PL-17-2320 ~� Miami Shores Village
g RSC � D
Building Department SEP 7 2017
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305)795-2204 Fax:(305)756-8972 BY,
INSPECTION LINE PHONE NUMBER:(305)762-4949 � ----__
F BC 20 if S++^
BUILDING Master Permit No. 9,c,)-I- 131�,,
PERMIT APPLICATION Sub Permit No. P L Q _•Z310
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION DRENEWAL
• PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
q [� ` 1 p CONTRACTOR DRAWINGS
JOB ADDRESS: LO / Z� ,y C—_ /S fii S-�rZ"E Q
City: Miami Shores County: Miami Dade Zip: 3 3 S
Folio/Parcel#: ( -Sao 5- O(Qj —0 3$d Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): Cc>dy SA S4S Phone#:
Address: /vim e-xz S �"
City: 01;6wY1 t State: Zip:
Tenant/Lessee Name: Phone#:
Email: �� J n �7
CONTRACTOR:Company Name: Phone#:QZ
Address: /v�{� 7�(D �—� 7 [�
City: /� State:S'G� Zip: 3 71 6 7
Qualifier Name: Phone#:�� y�f r-3v��
State Certification or Registration#: O Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: rn City: State: Zip:
Value of Work for this Permit: J v Square/Lineaar--F-000tage of Work: �7�f-1 -5/,—
—
Type of Work: ❑ Addition Alteration fJ ❑ New \ 1�pair/Replace F— Demolition
Description of Work: //C�/KOIle 'LCC' -0 �3VA oi,�� ard sx IF �
Specify color of��color thru tile:
Submittal Fee$ `��5o id Permit Fee$ LJ'� r CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ 2 25 Notary$ 16
Technology Fee$ Training/Education Fee$ Double Fee$
;Structural Reviews$ Bond$
f. TOTAL FEE NOW DUE$ I �Z• (Y-::>
(Revised02/24/2014)
. � 1
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 approv an reinspection fee will be charged.
Signature Signatur
i OWNER or AGENT CONTRACTOR
The foregoing instrume t was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 201 , by day of 201 . by
who is personally known to , ho is personally kno to
me or who as produced �. L— as me or who has produced t3• kZ4-1CA47 as
identification and identification and who di
.N'.Ao ANGELICA DUTRA � ANGELICA DUTRA
Ay �,sr r
NOTARY PUBLIC: :°' \�� My COMMISSION#FF129�7 NOTARY PUBLIC: Vii' �°O�. MY COM
NOTARY
EXPIRES:JUN 04,2018 �Onded
IRES:JUN 04,2018
B ed th gh 1st State Ins nce °F hrough 1st State Insurance
Sign: Sign:
Print: Print:
Seal: Seal:
M�M�N�N�M:W�K M:WWN��K#:WW�N M:W k�WW WWN:M:�KWW:N:NW WWWWWWWM:WN:W�Y*M��N*WOK M:WN:WM:WN:W�N N�WWWWN:WW N�W:N+K N�N�N:M:N�M:N�M�M��MKK�N M�N�N�M�N�N�NM�M�N�N�M�N�N'N��hM�M�*�F�h Mih
n
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
�Sw.oREs
Miami shores Village
Building De prtment
�. g p .
r 10050 N.E.2nd Avenue
fiIORiD� 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:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this y of 20_t
By who is personally known to me or has produced
V' as identification. /
Notary: ANGELICA D
MV COMMISSION UTRA
SEAL: EXPIRES:JUN 04,2w
Bended through 1st State,,an Ia-
r
r. DRINGINAL PLUMBING, INC
18001 NW 2nd Place,Miami,FL 33169
P.954-274-3041
Date: O
State of T to r 1 rJ�
County of c L
Before me this day personally appeared tis .+ who, being duly sworn,
deposes and says:
t
That he or she will be the only person working on the project located at: f 0 f3 /J' Mx
FL. 3-3138
Contractor Signature
Sworn to (o affirmed) and subscribed before me this day of 20�
by
Personally kno
OR Produced Identification 2'bws Nca.cAV
Type of Identification Produced t
Print, Type or Stamp Name of Notary
ANGELICA DUTRA
? MY COMMISSION#FF129987
EXPIRES:JUN 04,2018
°F Bonded through 1st State insurance
ORIGINAL PLUMBING,INC
18001 NW 2nd Place,Miami,FL 33169
P.954-274-3041
r