DS-16-3383tis t-3�
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit NO. DS -12-16-3383
Permit Type : Driveways/Sidewatks!Stabs
Pe t �' Work Classifications Addition/Alteration
Permit Status: APPROVED
Issue Date: 12/1
2016
Expiration: 06/13/2017
Parcel Number
Applicant
10190 NE 12 Avenue
Miami Shores, FL 33138-
1132050190130
Block: Lot:
CAROLYN SHOOK
Owner Information
Address
Phone
Cell
CAROLYN SHOOK
10190 NE 12 Avenue
MIAMI SHORES FL 33138-2631
Approved: In Review
Comments:
Date Approved: : In Review
Date Denied:
Type of Work: ASPHALT RESURFACE OVERLAY OVER
Bond Return :
Scanning: 3
Additional Info: ASPHALT RESURFACE OVERLAY 0
Classification: Residential
Fees Due
Bond Type - Contractors Bond
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$500.00
$3.00
$3.00
$3.00
$1.00
$200.00
$9.00
$4.00
$723.00
Pay Date Pay Type
Invoice # DS -12-16-62370
12/15/2016 Check #: 1619
Bond #: 3279
Amt Paid Amt Due
$ 723.00 $ 0.00
Available Inspections:
Inspection Type:
Final
Foundation
Review Planning
Review Building
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 information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhermore, I authorize the above-named contractor to do the work stated.
Authorized Signature: Owner / Applicant Contracto / Agent
Building Department Copy
December 15, 2016
ate
December 15, 2016 l : 1
BUILDING
PERMIT APPLICATION
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
DEC 1 5 2016
BY:
FBC 20H
Master Permit No. S IC7- S g 3 3
Sub Permit No.
UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION El RENEWAL
El PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: t OO 1) E 12 LVe
City: Miami Shores County: Miami Dade Zip: 7j3 13 $
Folio/Parcel#: II 370$ 0161 01'i0 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): CO / 0 LAI
Address: 101C10 0.-)€ 2 Ave
City:
Phone#:
►J, . S t1 O re s
State: Zip: 3 1 3 2
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: O Vl e SID 1 'a 1/4.)''n 5 Tyke Phone#: -18 (¢ Zeta (3 51
Address: -`Ka 7> N& (13 5
City: 13 - .State: `f �— Zip: 33 1 (9
Qualifier Name: CO ,kc z s4 Phone#:
State Certification or Registration #: E 2 3) 50 0 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: 4 City: State: Zip:
Value of Work for this Permit: $ 400. CN Square/Linear Footage of Work: 2 7 -
Type
Type of Work: ❑ Addition n Alteration
Description of Work:
❑ New Repair/Replace n Demolition
OStLa H ilp 5ui l,Ace C00q/ ) C) t� D y� S 41' vN
(Av. v -e vV•Gic I
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(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 approved and a reinspection fee will be charged.
Signature Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of Dec , 20 (P , by ` 1 day of c , 20 I y , by
CONTRACTOR
CQl20L') 5 #})OK-
1
or who has produced
, who is personally know
ratification and who did take an oath.
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SeI:
TARY PUBLIC:
..,L3APe 103RIN0
O►••\;IS` a # FF 195634
IS!z,ay3,2019
•i.;t.r7 r,:blic Underwriters
cP1Z La s ACocT , who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
drir
Sign:
Print:
Seal:
BARBAR`v : 03RIN0
• MY COMMISSION i, FF 195634
• EXPIRES! February 3, 2019
Bonded Thre Notary Pubic Undc writers
.0.3.111011,4111 4.0.4.7
*****************************************************
APPROVED BY Plans Examiner Zoning
Structural Review
(Revised02/24/2014)
Clerk
STATE OF (FLORIDA)
COUNTY OF (DADE)
Miami Shores Village
Building Department
SURVEY AFFIDAVIT
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
The undersigned Affiant, Cadrn 54"/L , does hereby attest that
(Property owner)
The attached survey, performed by 740r/a
(Name of surveyor's company)
For address: /0/90 /0E /2 Ode /"ion'' 5I7 Irs
TL
33/38
Performed on V? s /7i (date of survey) is an accurate representation of the existing conditions and
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property
without first providing a survey Tess than seven (7) years old old. The Affiant, as property owner, further agrees to
remove or obtain permits for any structures which now may exist on the property which are not permitted or which
may violate zoning or building code regulations. The Affiant further understands that the existence of any such
structures may affect final inspections as applicable to this or other permits.
Further, ay eth naught.
Property Owner Signature
Co+ ghoak.
Property Owner Print Name
SWORN TO AND SUBSCRIBED before me this day of a 2a /
Affiant is personally known to me, produced
as. dentificati
n.
`1rAY P;''•• BARBAR4 SOBRINO
MY COMMISSION # FF 195634
EXPIRES: February 3, 2019
c't pd.Fy, Bonded Tn.: Notary Public. Und
Revised on 5/22/2009/ Revised on 6/12/09
Notary
Mia Shores
mi %iiIIag
e
BuildingDepartment
partment
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Notice to Owner -Workers ComFax: (305) 756.8972
• ensation Insurance Exem •
tion
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida
allows Corporate officers in the construction industry to exempt themselves from this requirement for any construction
obtaining a buildingStatutes. Fla. Stat. §440.05
permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: project prior to
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 anoffccr 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: _
0 ner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this P1 day of
COLO I7 h S 400k-
By
Dec
,20 ip
who is personally known to me or has produced
as identification.
Notary:
,qe''•. BRRBAR:iSCBRNO
+c MY COMM SSiOiN # FF 195634
EXPIRES: February 3, 2019
Bon?ed Thru Notary UnCsrwritrr.F. -.
SEAL:
Paving Inc.
TO: a1 pal l S .th)Q- 5 V 1 LLQ GE PROJECT:
NAME: NAME:
ADDRESS:
PHONE:
FAX: DATE
Q5 pciJ as,/,
ADDRESS:
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CO3`v S W`0 S hox
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10C -.eJ! of /0/ 9v it -4 /�,4yE a 5313$
4044 s 04 0' Le of Lfee 'tee 4 -kr
[doe- SO Up 47 CketO5 oeSGo f%n.
BARBAN.; 30 21311,10
MY COM,,VISSiorv,1 FF 195634
EXPIRES. Febr;;;:y 3, 2019
•F„„5„, e5n?ed Thr Notary public Undecwntlrs
1463 NE 173 ST N. MIAMI BCH. FL 33162 PHONE: 786 2991354
FAX: 305 947 3233
TO:
Paving Inc. Proposal/Contract
CGC 1513719
PROJECT: 0,4 7
NAME: CGS, S'l" 1- NAME:
ADDRESS: % ADDRESS: 11» yo ►%)F /7-
U ►✓
sem}
PHONE: 9064 iro / 3
317
FAX: DATE I Z s// b
DESCRIPTIO
WE PROPOSE PERFORM ALL MATERIALS, LABOR AND EQUIPMENT NECESSARY FOR THE FOLLOWIG SCOPE OF
WORK:
Ott 57 Cit /l '/
„ 0 j t 7! S- I/�
lG 571_ ,a-
7'
The work and performed by the co may result in a lien being placed an the premises described above, in case the owner or contractor default its in any
payment under this contract owner hereby agrees to accept full responsibility for alt fences, sidewalks, as underground pipes, wires septic tanks, drain lines,
wells, etc. unless stated above. Owner is liable in full amount of contract in the event owner covets atter work has started. The co shall not be responsible
for damage or delays do to strikes, fires, accidents, or the others cause beyond its control, not for inherent defects in the premises on which work to be done.
In the event of any default of this contract by owner -owner agrees to pay all cost and reasonable attorneys fees incurred by One Stop Paving, Inc. as a result
of said default. All materials are guaranteed to be as specified. All work to be completed in a workman like manner according to standard practices. Any
alteration or deviation from above spedfications involving extra cost will be executed only upon written orders and will become an extra charge over and
above the estimate. This proposal subject to acceptance within_ days and is void thereafter at the option of the under signed work shall begin within 10
days Of this contract being signed by alt parties here and retum to the co. On stamp concrete work contractor will not be responsible for variation results on
the color select by Owner.
TOTAL PROPOSAL
SUBMITTED BY: Carlos Acos
Acceptance of contract
The above prices, specficatio s and conditions are hereby accepted. You are to do the work as
specified payment will be rd aS outlined above.
APPROVED BY:
DATE: 12 ;i /i&
1463 NE 173 ST N. MIAMI BCH FL 33162
PHONE: 786 2991354 FAX: 305 947 3233
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