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RC-16-2898 (3)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
BUILDING
PE MIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS: 8C1 IVFi Wei 4 1 (S+C{Pit
City: Miami Shores
Folio/Parcel#: (-/ - 2(3 - 01l -0 SS(3
Occupancy Type: Load:
County:
Construction Type:
Master Permit No.
Sub Permit No.
❑ REVISION ❑ EXTENSION
RECEIVEL
APR 24 2018
S
FBC 20N
�CI131 b 2$6a
El RENEWAL
[g CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
Miami Dade Zip:33/(0 )
Is the Building Historically Designated: Yes NO
Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Qq ►'llr 1 POLte,I
Address: Bci Ne 1 oc+
City: ivy) &U l l
State: FL_
Phone#: gS - (132 (o(p6
Tenant/Lessee Name: Phone#:
Email:
Zip:S3/ b I
CONTRACTOR: Company Name: SR- 12 0 1 Copliv�.cf u Co f Phone#: 5- �93& _No
Address: gyp, " 1 O SIASQo (* • J
City: coci,V1 State: FL Zip: 333
Qualifier Name: l /I 6AR) I 'n - - oni 0
State Certificatioh or. Registration #: G .C. is) Z 15 I Certificate of Competency #:
}
Phone#
DESIGNER: Architect/Engineer: - Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Z i 060
Type of Work: ❑ Addition Alteration w
Description of Work: .. t V {2, r 1'OQ' c,evk
Square/Linear Footage of Work:
❑ New ❑ Repair/Replace
wiotX e ir
i .
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's'Name (if applicable) .
Bonding Company's/Address
i
City f I - -- State Zip
Mortgage Lender's Name (if'applicable)
i
Mortgage Lender's Address
City „N 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 2 h
OWNER or AGENT
The foregoing instrument was acknowledged before me this
Z`mil
day of f\-pc \, ,20 ,e ,by
G 1p
JCtc1Y(J+1 Q.,1 , who is personally known to
me orwho has produced 'N 1 as
identification -and who did take an oath.
NOTARY PUBLIC:
S
Print:
Seal:
APPROVED BY
ARAI K. GONZALEZ
'**** MY COMMISSIS
•• :*- S: November 2, 2020
'O= Notary Pu • w ... .
•
•e- edThN
"4;a:N.0 Bond
Signature
CONTRACTOR
The fore oing instrument was acknowledged before me this
2. day of 47y-1 , 20 by
I/ W r c holis�Ce�rsUona I own to
l` I �1.� �1T�1 ��Nll, P �
me or who has produced 1 1 1(9,r) as
identification and who did take an oath.
NOTARY PUBLIC:
Sign
Print:
Seal:
Plans Examiner
Structural Review
1
1:a :P�'•. MAHARAI K. GONZALEZ
�� ,.. MY GVMMISoiON s Gu 044b02
"..°` ,o EXPIRES: November2, 2020
'•r„or ,.' bonded Thru Notary Public Underwriters
Zoning
Clerk
(Revised02/24/2014)
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 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: 71 1
Ov$ner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this 2LI day of Kr 11 , 20
By I QQ 1 () 1 1 ecou
i(QXI-0
who is personally known to me or has produced
as identification.
Notary
SEAL:
�:'�e'• MAHARAI K. GONZALEZ
• .�, •C = MY COMMISSION # GG 044602
d EXPIRES; November 2, 2020
,,f, •yes''' Bonded Thru Notary Public Underwriters
April 24th, 2018
State of Florida
County of Miami Dade
S L
BUILDING CONTRACTORS CORP.
SFL
CONTRACTOR
.COM
CERTIFIED GENERAL CONTRACTOR
Before me this day personally appeared Michel Alfonso who, being duly sworn, deposes and
says:
That he or she will be the only person working on the project located at:
89 NE 109th Street, Miami Shores, FL 33161
Michel Alfonso-1 to V YQ CIO
Certified General Contractor
CGC1512151,
Mobile 954-636-0101
SFL Building Contractors Corp.
6190 SW 56 Ct.
Davie, Florida 33314
PH: 954-600-4066 FAX: 888-908-1043
Email: michel.alfonso@sflcontractor.com
Personally know 11
Or produced identification Or
Type of identification produced
MAHARAI K. GONZALEZ
MY COMMISSION # GG 044602
EXPIRES: November 2, 2020
Bonded Thru Notary Public Underwriters
Print, type or stamp name of Notary
Owner's Name (Fee Sim le Title Holder):
Owner's Address: SLA-p_ t© `t.
City: 4,Ac' -Nc 'i\o ce S
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
r1[ CHANGE OF CONTRACTOR / ARCHITECT
Permit N. L i%ti `D4g
'SaQru 4;
Iket.Neudr PaAcA y pcot.e.k Phone #: 345•a8 t-65SCk
State : \O't`4.4�
Zip Code: 3 \ 6e
Job Address (Of where work is being done): E3CA, N. R. OSS. S*
City: Miami Shores State: Florida Zip Code: J 3 6 I
l J �
Contractor's Company Name: in ilk/Phone #:
Address: Inc; D pPGCv 1'-P.1✓
City: I\k i CAM
Qualifier's Name :
Or.
State:
F,
Architect/ Engineer of Record Name:
Address:
City: / State: Zip Code:
Describe Work: -*,t/ 'iGY�PiUG!/�!t'/CAi (bit/Ore k .Salo, h�n, /34/4rwwMS
hereby certify that the work has been abandoned and/or the contractor/architect
is unable or unwilling to complete the contract. I hold the Building Official and the
Miami Shores harmless of all legal involvement.
:cos - i i-q Rqi
Zip Code: \
Lic. Number: C - JS01 j.3 t 4-
Phone #:
Signature
Signature
The foregoing instrument was aknowledged orbefore me
this day of NIA I ,20 y� Y
Who is personallylyknow t me or who
as produced
as indentification.
MAHARAI K. GONZALEZ
MY COMMISSION # GG 044602
EXPIRES: November 2, 2020
Bonded Thni Notary Public Underwriters
e fore
this
who i
Contractor or Architect
ing instrument was aknowledged before me
day of 'QP 'S \ , 20 i gby
ersonally know "p me or who has produced
Notary,
Sign:
Seal:
blic:
as indentification.
y Dawn Marie Leighton
O, NOTARY PUBLIC
Si' STATE OF FLORIDA
Comm# GG110341
Expires 5/31/2021