REV-17-347 Miami Shores Village
Building Department ��-s --
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949e
FBC 20
BUILDING Master Permit No. ��` —���
PERMIT APPLICATION Sub Permit No ri
❑BUILDING ❑ ELECTRIC ❑ ROOFING ® REVISION EXTENSION [:]RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
/ CONTRACTOR DRAWINGS
JOB ADDRESS: %2 -?7 ,V i /� 11 C--
City:
_City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): ���� � �� � Phone#:
Address:
City: State: Zip:
Tenant/Lessee Name: ��� Phone#:
Email: l ��
CONTRACTOR:Company Name: '� s `� ' C '' " Phone#: ��`� —� � 7
Address: 2 C,/ xv Q
—
City: '� State � Zip: � � J-1,- -/7
Qualifier Name: �a'✓/� ll� s"0 Phone#:
State Certification or Registration#: C /�� J� l Certificate of Competency#:
DESIGNER:Architect/Engineer: �' / `` Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 2. Square/Linear Footage of Work:
Type of Work: ❑ Addition f❑ Alterat'n El New ❑ Repair R place ❑ Demolition
Description of Work: .s - .. f G f/ i7
Specify color of cglor thru tile:
Submittal Fee$ Permit Fee$ /�s® CCF$ CO/CC$
Scanning Fee$ C1 Radon Fee$ DBPR$ Z Notary$
Technology Fee$ Training/Education Fee$ �� Double Fee$
Structural Reviews$ Bond$ 1
TOTAL FEE NOW DUE$ T ��
(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 approve and a reinspection fee will be charged.
Signature .,��� :` � Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of � 20 f by day of 20 > 7 by
who is personally know.n.to �%� � i ' - ���wM is personally known to
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:
Sign: ,r Sign:
Print: 1 `�`'�,a C / � ' �T'� Print:
VNIAM GARM
Seal: Par P�� MARW C.RBDR(BUQ Seal: {{ IAr #FF ie=
* * W COb11�1fSSIDN#EE 81103 T:; Bondedltw No�ry PubCa Ilnde�lEen
EXPIRES:AApprN 26,2011
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0031EBd AIIU i 'S�vlces
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APPROVED BY - �? Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
IMPORTANT '
STATE OF FLORIDA I Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation
DEPARTMENT OF FINANCIAL SERVICES Who n exemption from this chapter by filing a certificate of
electioioun
n under this section may not recover benefits or �
DIVISION OF WORKERS'COMPENSATION a�� I F compensation under this chapter.
CONSTRUCTION INDUSTRY EXEMPTION IO
L Pursuant to Chapter 440.OS(12),F.S.,Certificates of election to
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA be exempt...apply only within the scope of the business or trade
WORKERS'COMPENSATION LAW I D
EFFECTIVE DATE: 2/22/2017 EXPIRATION DATE: 7/22/2019 listed on the notice of election to be exempt.
PERSON: RODRIGUEZ MARIA C I H Pursuant to Chapter 440.05(13),F.S.,Notices of election to be
FEIN: 650219797 I E exempt and Certificates,of election to be exempt Shall be
BUSINESS NAME AND ADDRESS: I R subject to revocation if,at any time after the filing of the notice
LA CASA DE LAS PISCINAS INC. I E 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
2601 NW 16 TERR I a certificate at any time for failure of the person named on the
MIAMI FL 33125 I certificate to meet the requirements of this section.
SCOPES OF BUSINESS OR TRA f
LICENSED POOL SWIMMING POOL
CONTRACTOR_ _ — — CONSTRUCTION-NOT _ _ _ _ _ — — — — — — — — —