MC-17-2203Miami 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
BUILDING
PERMIT APPLICATION
El BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING liMECHANICAL ❑PUBLIC WORKS
JOB ADDRESS: 1 1 5 N g 103 5+
RECEIVED
AUG 3110A
FBC 2018
Master Permit No. V- (_ fl -2202
Sub Permit No. KC 1 - ZZ -O 3
❑ REVISION ❑ EXTENSION
❑ CHANGE OF
CONTRACTOR
❑ CANCELLATION
RENEWAL
❑ SHOP
DRAWINGS
City: Miami Shores p County: Miami Dade
Folio/Parcel#: J L 32-05-0 l 1 -005D Is the Building Historically Designated: Yes
zip: 33(3?,
NO
BFE: FFE:
Occupancy Type: Load: Construction Type: .y.,� Flood Zone:
•FiAl-FoRX7 NI
OWNER: Namei(Fee Simple Titleholder): Me/Si-AN DV 5k- +µ ,��1IJ�/ Phone#:iC6ZO19 t07
Address:V �' �' J ! ,�� A6t) `J { 1, ( vS+ `
City: NiI' M i/}/i State:
Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: _ \ NC, COVPt Phone#: Sa' 4J;C'6V5Q
Address: 1 I!J &2 6(.0444
et -
city: tow,'
State:
Qualifier Name: YOP \Y'Pfl.ctD trA.,
PL Zip:5+-
//��� n j Phone#:qpj(,? -2J°
T Ua
State Certification or Registration #: t_/��� f `R1 Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $ 50a eQ
Type of Work: ❑ Addition Iteration
Description of Work:
Phone#:
City: State: Zip:
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace ❑ Demolition
fAVF
k,,
Specify coloriof color,thru .tile: \F.;.
Q .t'S11t,X�
Submittal Fee $t ':-• •� •,-.,tiP t Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
-S/v\-kr-NO
6 ndletVt 1/10°
CCF $ CO/CC $
DBPR $ Notary $
4
Double Fee $
Bond $ k
(Revised02/24/2014)
TOTAL FEE NOW DUE $ ) 0 (' 35
rt,fr
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.
Signatur
OWNER or AGENT
The foregoing instrument was acknowledged before me this
*it t day of , 20 ( 7 , by
\IM - l(,!_ \1 , who is personally known to
me or who has produced-tr....c-,z j46 -'7 VYMas
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
NAM WW1 PI%/A:•-
APPROVED BY
(Revised02/24/2014)
NDREW IZAGUIRRE
MY COMMISSION # FF151364
oFFl--
°` EXPIRES: August 14, 2018
I
—Signature
IThe foregoing instrument was acknowledged before me this
'i1- d/a�y,of ' U(V ,20 I-4 ,by
VO Pi X1-0-.AGi)GZ , who is personally known to
me or who has produced e' rso - c, \7 /6,70Lart as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: L I CtrIA C rkn)-1
Seal:
Maria
son
�w o
t , �''- Commission# FF982867
"� "= Expires: April 17, 2020
*********
PI
s Examiner Zoning
Structural Review Clerk
COOL WIND CORP.,
16612 SW 114 CT
MIAMI, FL 33157
coolwindac@aol.com
305-879-6580
State of: IQrlc�cx
County of: rrNm. - Dad e
Before me this day personally appeared Yo el kfir, c+ dict who, being duly
sworn, deposes and says: C A 'Vt�
That He or She will be the only person working on the project located at: 1(50 I o3c .
MIAMI ���s �,. 33)3-,
Sworn to (or a it ed) and subscribed before me this 2,61 day of f+ v 905} . 20 L- , by
Contractor Signature
Personally know: QPrsonot I).( KA/X.0(A)
or Produced Identification:
Type of Identification Produced:
(SEAL)
Maria Carlson
,.� .fl _ Commission 1 FF982867
o ,;� Bonded thru April
on 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.
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this
By 1d % ii • l�ov�o
day of ,201" .
who is personally own to me or has produced
as identification.
Notary:
SEAL:•
ANDREW IZAGUIRRE
MY COMMISSION 4 FF151364
`44,0,0, EXPIRES: August 14, 2018