PW-17-1845Miami Shores Village
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address
Permit
Permit NO. PW-7-17-1845
Permit Type: Public Works
Work Classification: Public Works
Permit Status: APPROVED
Issue Date 7/27/2017
Expiration: 10/25/2017
Parcel Number
Applicant
29 NW 99 Street
Miami Shores, FL 33150-
1131010180520
Block: Lot:
QUICK EQUITY BUILDER INC
Owner Information
Address
Phone
Cell
QUICK EQUITY BUILDER INC
29 NW 99 Street
MIAMI SHORES FL 33138-
(954)605-7880
29 NW 99 Street
MIAMI SHORES FL 33138-
Contractor(s)
LONGA CONSTRUCTION INC
Phone
(954)254-0491
Cell Phone
Valuation:
$ 500.00
Total Sq Feet: 180
Scanning: 1
Available Inspections:
Inspection Type:
Excavation
Review Public Works
Final Public Works
CAtiz
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Notary Fee
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$0.00
$o.00
$0.00
$0.20
$5.00
$100.00
$3.00
$0.80
$109.00
Pay Date Pay Type
Invoice # PW-7-17-64621
07/27/2017 Check #: 1610
Amt Paid Amt Due
$ 109.00 $ 0.00
to
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 ELE 3RICAL, PLU G, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNER
constru
at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
ore, I authorize the above -named contractor to do the work stated.
ner / Applicant / Contractor / Agent
Building Department Copy
July 27, 2017
Date
July 27, 2017 1
w C
Miami Shores Village JUL 19 2017
Public Works Department
(305)795-2210 By.
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 33138.
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#: 1))-5 17 i' 7 ('
Name of Applicant (if utility see below):
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address:
UTILITY NAME:
�41y‹,A
Qualifier/Authorized Agent: r i yr L a-i 4, A
Address:
City: _ State: ZIP:
Telephone: 15142 2 s.'1 U%4 ( Email:
State Certification or Registration #: 2'(7 2- 5" S Certificate of Competency #
CONTRACTOR NAME: to )C/€?,
Qualifier/Authorized Agent:
Address:
City: State: ZIP: CJCEL[EO
Telephone: Email:
State Certification or Registration #: C6C ace ? L s 5 Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: t.S4-r n i4-f s ' ;4 ,.,"'
r Type of Work: �aving ❑'"Utility Sidewalk ❑,I�t �ic ❑ Irrigation
❑ Landscape )f ntenna ❑ Other:
w
DESIGNER: Architect/Engineer:
Address:
City: _ State:
Telephone: Email:
Registration #: _.
ZIP:
Value of Work for this Permit: $ _� • Square/Lineal. Footage of,Work:,, ( CA
***** Fees
*****; r.•,;t
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ I6. . Q
Bonding Company's Name (if applicable):
Bonding Company's Address:
City: State: ZIP:
Application is hereby made to obtain a public works permit to do the work in the right of way 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, regulation construction in
this jurisdiction. I understand that separate permits must be secured for
APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be
done in compliance with applicable laws regulating construction and specifically construction in the
right-of-way.
"WARNING TO APPLICANT: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN
YOUR PAYING TWICE FOR IMPROVEMENTS TO THE RIGHT-OF-WAY. 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 public works permit with an estimated value
exceeding $2,500, the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is issued. In the
absence of such gQsted notice, the inspection will not be approved and a reinspection will be charged.
ov
Signature
Appli
The foregoing inst
me this it d
is personally known to me or
1.4
identification.
NOTARY PUBLIC:
Sign:
Print: 0--ik`I O vi
SEAL:
t orized Agent
acknowledged before
20 11--by
who
duced
as
igil.i% ; JILLIAN A TAIPALE
'"' 19 MY COMMISSION # FF987003
I �• EXPIRES April 27, 2020
(do7) 998-0t51 Florid.NoteiyServb°•oom
APPROVED BY:
2017-04-15
Signature
Company/Utili Agent
The foregoing instrume was acknowledged before
me this I day of , 20 ( - , by
OSea - ONEi J e
n to me or who has produced
7 as
Lversonal
1- \jam
identification.
NOTARY BLIC:
Sign.
Print: ciNPIL.
SEAL: ''',r1r'vv"4^rNrtir•
o• ar nO Notary Public State of Florida
> : . Sindia Alvarez
• y, My Commission FF 156750
,0,0.Expires 09/03/2018
who
******#$********************************
, Public Works Director, or Designee
,
t.
LONGA CONSTRUCTION
Date: _ t 11 V2-0 ( 4
State of LUN-2-1 DA
County of pt1,,1, zt,k_
Before me this day personally appeared C) i .1a2 JJ who, being duly sworn, deposes and
says:
That he or she will be the only person working on the project located at: Z9 NV'/ 9Ci
Contractor's Signature
Sworn to (or affirmed) and subscribed before me this I % day of 3 U L 2O n-, by
Ogcsvo Los 2
Notary Public State of Florida
' Sindia Alvarez
My Commission FF 156750
Expires 0910312018
Personally know
OR Produced Identification
Type of Identification ProducedTL- a kk-g—
L I ek---Ns.
Print, Type or Stamp Name of Notary
4
1111111masr
iami
hores
illage
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 ACKNOWL ! . E THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
ner
State of Florid
County of Miami -Dade
The foregoing was acknowledge before me this l day of
BY -Pa D` 1-0,\0 il)
`0(tVQ_ L\ c•e-n S-e
Notary:
SEAL:
4 •
, 20
who is personally known to me or has produced
as identification.
•
''•; JILLIAN A TAIPALE
z' Pr •s MY COMMISSION # FF987003
+, •
,a,• to EXPIRES April 27, 2020
(407) 3980153 FbridlNolery$Nvice.mm