EL-16-2307BUILDING
PERMIT APPLICATION
❑ BUILDING ELECTRIC
PLUMBING ❑ MECHANICAL
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
❑ PUBLIC WORKS
JOB ADDRESS: 6-7 A/ tV 9p1
City: Miami Shores
if*
FBC 20 N
Master Permit No 0-1 G— G- I
Sub Permit No. flj ` 23 0
❑ REVISION ❑ EXTENSION
❑ CHANGE OF
CONTRACTOR
❑ CANCELLATION
❑ RENEWAL
❑ SHOP
DRAWINGS
County:
Miami Dade Zip:
Folio/Parcel#:
Occupancy Type: Load:
Is the Building Historically Designated: Yes NO
Construction Type: Flood Zone:
OWNER• Name (Fee Simple Titleholder): 'AV r .S L L
Address: 7 2/ go/ k,d.� Ft. . re
BFE:
FFE:
Phone#: 3 '6 - gO2.. YO
City: /-l4tjr1! State: /Z, Zip: 33 /'3 /
Tenant/Lessee Name: / Phone#:
Email: 7 A' aS.fc e<afoo16.ris'
CONTRACTOR: Company Name: --1-4 (-12.e .eCa * e Gi
Address: /o / (/t(,' /(
Phone#: 7- '-g64/-909/
City: ft/Wf2(74/0_4,- State: 7--Z Zip: 773 2 2
Qualifier Name:77 t -z y 344,4,47 Phone#:
State Certification or Registration #: �G ' /3 0l0 c2 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ lefL� Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:'.a,?'-I-65- `7`0 ,e L'4 T9-yi,e'R /.7,(0.6-(7—
We c- �.s,�4 cl Zi 1,7'44, 7
5 Y
Specify color of color thru tile:
Submittal Fee $ SCJ Permit Fee $ '7'Z`s" 1) CCF $ •2 0 (��� CO/CC $
Scanning Fee $ w Radon Fee $ 28 DBPR-$ 3 e 38 Notary $
Technology Fee $ 1 - 6 0 Training/Education Fee $ Q ' C+T0 Double Fee $ 0
Structural Reviews $
(Revised02/24/2014)
Bond $ 0
TOTAL FEE NOW DUE $ • 9 G
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 rei pection fee will be charged.
Signature
OWNER or AGENT
CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
S— day of v-1 y , 20 7 , by e day of 7C,,1 ' , 20 % 4 , by
/VA do /a ��y, , who is personally known to ��J�� .Th4wyo , who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
•
##################******j yi�F#
APPROVED BY
(Revised02/24/2014)
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:;
rJaJ�r ( aiur�loNva81A
Seal: rJyJJ
.ri.i.r✓.r C�' 8311116
Bonded through tatSptii
Plans Examiner
Zoning
Structural Review Clerk
Miami Shores Viiiage
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Wo`rkers' 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 ACKNO LEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
State of Florida
wner
County of Miami -Dade
The foregoing was acknowledge before me this g $ day of 1E/1 V , 20.
By e < "14.k c g II who is personally known to me or has produced
as identificAtion.
•
ANTHONY i NUS
My COMMISSION MEM
XPIRES: FEB 23,ms
—t isl Stale NgINlCfi
J & J Telecom & Electric
10901 NW 11th Court
Plantation, Florida 33322
Date:
State of Wk.(
County of LE) \-6 6.6)
Before me this day personally appeared Timothy Bruno who, being duly sworn, deposes and says:
That he or she will be the only person working on this project located at: 62 ui 42 LUIVh-42 `e -s
FLO ck*v)v\
Sworn to (or affirmed) and subscribed before me thisr-day ofd-rsrC.2by I7\t o k c�Jk.A^0
I
Personally Know
OR Produced Identification
Type of Identification Produced
•
1St Stale MINIMS
-Pri
Ty
e or Stamp Name of Notary
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
County of Miami -Dade
The foregoing was acknowledge before me this (f day of d Cf , 20 16 .
By +f.z. c` .aQ(i L, C,4,ez,94 who is personally known to me or has produced
• s fir**`, n • • �•,,• . r�... . ,,.
as ider4l1 at' •'
alt.
SEAL:
iNTHONY M
MMISSIOl1
ES: ree�,em
Th 1St St
1
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit
Permit NO. EL -8-16-2307
Permit Type: Electrical -Residential
Work Classification: Alteration
Permit Status: APPROVED
Issue Date: 1119/2016 Expiration: 05/08/2017
Parcel Number
Applicant
67 NW 92 Street
Miami Shores, FL
1131010170140
Block: Lot:
VERO HOMES LLC
Owner Information
VERO HOMES LLC
Address
701 BRIECKELL AVE
MIAMI FL 33131-
701 BRIECKELL AVE
MIAMI FL 33131-
Contractor(s)
J & J TELECOM & ELECTRIC INC
Phone CeII Phone
(954)864-8091
Phone
(305)902-4660
Cell
Valuation:
Total Sq Feet:
$ 1,800.00
0
Type of Work: OUTLETS TO BE GFI AND TAMPER PROOF
Additional Info:
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$1.20
$3.38
$3.38
$0.40
$225.00
$3.00
$1.60
$237.96
Pay Date Pay Type Amt Paid Amt Due
Invoice # EL -8-16-61004
11/09/2016 Credit Card $ 237.96 $ 0.00
Available Inspections:
Inspection Type:
Review Electrical
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 certi - . the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constructiobove-named contractor to do the work stated.
November 09, 2016
- •-''gna ure: owner / Applicant / Contractor / Agent
Building ' epartment Copy
ate
November 09, 2016 1