: MORENO ROBERTO
FEIN: 223918884
BUSINESS NAME AND ADDRESS:
YORK ELECTRIC CORP
2517 SW 13 STREET
MIAMI FL 33145
SCOPES OF BUSINESS OR TRADE:
ELECTRICAL WIRING
WITHIN BUIL
Pursuant to Chapter 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 Chapter 440.05(12),F.S..Cer'aficates of election to be exempt.. apply only within the scope
of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 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,vie 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 tae
person named on the certificate to meet the requirements of this section,
DFS-F2-DWG-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609
5t►ORFS LSC
Miami shores Village
Building Department
`0 ID
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
SWIMMING POOL OWNER'S CERTIFICATION
Date
Miami Shores Village
Building &Zoning Department
Attention: Building Official
I certify that I am the legal owner of the property described as
66ct—= 6d &yE1),j , located at loco) K)c C, ,, AVC.
In accordance with Section 33-12(f), Code of Metropolitan Dade County, I certify that I
understand and agree that the swimming pool to be constructed at the above address cannot
be used or filled with water until separate permit has been obtained for an approved safety
barrier, and such barrier erected, inspected and approved.
I further understand that this certification, however, does not eliminate the need for
obtaining a permit and erecting and approved barrier prior to final inspection and use of the
pool.
Legal Owner
�a Ijc (7Mk)^►s 1,4( c - Gv&v,
Note: This certification is to be submitted with a swimming pool permit application in duplicate.
Miami shores Village
tttl �� tllit
wade
Building Department
\� COR; +
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
RESTRICTIVE COVENANT PROTECTIVE POOL ENCLOSURE
KNOW ALL MEN BY THESE PRESENTS: pp
WHEREAS,the undersigned_ ar Mja 6i V-V. 't J is/are the fee
simple owner(s)of the following described property situated and being in Miami Shores Village,Florida:
_
Address: o4at--,)rGrir Ay.y -- -- -
Whereas,the undersigned owner(s) _—
desire to utilize said Lot(s)as a single building site,and the undersigned owner(s)do(es)hereby declare and agree as follows:
I. That the property will not be used in violation of any ordinances of Miami Shores Village or Miami-Dade
County now in effect or hereinafter enacted.
ll. That the purpose of the covenant is to induce Miami Shores Village to issue a permit for a pool where the
required enclosure is not on the subject property where the pool is located.
III. That if any of our adjoining neighbors remove any portion of their fence or wall,or it our/my property shall fail
to meet code requirements for pool barriers,we.as owners will immediately install a protective enclosure to
meet code requirements and will obtain a permit for such fence.
IV. That.I/we,as owner(s)hold Miami Shores Village harmless for any negligence or injury that results from not
having the enclosure.
V. If enclosure belongs to said property,I agree to maintain&or replace said enclosure in the event that is
damaged or removed by any case.
NOW,THEREOF,for good and valuable consideration,the undersigned do(es)hereby declare that he/she will not
convey or cause to be conveyed the title to the above property without requiring the successor in title to abide by all terms and
conditions set forth herein.
FURTHER,the undersigned declare(s)that this covenant is intended and shall constitute a restrictive covenant
concerning the use,enjoyment and title to the above property and shall constitute a covenant running with the land and shall be
binding upon the undersigned,his/her successors and assigns and may only be released by Miami Shores Village,or its
successors,in accordance of said Village then in effect.
A 4 12s?
OWNER SIGN&PRINT OWNER SING&PRINT
I Hereby Certify that on this day personally appeared before me _ and has produced ID
# as identification and he/she acknowledge that he/she executed the foregoing,freely and voluntarily,
for purposes there in expressed. /-
SWORN TO AND SUBSCRI4 or r e on this_z`� _day of 0 j
Puhlic:;tare of Florida
r '`' S'ancno., OTA STATE OF FLORIDA
(Revised 05/2209 F r t,, ` °^I FG4se95
2014