PL-17-2144BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
PLUMBING ❑ MECHANICAL
G13 1V�
County: Miami Dade Zip: ! 3
Is the Building Historically Designated: Yes NO
JOB ADDRESS:
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
RECEIVED
AUG 2 g
54t4
FBC 2019
Master Permit No. 1-1- 1 I
�
Sub Permit No. �-11
❑ REVISION ❑ EXTENSION
❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION
CONTRACTOR
O RENEWAL
❑ SHOP
DRAWINGS
City: Miami Shores
folio/Parcel#:
Occupancy Type:
Load:
Construction Type: Flood Zone: BFE:
FFE:
OWNER: Name (Fee Simple Titleholder): 1��5 Phone#: 11 - 49'2--! 0"' j Ok-
Address: \ C� G IN\ ,4•47-1-4-
City:
i - City: )i 1 lei- w'"1 1 State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: 0 A.1 lCAI L-ovv'(:4't j C
'
Address: [To 01 NW (j v
City: ii II
Qualifier Name: POI ('Kis tl-oc
State Certification or Registration #: re- d 7 70
DESIGNER: Architect/Engineer: 4 tk h4 ,t -A tJ
Address: 1(A KW z�34-${ VJ.i -Q
Value of Work for this Permit: $ Zy 5425-0 b 0 1
Phone#: 9&f- - 74f 3o to
'7)//i a State:
Zip: 3/ 9
Phone#: l ti' -,2 77 -36
T /
Certificate of Competency #:
Phone#: 3.0c 1448^4 (3
p kao
City: Cf lk-12,n(,CE. State: F. Zip:
Square/Linear Footage of Work: S1, 5F
Type of Work: 0 Addition Z Alteration 0 New, 0 Repair/Replace ❑ Demolition
Description of Work: t-1.- Ex /....74-7 Xi g'$1ie0 D_ ii •&-i-vi� I' 1 /
ro,.-----..L, o ,<.-,-.12--.....,_ ct.„,,;( 4 ter PQ-- x,07 ohi.c2. .P.�
,r,-x_---47,—Ks2-------;--6, ._!,-----Ks-r;
fix -
Specify color of color thru tile:
Submittal Fee $ 5t) \--1v Permit Fee $
Scanning Fee $ Radon Fee $
CCF $ ' L/ CO/CC $ —r
DBPR $ 2 ' 2 $ Notary $ �—
Technology Fee $ (� • �V' Training/Education Fee $ v9 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.
//, la)
Signature t
b
OWNER or AGENT
The foregoing instrument was acknowledged before me this
'2729 day of -t2--t , 20 1'7 , by
p �
c 0511/41C
ifAV`D , who is personally known to
me or who has produced '4? aglike.S
identification and who did take an oilltllll//////
NOT PUBLIC: �����Av� �a•. ,44
Sign:
Print:
Seal:
1p2-# rt_ 104/ 2-207-77
11. kfrotkpahidr4010;44
APPROVED BY
(Revised02/24/2014)
133244
.45.°04.4t4'
moo -
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of Adjvs'T , 20 1'I by
,4 i r; i S , 4 ,9 h -foIJ , who is personally known to
me or who has produced f D L as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
Plans Examiner
Structural Review
4111
11111
•F•
MY COMMISSION # FF 234094
EXPIRES: September 18, 2019
Bonded Thru Notary Public Undenvritere
Zoning
Clerk
Date: //, g- •i
, R/ /
State of �4-,
ORIGINAL PLUMBING
180021 NW 2nd Ave.
MIAMI GARDENS, FL 33169
(954) 274-3041
County of �7fOaIg"rd
Before me this day personally appeared
sworn, deposes and says:
44ris 1-10“Ahl-eia
Thpt he or ale will be the only person working on the project located at:
R ®o t\ 6 ick c (2-1-A--C.b ►^k \/1 -VIA & *D ?_ 3 (?. Z
who being duly
Sworn to (or affirmed) and subscribed before me this 3'` day of 1
20 a , by ,L/G1-/'it3
r,rara
Personally known
OR Produced Identification
Type of Identification Produced
ANNETT L BARNES' wi zI
z .�;� Notary Public - State of Florida ,'Y"
E Commission # FF 939428
My Comm. Expires Jan 29, 2020 Print, Type or Stamp Name of Notary
nded through National Notary Assn. "
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
Abe 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.
Signatur
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this
BYOmUrd0QeI chi IIiPS
l IC-QA\S�Q�
Nota
day of OC,,'
,20 "
who is personally known to me or has produced
as identification.
SEAL:
"I\ 111■1117r1/11110111611011■01111.1111110111111mmomftWOMPININIMMIN
45!‘41:t*".
5"'" ' MAHARAI K. GONZALEZ
•41. MY COMMISSION # GG 044602
��� •,o EXPIRES: November 2, 2020
-d ThirPo.ry Public Underwriters