PT-15-1559PAINT
PERMIT
JOB ADDRESS:
City:
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
/FBC20��
Master Permit No.' 1� TTs-- 15-1
APPLICATION Sub Permit No.
(tgb (Je foS s�
Miami Shores County:
Miami Dade
Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
OWNER: Name (Fee Simple Titleholder): 'j Q `14A Phone#:
Address:
S`4co KW a
340 5
City: KA►C(.%AZ
State:
Zip: 3312A-
Tenant/Lessee
31ZA
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: MAI',, 6 �34 St J
City: t&A ark.kA State: Zip: 33 1 Z_
Wekdeci U
Phone#: S5 t36D
Qualifier Name: Viritpi LAVA &-4 e/ Phone#: '
State Certification or Registr1ation #: COC, 0s9 T cts- Certificate of Competency #:
00
Value of Work for this Permit: $ ® 0 o Square/Linear Footage of Work:
Description of Work: (0,...*
C 4.e 1 a , ( LC P t®,!
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, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS,
HEATERS, TANKS, AIR CONDITIONERS, ETC
"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 an inspection fee will be charged.
Permit Fee $ CCF Fee $ Notary $
Technology Fee $
Training/Education Fee $ Double Fee $
TOTAL FEE NOW DUE $
PAINT COLOR APPROVAL AND AGREEMENT
All elements on the site must be listed and indicate the color to be painted
DIRECTIONS: Please circle corresponding number to appropriate color sample.
Walls:
2
3 4
Fascia: 1
Drip edge: 1
Soffit: 1
Flower Bins: 1
Shutters: 1
Awnings: 1
Chimney: 1
Doors & Jambs: 1
Garage Doors: 1
Railings: 1
Fences: 1
All Brick: 1
2
3 4
2
3 4
2
3 4
2
3 4
2
3 4
2
3 4
2
3 4
2
3 4
2
3 4
2
3 4
2
3 4
2
3 4
Stucco Bands: 1 2
3 4
Other Stucco
Feature: 1
2
3 4
Accessory Bldg: 1
2
3 4
Attach color sample with name and number
1.
2.
3.
4.
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.
Signature
OWNER or AGENT
The foregoing instrumentnwas acknowledged before me this
2S day of ()Lf\e , 20 l C , by
iQfi C --DOSS , who is personally known to
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of J (� NC , 20 � by
DIVIO�� O -C , who is personally known to
me or who has produced 1l. ()LW' a C12.00' Okt -8-1" ao23-°me or who has produced
identification and who did take an oath.
NOTARY PUBLI
Sign:
Print:
Seal:
0 130494 .
Sig
identification and who did take an oath.
NOTARY PUBLIC:
APPROVED BY:
as
Trint:
•
NOTARY
PUBUC i Seal:
•.i t1t••�'••...• `S4
lif#OFFLOYS %%‘
Al,— �o� ,_4,
011114 NANCY CORTES
1 A Notary Public - State of Fluids A
. 1 Commission # FF 201085 1 h
'!. _ 0;. My Comm. Expires Feb 24, 2019
'��S..20 Men through National NotaryArnw„ Official
Historic Preservation Board
Detail by Entity Name
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Detail by Entity Name
Page 1 of 2
Florida Limited Liability Company
FIRST MB PROPERTY, LLC
Filing Information
Document Number L09000098832
FEI/EIN Number 271114007
Date Filed 10/13/2009
Effective Date 10/13/2009
State FL
Status ACTIVE
Last Event REINSTATEMENT
Event Date Filed 10/05/2011
Principal Address
3400 NW 7 AVENUE
MIAMI, FL 33127
Changed: 04/11/2015
Mailing Address
3400 NW 7 AVENUE
MIAMI, FL 33127
Changed: 04/11/2015
Registered Agent Name & Address
GAYOSSO, AMALFI
3400 NW 7 AVENUE
MIAMI, FL 33127
Address Changed: 04/11/2015
Authorized Person(s) Detail
Name & Address
Title MGRM
AMALFI GAYOSSO
3400 NW 7 AVENUE
MIAMI, FL 33127
Annual Reports
http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 5/6/2015
Miami Shores Village
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
d
Owner
County of Miami -Dade
The foregoing was a knowledge before ' e this � day
rrllof ! ' , 20 I
ST
P�A � 7O t i?s pe gna1Yy ipwn to me or has produced
3ti
By Lot i LUi$4
as identificatr�. 5J• ���'0
leviv.
'sro Fe. a000,toomity�"
SEAL. • �• c
l
WAD RA
46 NW 36st apt 5 miami F133127
May 20, 2015
State of Florida
Miami -Dade County
Before me this personally appeared Draguisa Cure who, being duly sworn,
deposes and says:
That she will be the only person working on the project located at, 1090 NE 105
Street Miami Shore, FL 33138.
Sworn to and subscribed before me this May day of 20 2015 by
Personal know
Or produced Identification C. G 1 1-13 ✓ 5 - "b
Type of identification produced L Dr, uti L U -
Print, type or stamp name of notary
,ar"yt•,, NANCY CORTES
(t(- Notary Public - State of Florida
• Commission #r FF 201085
My Comm. Expires Feb 24, 2019
Blinded tirouph National Lary Assn