EL-15-1037 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-235957 Permit Number: EL-4-15-1037
Scheduled Inspection Date: June 03, 2015 Permit Type: Electrical - Residential
Inspector: Devaney, Michael Inspection Type: Final
Owner: BERRY, NICKOLAS Work Classification: Low Voltage
Job Address: 295 NE 91 Street
Miami Shores, FL Phone Number
Parcel Number 1132060133470
Project: <NONE>
Contractor: M&D ELECTRICAL SERVICE INC Phone: (305)318-7005
Building Department Comments
LOW VOLTAGE PERMIT Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed EE
Failed ��� /S
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
June 02, 2015 For Inspections please call: (305)762-4949 Page 27 of 28
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Project Address Parcel Number Applicant
295 NE 91 Street 1132060133470
Miami Shores, FL Block: Lot: NICKOLAS BERRY
Owner Information Address Phone Cell
NICKOLAS BERRY 295 NE 91 ST
MIAMI SHORES FL 33138-3127
Contractor(s) Phone Cell Phone Valuation: $ 250.00
M&D ELECTRICAL SERVICE INC (305)318-7005
Total Sq Feet: 0
Type of Work:LOW VOLTAGE PERMIT Available Inspections:
Additional Info: Inspection Type:
Classification:Residential Review Electrical
Scanning: 1
Fees Due ]MnPay Date Pay Type Amt Paid Amt Due
CCF
DBPR Fee Invoice# EL-4-15-55396
06/02/2015 Credit Card $ 108.60 $0.00
DCA Fee Education Surcharge Permit Fee-Additions/AlterationsScanning Fee Technology Fee Total:
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,PLU BING,MECHANICAL,WINDOWS, DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVI I t;e fy that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zo g. F ermore, I authorize the above-named contractor to do the work stated.
_ June 02, 2015
Authori e S ature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
June 02, 2015 1
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Miami Shores Village RFGFT\7
Building Department APR 30 2015
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
ii��
FnnBC 20 ( 0
BUILDING Master Permit No.;2 - )03
PERMIT APPLICATION Sub Permit No. — J` d3�
F-IBUILDING [2/ELECTRIC ROOFING REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: a C' S_ N e 1 S4,-ee'�
City: Miami Shores County: Miami Dade zip: 3 3 13 8
Folio/Parcel#:11 -'�)O(o—O Is the Building Historically Designated:Yes NO X
Occupancy Type: Load: Construction Type: {{�� _Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder)Wi kol °�u i �rY Phone#:&DS--7S
Address: ';'5 S N 1_- 611 H red
City:M-,Umi �'mDr eJ State:
Tenant/Lessee Name: Phone#:
Email::gel4uke rry r 6y1%G 1 PIN
CONTRACTOR:Company Name: r CJ /2C�.GCCi,d Ali/Ce Phone#:
Address: //Z//S2 SGc� / C Z�
City: 14111r171 Stater Zip: 3-3,177
Qualifier Name: 11:f 10.eA/L Phone#:
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: _ _ ___Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ C3 .O ci Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: Lam Y h 4G►o_perhn i+
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ /„fG>wlD CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
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.
Signatu Signature
OWNER or AGEN CONTRACTOR
Th foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 C� by %"' day ofa ,20� by
who is U/personally known to �i�c-K\/Qi'h-f' Mo ld e' who is personally known to
me or who has produced (idPr,S t 21�c_ as me or who has produced &✓1 WY6 L!e?Zfie as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign/ + Sig . we
Print: Print:
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t'c MY COMMISSION#EE843691 'P� �s AAARISOL PERlZ
Seal: Seal: •; ,,• ply COMMISSION#EES43691
EXPIRES October 15,2018 EXPIRES October 15,2016
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I r
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
M & D Electrical Services
21152 SW 128`t`Court
Miami,FL 33177
Phone-(305 )318-7005
Fax-(786)573-3402
May 6th, 2015
State of Florida
County of Dade
Before me this day personally appeared Ihosvanny Morales who, being duly sworn, deposes and says:
That he is the only person working on the project located at 295 NE 91St Street Miami Shores, FL
33138.
Sworn to (or affirmed) and subscribed before me this 0 day of Ot 201!5 by
Its
Personally known /
Or Produced Identification !/
Type of Identification Produced V t f5 (4' Cn CG
�CU(iw ( Pca 2.,
Print, Type or Stam Name of Notar
MARISOL PEREZ
X'= MY COMMISSION#EE843691
� EXPIRES October 15,2018
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7 Miami shores Village
Building Department
ORIDp' 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:
I. "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: 4/`—
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this _� l day of_m U 20 I
BY�h OS X10{nn� �� I S who is personally known to me or has produced
as identification.
Notary: MARISOL PEREZ
_• '"C;;:
'= MY COMMISSION#EE843691
SEAL: EXPIRES October 15,2016
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