ELC-16-3484Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Pe
•mit
Permit NO. ELC-12-16-3484
Permit Type: Electrical - Commercial
Work Classification: Addition/Alteration
Permit Status: APPROVED
Issue gate: 1/3/2017
Expiration: 07/02/2017
Parcel Number
Applicant
415 NE 105 Street Number: CHURCH BLDG 1122310430010
Miami Shores, FL Block: Lot:
ST ROSE OF LIMA CATHOLIC C
Owner Information
Address
Phone
Cell
ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD
MIAMI FL 33138-2970
(305)758-0539
Contractor(s)
G3 ELECTRIC CORP
Phone
(305) 322-2489
Cell Phone
Valuation:
Total Sq Feet:
$ 400.00
0
Type of Work: TEMPORARY CHURCH CARNIVAL JAN 27-29
Additional Info: TEMPORARY CHURCH CARNIVAL JAN 27-29
Classification: Commercial
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$0.60
$15.00
$15.00
$0.20
$1,000.00
$3.00
$0.80
$1,034.60
Pay Date
Invoice #
12/29/2016
01/03/2017
Pay Type
ELC-12-16-62491
Check #: 10705
Check #: 10713
Amt Paid Amt Due
$ 50.00 $ 984.60
$ 984.60 $ 0.00
Available Inspections:
Inspection Type:
Final
Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Review Electrical
W. W.
Underground
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, Futhermore,I authorize the above-named contractor to do the work stated.
uthorized Signatur Op•4' Applicant
Building Department Copy
Agent
January 03, 2017
ate
January 03, 2017
1
\t
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
Permit Type: Electrical
JOB ADDRESS: 415 NE 105th Street
RECEIVED
D 292016
BY: _ am
FBC 20 C 4"
Permit No. E LC 16- ?)184
Master Permit No.
City: Miami Shores
Folio/Parcel#:
Is the Building Historically Designated: Yes
County: Miami Dade Zip: 33162
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami
Address: 9401 Biscayne Blvd.
Phone#: (305) 727-6241
City: Miami Shores 4 State: FL
Tenant/Lessee Name: St. Rose of Lima Catholic Church
Email:
zip: 33138
Phone#: (305) 758-0539
CONTRACTOR: Company Name: `�
Address: 46�—;-cf 5c4j1 77 2
City: Al^1,( State:
Qualifier Name:'
State Certification or Registration #: Fe— 1 3f%b#Z-iOCertificate of Competency #:
Contact Phone#: Email Address: _ G = -1.
DESIGNER: Architect/Engineer: Phone#:
`((1-(a Phone#: .36532-2--2/76/
Zip:
Phone#: ,ZZ15 372C17 C(
Value of Work for this Permit: $ 400.00
Type of Work': "OAdilfess''" - 01k t r'i titin *<
.. ,.iP� 7 1 y'-..a�, 1,
Description of Work: Temporary;ChurchyCarriival
Square/Linear Footage of Work:
ORepdir/Replace,-ft,"
Jan. 27-29 2017,
❑Demolition
C't �.11'.P....� � •yt` `:ft r ..,, •1 1.. ,9' •.,C:
•,y;+yK•,,d.saFmw.
***************************************Fees********************************************
Submittal Fee $ DO1X11 (I Permit Fee $ /p6GGta,v, CCF $ 0 GO co/CC $
Scanning Fee $ - • CYC.:3 Radon Fee $ 1 . W DBPR $ 1 Bond $
Notary $ 0 Training/Education Fee $ 0. 20 Technology Fee $ 0 - e -
Double Fee $ f Structural Review $
0
TOTAL FEE NOW DUE $ (t.* (r
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 bjproved and a reinspection fee will be charged.
Signature
Owner or Agent
Signature
F r
ontractor
The foregoing instrument was acknowledged before me this I? `t The foregoing instrument was acknowledged before me this 11 T l
day of Chi; -,era ; 20 16 , by for. ,Ara- P>acYuvc1T I W,M-1t , day.of Q6" ., 20 i b, by •t; t, yvoz.x LJ K'cw-r'nr.'fLZ_
who is rsonally know b me or who has produced who is ersonally knot' to me or who has produced
- `, ' " As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
NOTARY PUBLIC: 1
Sign:
Print:
.12„ ,x
1jY cfrotiI1
My Commission Expires:
BfY PYbIiC S17S^ • ''br• •
B'i,'r, 1. MOrfn5sey
My Cr:n m4wia FT ;t= 176
Expires 01/04/2011/
Sign:
Print:
MyC
************************************************************************************************************
APPROVED BY
7 9 446s Examiner Zoning
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Clerk
Miami Shores Viilage
Building Department
CONTRACTORS' REGISTRATION
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. v' COPY OF QUALIFIER'S STATE LICENCES
B. %OPY OF LOCAL BUSINESS TAX RECEIPT
C.
PY OF LIABILITY INSURANCE*
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
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: 6;7- 3' (7 /, c. a,
BUSINESS ADDRESS: ?%G/ -5-60 '2 szcetf #9Y9 CITY /4/.7,• STATE /2 ZIP
BUSINESS PHONE: (5 ) 3 --y''9 FAX NUMBER ( )
CELL PHONE (4-4- ) 3z z -2V-"9 QUALIFIER'S NAME: 4/77g i - ha,/5%
QUALIFIER'S LIC NUMBER: ee%'.t'M..290
G-3 ELECTRIC Corp
EC 13006290
AV..
Should you have any questions, please contact me at (305)322-2489 or
Respectfully.
Gonzalo Fernandez
President
G3electriccorp@hotmail.com
8724 SW 72 Street #449 Miami, FI 33173
G-3 ELECTRIC Corp
EC 13006290
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND
PROFE , ' REGULATION
EC13006290 07/28/2016
CERTIFIED E
FERNANDEZ,
G-3 ELECTRIC C®
IS CERTIFIED under the provisions of Ch 489 FS.
Expk tion 4 . AUG 31.2018 L1607280002340
Should you have any questions, please contact me at (305)322-2489 or
G3electriccorp@hotmail.com
Respectfully.
Gonzalo Fernandez
President
8724 SW 72 Street #449 Miami, FI 33173
G-3 ELECTRIC Corp
EC 13006290
Local Busi ness Tax Ilacei pt
M iami-Dade County, State of Florida
-THIS IS NOT A BILL - DO NOT PAY
4983681
BUSINESS NAM EILOCATION
G 3 ELECTRIC CORP
4151 SW87AVE
MIAMI, FL 33165
OWNER
G 3 ELECTRIC CORP
Worker(s)
mTD
1
RECEIPT NO.
RENEWAL
5204011
SEC. TYPE OF BUSINESS
196 ELECTRICAL
CONTRACTOR
EC13006290
EXPIRES
SEPTEMBER 30, 2017
Must be displayed at place of business
Pursuant to County Code
Chapter 8A Art. 9 & 10
PAYMENT RECEIVED
BY TAX COLLECTOR
75.00 07/20/2016
0233-16-001069
Itis Local Business Tax Receipt only con"rns payrnent d the Local Business Tax. The Receipt is not a license,
permt, or a certi "cation of the hdder's quail "cations, to do business. Folder must comply with any gnvernmsatal
or nongoverntrental regulatory laws and requiren ntswhichapplytothebusiness
The RECEIPT NO above must be displayed on all commercial vehicles - Miall -Cade Oxie Sec 8a-278.
For more information. visit www.nianidade gov/taxcdlectar
Should you have any questions, please contact me at (305)322-2489 or
G3electriecorp@hotmaiLcom
Respectfully.
Gonzalo Fernandez
President
8724 SW 72 Street #449 Miami, FI 33173
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: 1/25/2016
PERSON: FERNANDEZ
FEIN: 542082896
BUSINESS NAME AND ADDRESS:
G 3 ELECTRIC CORP
EXPIRATION DATE: 1/24/2018
GONZALO
8724 SW 72 ST #449
MIAMI FL 33173
SCOPES OF BUSINESS OR TRADE:
LICENSED ELECTRICAL
CONTRACTOR
Pursuant 10 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 tho 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 cenificate. The department shall revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609
Miami Shores Viiiagd
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:
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of O6cc r dale-, 20 I ( .
By re,. Geoics c -1C vva'ri'1 tares A who i8/personally knower to me or has produced
as identification.
Not
SEA
Notary Public State of Florida
:a• �/'; Brian L Morrissey
cerMy Commission FF 187178
Atter"
Expires 01/04/2018
rritrour
11/09/2016
State of r1-v>o m+—
County of rt1 rel b")06
ER 13006290
Before me this day personally appeared GOIn/ zr•w Fz'vz.r43nv'Gz who, being
Duly sworn, deposes and says:
That he or she will be the only person working on the project at:
Village of Miami Shores
10050 NE 2nd Avenue
Miami Shores, FL 33138
Sworn to (or affirmed) and subscribed before me thisday of
lvr3v�r,r�,2 , 2016, by
Personally know /
OR Produced Identification
Notary Public State of F
. Brian 1. Morrissey
pOMy Commission FF 187178
Expires 01/0412019
Print, Type or Stamp of Notary
Should you have any questions, please contact me at (305)322-2489 or
G3electriccorp@hotmail.com
Rei tfullji .,r
,ac o F Rtr1 a?idez
' i t1 -a
2002 � - 8724 SW 72 Street #449 Miami, FL 33173