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EL-17-1871 (2)BUILDING PERMIT APPLICATION ❑BUILDING 14 ELECTRIC 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 ❑ ROOFING ❑PLUMBING ❑ MECHANICAL 0PUBLIC WORKS JOB ADDRESS: b P 9 sk City: rCE IED J111.26''2O1F' 5 fr FBC20 Master Permit No. V__C l� )&pS Sub Permit No. Et I - )3-4-‘ ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS Miami Shores County: Folio/Parcel#: 1` 21-2.0.D - 017 0 i 60 Occupancy Type: Load: Construction Type:ge5j EA Flood Zone: Miami Dade Zip: 33 Is the Building Historically Designated: Yes NO BFE: FFE: OWNER: Name (Fee Simple Titleholder): (J oli t.. I) 12-a.N 51.. 6i•) 2- Phone#: Address: i 7.A (a P ce_- ..--s St City: NUCAlskt S\G fL Z 5 State: 1=t- Zip: ?)---S 1 .5 Ct Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: "N Address: 3kja U,) 101 T•e 2 f2. c.tit2;C COma,p Phone#:(.7Q•5 )1$5 �6©3 City: 1' La N t ca i O f✓ State: Qualifier Name: Jae. 13 Oa v P oli i. State Certification or Registration #: - it -130 0 2-311 DESIGNER: Architect/Engineer: Address: Value of Work for this Permit: $ 3 i 0 0 F Zip: 4 a® Phone#: Certificate of Competency #: Phone#: City: State: Zip: Square/Linear Footage of Work: 3 --CO Type of Work: ❑ Addition Lal Alteration "" ❑ New ❑Repair/Replace ❑Demolition Description of Work: V I'� G It\R..IJ A ►J C1� Q-0 v/L h Q 001-Yk S R e ►n oda_ Specify color of color thru tile: Submittal Fee $ • Permit Fee $ /3262, w CCF $ 2 ' ® CO/CC $ 9 Scanning Fee $ - Radon Fee $ '2.. 2-5 DBPR $ 2 ZD Notary $ I Technology Fee $ 3 " ` Training/Education Fee $ Double Fee $ - oz, Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ 303 .90 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. Signatu rAGENT The foregoing instracknowledged before me this day of � \ , 20 __ , by Nrx Q,QZ. JJao-os04-07, who is persanallylnown to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign:l AC 12;1 tj a Pact,ceij: i Print: MGL„_.. ,__....._ :y.db (/-N Seal: „ MARINARADIO'ICH ► } .%: MY Ct„NM!SSION !k FF 912304 EXPIRES: December 23, 2019 Bonded Thru Notary PuNis Underwriters ******************************************** APPROVED BY (Revised02/24/2014) Signature CONTRACTOR The foregoing instrument was acknowledged before me this I I day of J , 20 1 , by J e' ew I) di a , who is personally known to me or who has produced _ as identification and who did take an oath. NOTARY PUBLIC: Sign: 1 "+GILL) tJ Print: Seal: CL elves MARtNARADKEVICH ..i= MY COMMISSION 9 FF 912304 •.r EXPIRES: Member 23, 2019 Sf "LP. Bonded Thru Notary PuNie Underkritars ************************************************* Plans Examiner Zoning Structural Review Clerk ONLY ELECTRIC COMPANY, INC 348 NW 102 Terrace Plantation, FL 33324 (305)785-6059 cell Date: State of F Loe , c� Country of Oa d t Before me this day personally appeared sworn, deposes and say: O'?_ 1.3o C.%) 011✓ �{ That he or she will be the only person working on the project located at: \Z1() cc.. 3-s s&_ N1ic who, being duly Contracto Signature Sworn to (or affirmed) and subscribed before me this 1 day of 4�. 20 1 7 , Byjoe.Ackit4t. Personally know X OR Produced Identification Type of Identification Produced e p'(4 ca d ate, ' CAN Print, Type or Stamp Name of Notary ` °,F twit <":Y'? RADKEVICH VI MY COM SSlON # FF 912304 �:.;EXPIRES: December 23, 2019 °p' Bonded Thru Notary Public Unduly/Mars Miami hores 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, parttime employees or subcouttactors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. State of Florida County of Miami -Dade The foregoing was acknowledge before me this ). Q day of J . , 20 1 . BY V 0 °jL ‘/-C1QIGN who is personally known to me or has produced as identification. Notary: SEAL: •'�:'•'i :•• MFlR:NARADttE CH '� e MY COMMISSION # FF 912304 j EXPIRES: December 23, 2019 Bonded Thru Notary Pu!lc Undenhritsrs