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Miami Shores Village e nj ��+ n(d8ntft
10050 N.E.2nd Avenue NE � )r W
TZITZ
Miami Shores,FL 33138-0000URI
21
Phone: (305)795-2204 b ��
Expiration: 09!01/2016
71
Project Address Parcel Number Applicant
597 NE 93 Street 1132060141040
Miami Shores, FL Block: Lot: IPI HOLDINGS LLC
Owner Information Address Phone Cell
IPI HOLDINGS LLC 1441 BRICKELL Avenue (786)763-2813
MIAMI FL 33131-
1441 BRICKELL Avenue
MIAMI FL 33131-
Contractor(s) Phone Cell Phone Valuation: $ 2,000.00
ROSMEL POOL INC (305)592-7900_.:::.. ..... __. R .... _..__ _ _... .._. Total Sq Feet: 0
Type of Work:POOL PIPING Available Inspections:
Type of Piping: Inspection Type:
Additional Info: Main Drain
Bond Return: Final
Classification:Residential Scanning:3 Rough
Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.20
DBPR Fee Invoice# PL-1-16-58310
$3.38 01/12/2016 Check#:13260 $50.00 $193.96
DCA Fee $3.38
Education Surcharge $0.40 02/03/2016 Check#: 13282 $ 193.96 $0.00
Permit Fee $225.00
Scanning Fee $9.00
Technology Fee $1.60
Total: $243.96
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 i ormation is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhermore,I authorize the ab a-named actor to do a work stated.
Ck
February 03, 2016
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
February 03,2016 1
t i
TMiami Shorey Village -
Building e art nt JAN1 � 095
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 i fir• I
Teh(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 04
FBC 20K
BUILDING Master Permit Na. L6+ 8�
PERMIT ii�LiC� 'i Sub Permit No. TL (6-
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ®PUBLIC WORKS ❑ CHANGE OF CANCELLATION
❑ [7 SHOP*
CONTRACTOR DRAWINGS
JOB ADDRESS: SCI-1 I-lC
City: Miaml Shores County Miami Dade
Fara/Farrel#: 1 1 � ., r"S1 I I g�y,�� Is the building Historically Designated:Yes �NO ✓ -
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE
OWNER:Name(Fee Simple Titleholder):_1 \ }► 1 dl 11G,S P#one-k- (7 -
Address•
City: }/i►a.r�M c'P� State: F~
-- Zip:��1355
Tenant/Lessee Name: e.\ I Ibs
Phone#:
Email:
CONTRACTOR:Company Name:_ �� ,. I ?bc) 1 Phone#: --�®'S �'j� •,�(��
Address: aS 5+ I v --
City: state: zip: 33► 7 F
Qualifier Name: t vck'r"C' Phone#:` X05 '59,3k._'I Cj 0
State Certification or Registration#: 0?G I L4=(AQL 1 Certificate of Competency#:
RESIGNER:Architect/Engineer:__ �C:i�►ii_ ryign rvAp-
`ll0?� Phone#: , •SOS_5`1A4
Address: �y � 319
City:__f•�1`i ce rte. l State:F Zip: 3-L
Value of Work for this Permit: Square/Linear Footage of work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ lace Re air Re
A I p ❑ Demolition
Description of Work:
Specify color of col®r thru We:
Submittal Fee$ Permit Fee CCF$ Co/cc$
Scanning Fee$ Radon Fee$ DBPR$
Notary$
Technology Fee$ Training/Education Fee$
Double Fee$
Structural Reviews$_
-----_._ Bond$
{R2visedfl2/24f2014}
TOTAL FEE NOW DUE$. ! `77 rD
r
i
Bonding Company's Name(if applicable)
Bonding Company's,Address
State Zip
City
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
State Zip
City
has
Application is hereby made to obtain a permit to do the work and installations as in icatemeetehe stands ds of that no work or
rlaws installation
t g
commenced prior to the issuance of a permit and that all work will be performed
regula
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.....
€WNEWS AFFIDAVIT: I certify that ail the foregoing information is accurate and that all work will be done In compliance with all
appiicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR-FAILURE TO RECORD A NOTICE IAFOMMUR PROPERTY.E"F EMENiT MAY
RESULT IN YOUR PAYING TWICE FOR IMPR®SEM�E S®RAN ATTORNEY BEFORE RECORDING
TO END
TO OBTAIN FINANCING, CONSULT WITH YOUR LEN
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 goad faith that a copy of the notice of commencement and construction noticelieof col w brochure
will must be posted e delivered to the the person s to
whose property is subject to attachment. Also,a certified copy of the recorded
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.
lea
_ Signature `>�
Signature__7���: ( CONTRACTOR
OWNER or AGENT
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledgedef�or�e me this
5 _®veo�•��9
O
1-7 day of �®`9er''�°b-�'�r' .20 Q � b Y 1-1_day of
who` ersonally known
�,, , �;,�.erlc, ,who is ersonally known
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:
Si n:
g �
Sign:
f Print: �
Print: `^
eleita Seal: AOLNLI.�Hel@iTa
Seal: �SIOM ii Ff 019059 LQPrg�SfON FF01�89
LY` EVIRES: eAM(19,2017
t� `*➢awa �, a�+� k��s+x�x��c��
e'tapoN3%arako#�a#�rirR�sket�as�'sk'�AagekAcsk,hioA sR+knt��ta,kskat#s#skS#a,+kekkdnrk• rk�skAoekde+kukok#,ksk,k#a's#at rk+'t
PROVED BY
Plans Examiner ________..—�
toning
AP
Clerk
Structural Review _--
(Revised02/24/2014)
51�oREs
� Miami shores Y
Building Department
�OR 11 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:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this 1 day of 12015
Bwho is�ersonally kno o me or has produced
as identification.
Notary:
SEAL:
.'• 1SSION�Ff
4
IPI Holdings, LLC
1441 Brickell Ave#1400
Miami, FL 33131
Statement of Authority of the Managers of IPI Holdings, LLC
On my oath and under penalty of perjury, I swear that Stewart Cameron and Nicholas Farrell are the
duly appointed Managers of IPI Holdings, LLC,a Delaware Limited Liability Company. I certify that they
have not been removed as Managers and have the authority to act for and bind IPI Holdings, LLC in
business transactions for which this affidavit is given as affirmation of they authority
o
s
Sworn and subscribed before me the undersigned authority, on
Notary Public
Wary PWft Stam of Flodda
Alin M Fadhel
Commission
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