EL-16-366 t
Miami Shores Village !3Y
10050 N.E.2nd Avenue NE
Miami Shores,FL 33138-0000
Phone: (305)795-2204 �€
s Expiration: 08/27/2016
Project Address Parcel Number Applicant
1235 NE 100 Street 1132050080040
Miami Shores, FL 33138-2603 Block: Lot: LOUIS DE THOMAS
Owner information Address Phone Cell
LOUIS DE THOMAS 1235 NE 100 Street (305)796-4922
MIAMI SHORES FL 33138-2603
Contractor(s) Phone Cell Phone Valuation: $ 500.00
SOUTH DOM ELECTRIC INC (305)626-5904
--- - Total Sq Feet: 1400
Type of Work:REPLACE UPGRADE KITCHEN OUTLETS Available Inspections:
Additional Info: Inspection Type:
Classification:Residential Review Electrical
Scanning:1
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60 Invoice# EL-2-16-58636
DBPR Fee $2'25 02/29/2016 Credit Card $109.10 $50.00
DCA Fee $2.25
Education Surcharge $0.20 02/09/2016 Credit Card $50.00 $0.00
Permit Fee-Additions/Alterations $150.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $159.10
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 AFFIDcertify tha all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction an ore,I authorize the above-named contractor to do the work stated.
1p� February 29,2016
Authorized Sig ure:Owner / Applicant / Contractor / Agent Date
Building Department Copy
February 29,2016 1
•` - �' Miami Shores Village
Building Department FEB o9 2016
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 S•4-L,
FBC 20H
BUILDING Master Permit No. ` ,C I ( 3�s
PERMIT APPLICATION Sub Permit No. ELI(p 3(oc0
❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: ;)-5 Y— — C>C) �5.7--
City: Miami Shores County: Miami Dade Zip: ® -3
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): 0d1-r 04U- c//70 4�:T Phone#: ;�6 7-:9 `o• �'� "
Address
City: State• Zip: ����
Tenant/Lessee Name: Phone#: -7 453 —,7;1&�
Email: ,k,.o e S c;,e�-77ta.,-" qF-s G_q e- e
CONTRACTOR:Company Name: 61-14 dJ010
C2:;X/C, INC Phone#:
Address: 0/ 7 57—
City:
TCity: State• T/ Zip:
Qualifier Name: cS A414-7-49, Phone#:3 aC112cllz Y
State Certification or Registration Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ > Square/linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New A2"Repair/Replace, ❑ Demolition
DescriptionofWork: � L l�`0 �a,4:'�e t
Specify color of color thru We:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$ (21
Scanning Fee$ w Radon Fee$ C), DBPR '�'� Notary
Technology Fee$ O Training/Education Fee$—20 Double Fee$ 7
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 appy a reinspection fee will be charged.
Signature Signature
kwNER or AGENT CONTRACTOR
Thepregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
11(�l daayc of � .20 by day of �� --120 .by
who is personally known to who is personally known to
au 2ly/
me or who has produced pa— (,a as me or who has produced 7`'�� as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: +�'t� nig S�����i� NOTARY PUBLIC:
012
Sign: - Of
S'
Print: _ �a�issi L Print:
.EEI 73059 ��r
Seal: %; �� .........•• \�.�` Seal: Notary Public State of Florida
FLO�����`` Joanna M Feliciano
My Commission FF 082753
avW"") Expires 01/12/2018
APPROVED BY ���L°��'� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
s
A CERTIFICATE OF LIABILITY INSURANCE ,'„ "
DDS CERTIFICATE IS NWED AS A MATTER OF 90MUATION ONLY AND CONFERS NO RK#ITS UPON THE CER 94CATE HOLDER,THIS
CERTIFICATE DOES NOT AFFOtNATIIELY OR IIEGA7WELY ASND,EXTEND OR ALTER THE CAGE AFFORDED BY THE POLXNES
BELOW. THIS CERTIFICATE DE PO IRAN E DDES NOT COMMUTE A CONTRACT BETWEEN THE ISSUING 8j,AUTHORMED
RE ITATNE OR Fes,AND THE CERTIFICATE HOL OM
MPORTANT: Iftheme holder is an ALIOMMAL IIS,Ue pots must be mid. BSL QATi�i IS1ANfI11P�.anbJeatto
the l8etms emu o, WtorLs Of the p'ur74 OmtOlm p may requ e m l om tIft emus doss mot r a fa rwo to dw
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COVERAGES CERTffqCATE NUMBER:- REVISION LIR
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISMO TO THE INSURM NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER WHIN 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 TEL,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LBBTS SHOWN MAY HAVE 8E>:N REDUCED BY PAID CLAIMS.
TYPE OF PaLwatoom Alm UNITS
GENERRLLWANLRY EACH OCCURRENCE s 1,000000
COMMERCIAL QEWMAL L.IAAMUTY 2
pRommmeomwmncw s 100,000
❑ ❑ SMS' 9] 0=JR PAV0079727 MEI)EXP ogre i a 5,000
A ❑ Y PERSONAL 02/1812016 02!18201 T g AOV MIJU RY s 1000,000
❑ 0 RAL A ATM s 2,o0000
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GERLAt TE LIMIT APPUESPER PRODUCis-COMP)oPAGG s 1.000000
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ELECTRICAL C ONTTRACTOR LICENSE d EC13005521
CERTIFICATE HOLDER CAVI
SHOULD ANY OF THE ABOVE DESCRIEW POLICIES BE 01INCELL®B
THE EXPIRATION DATE THS,NOTHCE WILL BE DELIVERED IN
Oily Of MWM So=Vftp Mdft Depelbnd ACCORDANCE W1THH THE POLICY PROVISION111.
10050 NE 2nd Ave
MW d Shores Fl 33136 Rang ATa�
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ACORD 25( )CF The AC ORD ride�Ttdmd AAU f wed.
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Date:
State of Florida
County of Miami-Dade
Before me this day personally appeared -S 2 �j�s who,being duly sworn,
deposes and says:
That he/she will be the only person working on the project located at:
/�S- Street. Miami Shores,FL 33138.
Affirmed and subscribed before me this Z day of 2015 by
] grL #7A-TO S
Produced identification �ilz
Type of Identification Pr duced: 14d$1,11
Arle�% ,,�,,.
ry
Print,Type or Stamp Name of 06%�NCO
O �
Off;'•. sy \\�
soon UNION 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:
7 er
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of
By -yt r
who is personally known to me or has produced
'on.
-Ores
Notary:
SEAL:
0 F
1/1"111111W\0
Inspection Worksheet
Miami Shores Village l/
10050 N.E.2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-262068 Permit Number: EL-2-16-366
Scheduled Inspection Date: June 29,2016 Permit Type: Electrical- Residential
Inspector:OM, Michel
r Inspection Type: Final
Owner: THOMAS, LOUIS DE Work Classification: Alteration
Job Address:1235 NE 100 Street
Miami Shores,FL 33138-2603 Phone Number (305)796.4922
Parcel Number 1132050080040
Project: <NONE>
Contractor: SOUTH DOM ELECTRIC INC Phone: (305)626-5904
Building Department Comments
REPLACE UPGRADE KITCHEN OUTLETS Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed
Failed
Correction ❑
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid
June 28,2016 For Inspections please call: (305)762-4949 Page 33 of 40