EL-16-2250 �f• �� Miami Shores Village ,- - ,ITVED
k
Building Department AU o 2016
10050 N.E.2nd Avenue,Miami Shores, Florida 33138 1- ' :
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 h
FBC 20M
BUILDING Master Permit No. 5 - 16_ 14 q
PERMIT APPL ATION Sub Permit No.�L ((o -2250
QBUILDING ELECTRIC ❑ ROOFING REVISION EXTENSION DRENEWAL
I
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
k'Q WADDRESS.. 19 0 K)IJ 100 Te v ro,C!e
City: _ �M ii Sho es Countv: Miami Dade Zip:
.olio/Parce. I1-31 U 1 -O d3 -O aso Is the Building Historically Designated:Yes NO
�Occcuuppa-n-ccy Type: Load: Construction Type: Flood Zone: BFE: FFE:
WO NER:Name(FeeSimpleTitleholder): �uZ �_\erG I�crc� Phei;: SUS 5_4 S.SSa
ddress. I�tO A)l,� QUO kerracc, ` �i
tcitv'1 Mair, S W/C � TL zip:--tf 33 ISO
Tenant/Lessee Name: Phone#:
Email:
'J)CONTRACTOR:Company Name: Orto, Wei-e44_ Phone#: g.Fb -rcrd V
Address: 9$ 6 l 0j
t
City: �✓►'►- State: zip: ��3�3
Qualifier Name: ` j�p Phone#: 3U� '
State Certification or Registration#: � 3�to a1.7 l Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
i
Type of Work: ❑ A 'on Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Descriptionof�Sr. �"` `C— �. .^ G.r-o_-cc..
Specify color of color thru tile:
Submittal Fee$ 0 Permit Fee$ CCF$ CO/CC$
Scanning Fee$ W Radon Fee$ - DBPR$ Notary$
Technology Fee$ �' Training/Education Fee$ 20 Double Fee$0
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ G �f �rO
(Revised02/24/2014)
;-J-
Bonding
,,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.
i
Sign'at Signature
OWNER or AGENT CONTRA OR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this�day of 1 / 201 , by 254k da of U 20 1� by
Z who is personally known to V Id T'I who i ersonally n t
me or who has produced P� as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: d Al�CA IfrLQ7- Print:
�.o;•••.,�� VERONICAPHWPS
Seal: Seal: MY COMMISSION#EE833708
k * MY COMMISSION t FF 068609 ,k
m EXPIRES:February 22,2018 ?%f• Q'�, EXPIRES September 15,2016
OF G' Bonded ThruBudgetNobryServlceS ��
(4071398At53 Flonrvice
dallotarySe .com
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
,• (lSJ
ELECTRIC SERVICE INC.
DONE WRIGHT A/C & ,
y' 10711 SW 216TH STREET,SUITE 109-MIAMI,FL 33170
2 .; (305)851-2137-FAX(305)278-9218
AW
State of 'F l0 r(d Q
County of Mi arni -'bade.
`Al 1
Before me this day personally appeared �QV t VV rl Yt who, being
duly sworn, deposes and says:
That he or she
(� /
will be the only person working on the project located
at
Sworn to (or affirmed) qnd subscribed before me this day of AUq US- 20 /4,
by
Personally known
OR Produced Identification" .ate•�, 3
7.
r � 1 {
Type of Identification Produced
x
Signature of Affiant
.. 'J')
-
' '� PRISCILLA ALEXANDER
MY COMMISSION#EE833708
Signature of Notary # },, �N rJY �'? '• EXPIRES September 15,2016
1(407)398.0153 FloridallotaryService.com
Ert set ti. CIE W- Ir
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Print, Type or Stamp_-Namerof Notary'
... . t .- a. _ ��;ye,��ti'•:'S;s r:Ww-,. _F.�}..3...:_.-S.r I�.,_..:a __,:ci �F,��`_.' 4 �_s-.,.>
♦5NORES G!
Miami Shore' s Village
Building Department
FNTes�N$ 10050"N.E.2nd Avenue
ORiDp' 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. I 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 covera e from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNIN BELO YOU ACK WLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
' I
Signature:
Owner
State of Florida
i
County of Miami-Dade
The foregoing was acknowledge before me this day of ,20
By Luz_ FLr--(11, i-Ep-P, who is personally known to me or has produced
Tl, D21 - LIC nJ as identification.
Notary:
000 PP*., Notary Public 3tata of Florida
SEAL: Sl N-p[p, % Sindia Alvarez
g My Commission FF 196956
Expires 00/03/2019
3
i
Permif No. L-1846-2250
6-2250
�aH°mss of Miami Shores VillagePetmit,Type:'EleCtl'ICaI -Residentlal
10050 N.E.2nd Avenue NW
�Perm!"t'
I/ltcrticCt ssatcettor�:A�fditlbt fAtteratlon
Miami Shores,FL 33138-0000 perrrttf Status:'APPROVED
Phone: (305)795-2204
torcYOA ,
Issue;oats:8/16/2016 Expiration: 02/12/2017
Project Address Parcel Number Applicant
190 NW 100 Terrace 1131010230250
Miami Shores, FL 33150- Block: Lot: LUZ ELENA LERA
Owner Information Address Phone Cell
LUZ ELENA LERA 638 NE 97 Street
MIAMI SHORES FL 33138-2471
Contractor(s) Phone Cell Phone Valuation: $ 6,000.00
DONE WRIGHT A/C AND ELECTRIC S
------ Total Sq Feet: 1
Type of Work:INTERIOR REMODELING OF KITCHEN Available Inspections:
Additional Info: Inspection Type:
Classification:Residential Final
Scanning: 1 Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Review Electrical
W.W.
Underground
Fees Due Amount Pay Date Pay Type Amt Paid jDe Due—
CCF
CCF $3.60
DBPR Fee Invoice# EL-8-16-60941
$3.38 08/10/2016 Credit Card $50.00 DCA Fee $3.38Education Surcharge $1.P0 08/16/2016 Credit Card $ 194.36
Permit Fee-Additions/Alterations $225.00
Scanning Fee $3.00
Technology Fee $4.80
Total: $244.36
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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
accepting4Lhis permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
requireWFA
PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
0WNEc that the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construor au ize the above-named contractor to do the work stated.
August 16, 2016
Authorized Signat :Owner / Applicant / Contractor / Agent Date
Building Department Copy
August-16, 2016 1