PL-16-3463Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address
Permi�
issu
Permit NO. PL-12-16-3463
Permit Type: Plumbing - Residential
Work Classification. Septic
Permit Status: APPROVED
te: 12129/2016
Expiration: 06/27/2017
Parcel Number
Applicant
15 NE 104 Street
Miami Shores, FL 33138-2026
1121360120090
Block: Lot:
ABDUL S MUKHTAR CAMILLE H
Owner Information
Address
Phone
CeII
ABDUL S MUKHTAR CAMILLE HARRIS 15 NE 104 Street
MIAMI SHORES FL 33138-2026
15 NE 104 Street
MIAMI SHORES FL 33138-2026
Contractor(s) Phone
STATEWIDE SEPTIC CONNECTIONS (954)963-0082
CeII Phone
Type of Work: REPLACE SEPTIC TANK & DRAINFIELD
Type of Piping:
Additional Info:
Bond Return :
Classification: Residential
Scanning: 3
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Amount
$5.40
$4.50
$4.50
$1.80
$300.00
$9.00
$7.20
Total: $332.40
Pay Date Pay Type
Invoice # PL-12-16-62461
12/23/2016 Check #: 6208 $ 50.00 $ 282.40
12/29/2016 Check #: 6211 $ 282.40 $ 0.00
Amt Paid Amt Due
Available Inspections:,ram^
Inspection Type:
4i
HRS Approval
Final
‘46,06--
Review Plumbing
V
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 ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS 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. Futjiermpre, I authorize the ajbevs-named contractor to do the work stated.
Authorized Signature: Owner
/ Applicant
/ Contractor
/ Agent
December 29, 2016
Date
Building Department Copy
December 29, 2016 1
Miami Shores Viiiage
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
TeI: (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 a2-. day of eC_ , 20 I .
By who is personally known to me or has produced
Notary:
SEAL:
as identification.
JERRICA' L. ARMSTRONG
Notary Public - State of Ric :4Ii .!
,
Commission • FF 1975V
My Comm. Expires Feb 9, 2 J 1 s
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