PL-14-2148 5
Miami Shores Village F' 7
Building Department I-r-
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
F fB11C20 L0
BUILDING Master Permit Noah,�.., V+ q-84
PERMIT APPLICATION Sub Permit No.RL—1 LI —2 L y�5—
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 766 ne 96 ST
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder):Lisa GuinOVart Phone#:
Address:766 NE 96 st
City- Miami Shores State: FL Zip: 33138
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name:1+4 k4.._,kL S � -S P'� L If"( 1-/ ,oCl(l/ Phone#:7 Qo 74
Address: (J Jy�J �d� ��b /-� "44- /
City: F State: Zip:
Qualifier Name tt P YPA Phone#:
State Certification or Registration#:VT C► /moi �� l Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 36`00 Square/Linear Footage of Work: //00
Type of Work: ❑ Addition ❑ Alteration 26ew ❑ Repair/Replace ❑ Demolition
Description of Work: Addition WMIM PLyM L3 r kUG
Specify color of c or tile:
Submittal Fee$ Permit Fee$ C r �l E� ^v-7 CCF$ CO/CC$
Scanning Fee$ — L 'V��J Radon Fee$ -�.) DBPR$ I- SD Notary$
Technology Fee$ y Training/Education Fee$ Double Fee$ Q�
Structural Reviews$ Bond$ :Be
TOTAL FEE NOW DUE$ LT
(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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature (X Signature
OWNER or AGENT 0 CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrum nt was acknowledged before me this
day of �- 120 by 2� day of 20 (Y by
L15A 6a#NDaAi7. I who is personally known to I�N Q who is personally known to
me or who has produced as me or who has produced as
identification z n takA .ROSSEAU
c�•, �ci, identification and who did take an oath.
COMMISSION#FF119045
NOTARY PUBL 0 4, 2018 NOTARY P
PIKES May JORGE ROSSEAU
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(40 &, 15 Florid;-Notary a��
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Sign: Sign: °Y EXPIRES May 4, 2018
Print b Print: 9-0153 Floridallotar; ervi ..
Seal: Seal:
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APPROVED BY ��'2-/Y Plans Examiner Zoning
Structural Review Clerk
(Revised 02/24/2014)
LMAFti(:iC �7W r I, UovFRM4k e$r4 °� ,tM >
KFN LAWSON. SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION -•
CONSTRUCTION INDUSTRY LICENSING BOARD
CFC1426169
The PLUMBING CONTRACTOR
Named below IS CERTIFIED ,'.
S�
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2016
GUERRA, FELIX DE JESUS - -
AA MASTERS MECHANICAL=AIRMOVING & ENGINEERING SYSTEMS CORP
15591 SW 105 TERRACE-" "'"'
APT
ERRACE- _ '"' � i,
APT 525
MIAMI FL 33196.
ISSUED.- 09/02/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1409-.20901536
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�logo ,,,,,� Irl iami Shores Village
Building Department
OR 10050 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. In these circumstances,Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore,you may be
personally liable for the worker compensation injuries of any person allowed to work under this permit. Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner Contractor
Print Name: L1 Print Name: 10 F, J OV
Signature: IyAl A AAA Signature:
State of Florida) AV State of Florida)
County of Miami-Dade) ROSSE 19045 County of Miami-Dad
Sworn to and subscribed be '" #FF
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