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EL-15-1000 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-233489 Permit Number: EL-4-15-1000 Scheduled Inspection Date: April 30, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: WILLIAM J.JURBERG, R.ANDREW DE Work Classification: Temp for Test once Job Address:9350 NE 12 Avenue i Miami Shores, FL 33138- Phone Number (305)609-3851 Parcel Number 1132050070150 Project: <NONE> Contractor: HIGHGRADE ELECTRIC CONTRACTORS CORP Phone: (305)576-8807 Building Department Comments TEMP FOR TEST Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments PassedE71 i -- i Failed G� Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. April 29, 2015 For Inspections please call: (305)762-4949 Page 17 of 29 / , og , s �s°RFs y Miami Shores Village perrtjhE' . t� li� 10050 N.E.2nd Avenue NEv , +1 111;C3, � Miami Shores,FL 33138-0000 gM a AP F Phone: (305)795-2204 � ` , r. <ORtDp` o 5 Expiration: 10125/2015 NO Project Address Parcel Number Applicant 9350 NE 12 Avenue 1132050070150 R.ANDREW DE PASS WILLIAM Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell 5701 N BAYSHORE Drive R.ANDREW DE PASS WILLIAM J. (305)609-3851 MIAMI SHORES FL 33138- 5701 N BAYSHORE Drive MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 200.00 HIGHGRADE ELECTRIC CONTRACTO (305)576-8807 Total Sq Feet: 00 Type of Work: Available Inspections: Additional Info: Inspection Type: Classification:Residential Final Scanning:3 Review Electrical Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# EL-4-15-55342 DBPR Fee $2.00 DCA Fee $2.00 04/28/2015 Credit Card $ 114.60 $0.00 Education Surcharge $0.20 Permit Fee-Additions/Alterations $100.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $114.60 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,RO FING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate7d that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above-named cVact o do the work stated. April 28, 2015 Authorized Signature:Owner / Applicant ct ontr / Agent ate Building Department Copy April 28, 2015 1 Miami Shores Villages BuildingDepartment RECETURD p 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 AP 27 2015 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2010 / BUILDING Master Permit No. Rc.7 13 5v -lin PERMIT APPLICATION Sub Permit No.ll/S-- 1000D ❑BUILDING N ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [-]RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 135-0 N6- 1 a Av,4 . City: Miami Shores County: Miami Dade Zip: 381 3 Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): / Phone#: Address: t City: /�i �' rl'%� State: Zip:3^�3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: 1j h GAAJe 6ON��4�4(A-5 Phone#: Address: 3 (p! 3 S .W. /(o 1v Ave City: M L J14 m F}R State: Zip: 3 30 X7 Qualifier Name: /k—)$ON s,}f Mk Phone#: State Certification or Registration#: E)l D 01 S1 3 fr Certificate of Competency#: 3 2? DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$_2X. Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description- Sp ri tion' esc p pT d „�,,, ...�� ,,�,.,. w.,._,. Specify eorr gr&1or fhru tile: Submittal Fee$ Permit Fee$ 0 4Pand 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,A-)---- Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrumennt was a/dknowledged before me this day of /� 20 S^ by day of f710/7g/4 20 / S by 7�� i G�naIIy!Spawn to — who is personall wn to 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 PUBLIC: NOTARY PUBLIC: Sign. JOSE M SANTANA +ik Sign: JO E M.SANTANA Notary Public •State of Florida `J' Notary PNblic-State of FlOrW Print: • omm 9P499 Fab 24, Print: MW canuri-iftollm Fab 24,201 Commission•EE 877149 Com cion N EE 8774+3 Seal: %:;,q,►„;;•` 8o�d Through N81=11 Notary Assn Seal: %�Ft '� =ugh National Notary Assn. SII,1, O��APPROVED BYA Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) S _gREs sell .....� Miami shores V Building Department ORIDp' 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: BUSINESS ADDRESS: CITY STATE ZIP BUSINESS PHONE: ( ) FAX NUMBER( ) CELL PHONE ( ) QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: 15�o'R'es t'l �c qa Miami shores Village logo milli Building Department ORIUA 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 voluntaryrevocation is filed or the exemption is revoked b the Division. P Y 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 �� ner State of Florida County of Miami-Dade The foregoing was acknowled e before me this�day ofJ '20/5 IF By who is personally known to me or has produced as identificat rl°�"aY p�B,-, MARTIN J. PALMER Notary Public-State of Florida •; :•`_My Comm.Expires May 23,2016 Notary: Commission#EE 173842 �'• Bonded Through National Notary Assn. SEAL: HIGHGRADE ELECTRICAL CO., 3613 SW167 AVE HIALEAH, FL. 33027 DATE: APRIL 26T"/2015 STATE OF FLORIDA COUNTY OF DADE -7-7BEFORE ME THIS DAY APPEARED f WHO, BEING DULY SWORN, DEPOSES AND SAYS: THAT HE OR SHE WILL BE THE ONLY PERSON WORKING ON THE PROJECT LOCATED AT: 9350 NE 12 AVE,MIAMI SHORES, FL. 33138 SWORN TO(OR AFFIRMED)AND SUBSCRIBED BEFORE ME THIS DAY OF2015 BY PRINT&�,§IGN If jr. ERSONALLY KNOW OR DID PRODUCE FDL# "t{tY P . `B MARTIN J.PALMER Notary Public-state of Florida N A &SIGNATURE e-My Comm.Expires May 23,2016 ,F `P Commission# EE 173842 Bonded Through National Notary Assn.