REV-17-2284Address:
JOB 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 `j h
Ff�BC 201L/t //__
Master Permit No. RZV / 76 9io
Sub Permit NjJ _
❑ EXTENSION ❑RENEWAL
RECEIVED
SEP222011
❑ ROOFING
❑ REVISION
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
?t7 N� 574-
❑ CANCELLATION ❑ SHOP
DRAWINGS
City: Miami Shores County: Miami Dade
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: _ Load: Construction Type: Flood Zone: BFE:
Zip: 33/36
NO
FFE:
OWNER: Name (Fee Simple Titleholder): V 7 6/Wl'L Phone#: 772 2 3/ c I?-7
City: / "(/ of 144 % %fly / ' State:
Zip: 33/ /
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Q ks(7Zc Q/
g-i C
Address: C CD �u' Q% 01 Or i4 Pr 3(i%
City: State: 7- zip: 3 3 / 7 'g
Phone#: Z q ci
Qualifier Name: 6,--t'/+-/VO el E' (QOESA-,2A- - Phone#:
State Certification or Registration #: ± e `c dl/ 7/-ge Certificate of Competency #:
DESIGNER: Architect/Engineer:: Phone#:
t
Address: City: State: Zip:
Value of Work for this Permit: $ 3) r 0'U ' C 0 Square/Linear Footage of Work:
;Type of Work: ❑-: Additjpn
4 Description of Work:
F.Alteration ❑ New
n Repair/Replace ri Demolition
Specify color of color thru tile:
Submittal Fee $ /`' Permit Fee $ 13S. OO CCF $ 80
Scanning Fee $ • q
Radon Fee $ 2.. DBPR $ •
CO/CC $ 0
Notary $ S , a
Technology Fee $ ' ! v Training/Education Fee $ 0 r00 Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $ 1 2. I • 00
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name Of applicable)
Mortgage Lender's Address
L _
City - + \ cA. 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 of 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 ap. . ved an.. reinspe o ee will be charged.
1,
Signature
l
iv
Signature
OWNER or AGENT CONTRACTOR 1 ,+ t ! ' t
V
The foregoing instrument was acknowledged before me this ,The foregoing instrument was acknowledged before me this
2 day off' F4 20 P by Z C , 3 day of
P\ -ihUr €X VI V", who is personally known to
me or who has produced 4i ,1 as
identification and who did take an oath.
s
me or who has produced
•
plt.y� ,20 � , by
go is personally known to
identification and who did take an oath.
NOTARY PUBLIC: NOT
S
Print:
Seal:
'MAHARAI K,GONZALEZ
EXPIRES: November 2, 2020
t"
`. Sign:
Print:
Seal:
Y PUBLIC:
as
s YPc •., MAHARAI K. GONZALEZ
•, MY COMMISSION # GG 044602
N ▪ EXPIRES: November 2, 2020
••,FOR 2o,• ▪ Bonded Thru Notary Public Underwriters
*********************************s**ss*s**s****s****ss***s**ss****s***ss*s******s***ss*******ss*sr*s*s******
APPROVED BY Plans Examiner Zoning
Structural Review
Clerk
(Revised02/24/2014)
4W
Notice to Owner — Workers' Com
p
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
ensation 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 a co tractor's company for day labor, part-time employees or subcontractors.
BY SIGNING BELO YOU HAT 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
1
By i Y-VIv r 60 ht.),
Tr►veY t i C7 fS
Notary:
SEAL:
2-7
day of
NOv-embrr, 20 1? .
who is personally known to me or has produced
as identification.
YANADY PRIETO
MY COMMISSION # FF 214031
EXPIRES: March 25, 2019
Y••Bonded Thru Notary Pubs inns