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EL-16-2638 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-267961 Permit Number: EL-9-16-2638 Scheduled Inspection Date: September 29,2016 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: LAMAZARES, MANUEL Work Classification: Addition/Alteration Job Address:230 NE 101 Street Miami Shores, FL 33138-2423 Phone Number (305)401-3012 Parcel Number 1132060134640 Project: <NONE> Contractor: SEMPER INC Phone: (305)216-3024 Building Department Comments REPLACEMENT RECEPTICAL BATHROOM 2 SWITCHES Infractio Passed Comments TOTAL 4 OUTLETS INSPECTOR COMMENTS False REPLACING EL-14-305 FROM RC14-63 Inspector Comments Passed Failed Correction 's Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. September 28,2016 For Inspections please call: (305)762-4949 Page 15 of 26 Permit MCSI -� - I + Miami Shores Village Pem# 'T E _ esiCf8t1 8 10050 N.E.2nd Avenue NE g Work dditiOn/Alteration Miami Shores,FL 3313&0000 Pe' h- � Perm#ftus: i�PRUVEa RSA Phone: (305)795-2204 :Issue Oats:912712018 Expiration: 03/26/201 7 Project Address Parcel Number Applicant 230 NE 101 Street 1132060134640 Miami Shores, FL 33138-2423 Block: Lot: MANUEL LAMAZARES Owner Information Address Phone Cell MANUEL LAMAZARES 230 NE 101 Street (305)401-3012 MIAMI SHORES FL 33138- 230 NE 101 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 250.00 SEMPER INC (305)216-3024 i _...., Total Sq Feet: 42 i Type of Work:REPLACEMENT RECEPTICAL BATHROOM 2 S Available Inspections: Additional Info:REPLACEMENT RECEPTICAL BATHROOM 2 S Inspection Type: Classification:Residential Final Scanning:1 Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical W.W. Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee $2 z5 Invoice# EL-9-16-61463 DCA Fee $2.25 09/26/2016 Credit Card $50.00 $114.10 Education Surcharge $0.20 09/27/2016 Credit Card $ 114.10 $0.00 Notary Fee $5.00 Permit Fee-Additions/Alterations $150.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $164.10 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. F ermore,I authorizIe-the above-named contractor to do the work stated. September 27,2016 Author' d Signature:Owner / Applicant / Contractor / Agent Date Buil ing Department Copy September 27,2016 1 Miami Shores Village SEP 26 2016 /Building Department BY: 410050 N.E.2nd Avenue,Miami Shores,Florida 33138 ej Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 5 FBC 20 iy BUILDING Master Permit No. �,(' , C9 ^ PERMIT APPLICATION Sub Permit No. Z49, �8 ❑BUILDING _2tLECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL F-IPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP C TRA OR DRAWINGS JOB ADDRESS: ! City: Miami Shores County: Miami Dade Zip: 3-313� Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): e4e, 7<S Phone#: Address: 32 City: oe� State: ip: L>?�� Tenant/Lessee Name: P ne Cir J�f� Email: CONTRACTOR:Company Name: e Phone#: ';, — Address: �'�✓� a� City: State: /�� Zip:. Qualifier Name: 41L, ' Phone#: State Certification or Registration#: Certificate of Competency#: DESIC,NER:Architect/Engineer: Phone#: Address: City: State:_ Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New epair/Re lace Demolition Description of Work: C �✓ �'©G � 6 � Specify color of color thru tile: Submittal Fee$ nr�O Permit Fee$ -O"40r-o®0 CCF$ (n lJ CO/CC$ Scanning Fee$ . l.J Radon Fee$ DBPPR�$y 2� Notary$ TechnologyFee$_® • `-Q Training/Education Education Fee$ - s g/ � Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 1 V (RPvm-dn7/?4/70141 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signatur OWNER or AGENT ONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this . 2-G day of 20 by 26 day of S.�QT'EM L ,20 CL • by who is personally known to � 1 k �I - who is personally known to me or who has produced B=-UaT P L•I as me or who has produce 't>(L-00Z;e ix—"Vas identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLI . LSign: Sign: PrintPrint: W Seal: a°4w,00 �n Notary Public State of Florida Seal: Sindia Alvarez ,oar°�o No Public State of Florida My Commission FF 156750 a° �^ Sindia Alvarez' Expires09I03/2018 My Commission FF 156750 °Fpo� Expires 09/03/2018 8�e$c &%c �kIIe k $e�e�e rz�agc *�c&&rie kIe*ialc#kik k## k%##* Qegc�kxeKcIIcgc #%�#�cffii� kk+Yk�k k+k APPROVED BY S �/� Plans Examiner Zoning Structural Review Clerk rRc„irnnln�/�n Nn�n1 q CTQB,, Construction Trades Qualifying Board BUSINESS CERTIFICATE OF,COMPETENCY 05E000580 4 SEMPERINC , D.B.A.: SEMPER FELIX A certified under the provisions of Chapter 10 of Mianii=Dade County: r r J QUALIFYING TRADE(S) 0001 ELECTRICAL 8' ' d y a C r, Juliana H.Salas P.E. Secretary of the Boartl Miami-Dade County retains all property rights herein. www.miamidade.govtecogomy c 006455 Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT A BILL—DO NOT PAY 5584322 1 T:j BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES SEMPER INC RENEWAL SEPTEMBER 30, 2017 283 GRAND CANAL DR 5824132 MIAMI FL 33144 Must be displayed at place of business Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS SEMPER INC 196 ELECTRICAL CONTRACTOR PAYMENT RECEIVED 05E000580 BY TAX COLLECTOR Worker(s) 1 $75.00 07/29/2016 FPPU04-16-011238 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holder"squalifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8a-276. For more information,visit www.miamidade aovftaxeollector 011887 Municipal Contractor's Receip i ami Dade County, State of Florida —THIS IS NOT A BILL—DO NOT PAY 5584322 M C BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES SEMPER INC NEW SEPTEMBER 30, 2017 283 GRAND CANAL DR 7488030 Must be displayed at place of business MIAMI FL 33144 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS SEMPER INC MMC ELECTRICAL CONTRACTOR PAYMENT RECEIVED 05E000580 BY TAX COLLECTOR Category(s) 1 $200.00 07/29/2016 FPPU04-16-011238 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holder's qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec ea-276. For more information,visit www.miamidade.gov/taxcollector 09/26/2016 MON 9: 15 FAX 0001/001 AGOR ® ...-...................--....-.............._, �..�- CERTIFICATE OF LIABILITY INSURANCE ! DATE(MM/DD/YYYY) _ --0— _ i 09/26/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF IN=pRMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT 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 E AFFORDED Y AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the oertlficate holder Is an ADDITIONAL#NSURED,the potley(ies)must be endorsed. If SUBROGATION IS YVAIVED,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 _— ._.__._—_........._...___ NN4I _— Nq `�T Maris Reyes Continental ill PHONE '- - - — __.�_, 5200 SW 8st Ste 250AI�Sc EIstJ: (305)207-7886 FAx 3 (grc•No1;,,-_.•(•05)207-0565 ; ARQRNfg. mreyes(Scontlnenlaipaacom ; Coral Gables,FL 33134 —- —--- --- __ INSURER(5y_AFFORDINo COVERAGE M--� _NA1C A Phone (305)207-7886 Fax (305)207-0565 INSURED INSURERA: United Specialty Insurance Company INSURER H Semper Inc- _---....._....__.----......-.- INS(►RER - 283 Grand Canal DriveJ_INsuRxD:-_.-_-_•,._.._.._..__..____._._..__.............._.. .__.__.....,.__..__...__......,......... ....._.__..__..._..._._,.. Miami FL 33144 1 INSURER E INSURER F: -{_..-..........,.__._....._.._ COVERAGES CERTIFICATE NUMBER: —__-._.. .__.__ ..._---.....,..—_-._,,.-.---_.._.,---_-_..•._._i._,..__. ....._._.._. _ _ _ REVISION NUMBER: _ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN i§SUED 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 MAYBE 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. ►NSR W ADD UBR -` --_._ -— .._. _..-........-.._....._._—_.._..---....__.._----,...._._........._.__...... LTR TYPE OF INSURANCE �I i rPp Y EFF 1 POLICY EXP LIMITS NS —_ POLICY NUMBER # ❑ COMMERCIAL GENERAL LIABILITY --._._._.. (/I _.�lYWYJ..IIINM/_ ...-_.------._.___._........._...._.—_..._...._.- I f 7•E_AQH OCCURRENCE s--._1.,000,00a oo CLAIMS MADE Q OCCUR DAMAGE TO RENTED El PRE, g 100,000.00 — k1lS .(he_QFairrenc@).._{'__.._..___._......_..-_,.__.__..._ A I MED EXP(Any orre person) ! $ 5,000.00 ❑ — CL1762747 08/06/2016 08/06/2017 —- !! ......."......................._.._.- PERSONAL aADV tNJURY y S 1,000,000.00 G�L-EN'L AGGREGATE LIMIT APPLIES PER: -.---....___. ..__.--_...--•--........ _.-._.,_........................... ._......, POLICY ❑ JPP T ❑ LOC GENERAL AGGREGATE _y S 2�000,00_OA0_ ❑ OTHER PRODUCTS-COMP/OPAGgLs 2,000,000.00 { AUTOMOBILE UABIUTY OMBIN D SINGLE LIMIT ❑ ANY AUTO L( �$ ,an.-•-- ALL OWNED SCHEDULED BODILY INJURY(Per person) S ......................❑ AUTOS ❑ AUTOS BODILY INJURY(Per accident] S _-- NON-OWNED _ --..,..... ._._...—. I MON OWNED PROPER—AMAGE L_._._ ......_......____�.".. ❑ HIRED AUTOS ❑ AUTOS [Per a �nt $ ......_- -- ❑:EX �BRELLAUAB ❑ ❑ T ❑�OUR MADE 1 -EACH OCCURRENCE_- g---- - DED ❑. RETENTION$ -- 1 i_AGGREGA7 ----- ......-_----- E S __-_..............._..... WORKERS COMPENSATION — - - - --..___. __ § _..........._ .-AND EMPLOYERS'LIABILITY tt --�" PER YIN[ I- OTH-i 1 ANY PROPRIETOWPARTNER/EXECU ,t SIATUT.E- -�-ER--•1 L-J OFFICER/M£MBER EXCLUDED? N/A E.L.EACH ACCIDENT ! (MandatorylnNHJ i _.................. -- _.-".._...._. $ ._..._........,.. If yes,deacr{ba under I j E.L.DISEASE-EA EMPLOYE g DESCRIPTION OF OPERATIONS below I i E.L.DISEASE-POLICY LIMIT g __.._....___� . _._.....__...__.----L___....-.._._.... . _ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more_...__apace Is requlretlJ ....... ....... _.._., I�Electrical work within building. ! 1 Policy subject to policy terms and conditions CERTIFICATE HOLDER --- --- -- CANCELLATJON _._._.....___....--.._.. .. ---..............._. 11I Miami Shore Village Building Department THE EXPIRATION DATE THEREOF, OT CE WILL B DELIVERED INFO BEFORE 10050 N E 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. E j Miami Shores,FI 33138 --- ••••-------- .. AUTHORIZED REPRESENTATIVE - ..........._..........__.__......._-_._._...._....._...__....._. ACORD 26(2014/01)QF ©998W--09D CORPORATION. Ali rights reserved. The ACORD name and logo are registered marks of ACORD 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: 7/15/2016 EXPIRATION DATE: 7/15/2018 PERSON: SEMPER FELIX FEIN: 202817401 BUSINESS NAME AND ADDRESS: SEMPER,INC. 283 GRAND CANAL DRIVE MIAMI FL 33144 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR 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.,Certificates 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, the 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 g aG r� a �0 ,�,W6/t/ 2, u SSM r V a Natarw r nlic State of Florida ;y Sindoa• varez I My commission FF 186750 ?�pd� Expire,091(13120 1 8 9/�`�6 S�OREs Gi s� Miami shores Village ogle poll Building Department artment 10050 N.E.2nd Avenue �IOIft 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 o lorida County of Miami-Dade The foregoing was acknowledge before me this 2 G day of c_�=, ?t 20 ((4. Byt�SWQL �\�'IP"��t�-�• who is personally known to me or has produced t2 lcF, as identification. Notary: SEAL: 1 °h4 Notary public State of Florida ;Q Sindia Alvarez My Commission FF 158750 %TOF Expires 0910312018