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PL-17-2621Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Permit NO. PL-11-17-2621 Permit Type: Plumbing - Residential Work Classification: Pool - Private Permit Status: APPROVED Issue Date: 11/6/2017 Expiration: 05/05/2018 Parcel Number Applicant 1116 NE 92 Street Miami Shores, FL 33138- 1132050270420 Block: Lot: VICTORIA NEWTON DUNN Owner Information Address Phone Cell VICTORIA NEWTON DUNN 1116 NE 92 Street MIAMI SHORES FL 33138- (305)303-2906 1116 NE 92 Street MIAMI SHORES FL 33138- Contractor(s) NATIONAL POOL DESIGN LLC Phone (305)559-1020 Cell Phone Valuation: Total Sq Feet: $ 1,000.00 0 Type of Work: PLUMBING FOR NEW POOL Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $3.38 $2.25 $0.20 $225.00 $3.00 $0.80 $235.23 Pay Date Pay Type Invoice # PL-11-17-65544 11/02/2017 Check #: 21279 11/06/2017 Check #: 21322 Amt Paid Amt Due $ 50.00 $ 185.23 $ 185.23 $ 0.00 Available Inspections: Inspection Type: Main Drain Final Rough Review Plumbing 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 responsibi' _for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for E - AL, PL B - ECHANI • L, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS constructio all the forego g information is accurate and that all work will be done in compliance with all applicable laws regulating ove-named contractor to do the work stated. uthorize . - igna Owner' Applicant / Contractor / Agent November 06, 2017 Date Building Department Copy November 06, 2017 1 • et - ) Address: BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC 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 LUMBING ❑ MECHANICAL PUBLIC WORKS JOB ADDRESS: L1OZ g 0 AON QaAI FBC 201`f ZZ v Master Permit No. PP' 6 ^ 11 Sub Permit No -7L IA.— 2-' ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS 1110 N6 RZ S i City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: BFE: OWNER: Name (Fee Simple Titleholder): (tI� Ntr City: ?&fr 1 sj1gtr5 v I c-lo 12 4 N, DdItiNiPhone#: �Z ST State: Tenant/Lessee Name: Email: U1L,}09-4_K-itet) DtMIA% a rito 4,. Coll CONTRACTOR: Company Name: / c?� �' �` C� Desl 7 19 Address: 23 2.1 City: M( '% State: Qualifier Name: AZP - O ,-6de ,5 6L CFL t 51 State Certification or Registration #: DESIGNER: Architect/Engineer: Address: City: Value of Work for this Permit: $ it 000 Square/Linear Footage of Work: Type of Work: ❑ Addition U Alteration n New Phone#: NO FFE: 34S-3T1-1319 Zip: Phone#: 3- $5d / d 2, 0 Zip: 351 Z5 Phone#: Certificate of Competency #: Phone#: State: Zip: ❑ Repair/Replace n Demolition Description of Work: ,4Mbani Poa c� Specify color of color thru tile: Submittal Fee $ ' W Permit Fee $ Scanning Fee $ 5 Radon Fee $ -Z r 2-S Technology Fee $ • 13 © Training/Education Fee $ Structural Reviews $ CCF $ l.f< O CO/CC $ DBPR $ • 8 Notary $ Double Fee $ 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. Signature • OWNER or AGENT Signature cere CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 20 day of 04;1 , 20 C' .- , by V1G��i1� N DJlll&J , who is personally known to 111A/6 14c4aa, who is per 24, day of QGT , 20 me or who has prod identification and who did take an oath. NOTARY PUBLIC: Sign: Print:) limit Seal: ************* CRISTINA RODRIGUEZ Notary Public - State of Florida Commission * GG l)1516, OS164 sitirMOIN **Tim Expires May 16.2051 f. Bon `r .�' as me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: 6,114$111M4 geoid" Seal: 11- by n to as ******************************* CRISTINA RODRIGUEZ Notary Public - State of Florida Commission 4 GG 105164 My Comm. Expires May 16, 2021 Bonded through National Notary Assn. APPROVED BY �,,`i% -l' ' Plans Examiner Zoning (Revised02/24/2014) Structural Review Clerk r r Miami Shores Viiiage 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. Signature: State of Florida County of Miami -Dade The foregoing was acknowledge before me this l 6 day of By who ime or has produced SEAL: