PL-14-1560s yt
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
FBC 200
BUILDING Master Permit No. ROI/ /920
PERMIT APPLICATION sub Permit NoPL. /9- )S'60
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
El PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /0 Z / +E f- e -
City: Miami Shores County: Miami Dade Zip: —/,?Gf2-
Folio/Parcel#: /1/1.4,2- 0 00/O," ea Is the Building Historically Designated: Yes NO
Occupancy Type: Laza Load: Construction Type: /41474- / Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):. /t///—e/ .01 •7�0f Phone#:.Fi•-31." P�5'�
Address: % Z ZP., ,'?49j
City: "•J9 ,-4,s P State: %:,:Z
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: ' .2/ --5-i
Zip:
City: State: Zip: _J
Qualifier Name: ;i i c fD Phone#:
State Certification or Registration #: �` C /7�z 74 7 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
State: Zip:
Address:
City:
Value of Work for this Permit: $ 'fi� G`r . zr,< Square/Linear Footage of Work:
Type of Work: ❑ Addition EA -Iteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: ,.,��/,J/j/j?js��l��j/!.Z
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ /50, Y CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE$ 1 (0
(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 a• nce of such pos d ice, the
Signature / AgeZe
inspection will not be approved an • - ection fee will be charged.
Signa
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AGENT
ent was acknowledged befre a this
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APPROVED BY
(Revised02/24/2014)
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Plans Examiner
Structural Review
Zoning
Clerk
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. 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
State of Florida )
County of Miami -Dade )
Sworn to and sub§cribed
day of `j u 5'
before me this lo
20 /
By 41c:G.ca/ /t%
(SEAL)
Type of Ident
Print Name:
Signature:
Contractor
State of Florida )
County of Miami -Dade )
Sworn to and bs ribed before me this /
day of Jv/y , 20
By
o �iibib'd:S;nl.:.mw�R�i•�
MY COMMISSION B EEs189
(SEAL)
Type of Identifrc
ROSITA N. SIMMONS
?: ... 'r. 189117