PL-18-543c,�
Miami Shores Village
`yh°RCS
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
F�ORLOp'
Permit NO. PL-3-18-543
Permit Type: Plumbing - Residential
Peri'll'it Work Classification: Addition/Alteration
Permit Status: APPROVED
Issue Date: 4/4/2018 1 Expiration: 10/01/2018
Project Address Parcel Number Applicant
1080 NE 92 Street 1132050270400
Miami Shores, FL 33138- Block: Lot: GUCO HOLDING LLC
Owner
GUCO HOLDING LLC
Address
2700 SW 3 Avenue
MIAMI FL 33129-
2700 SW 3 Avenue
MIAMI FL 33129-
Contractor(s) Phone Cell Phone
K.A. STAR CONSTRUCTION INC (786)260-9420
,e of Work: REPLACE CAST FOR NEW PVC PIPE, AND
,e of Piping:
iitional Info:
id Return :
ssification: Residential Scanning: 1
Fees Due
Amount
CCF
$3.00
DBPR Fee
$4.50
DCA Fee
$3.00
Education Surcharge
$1.00
Permit Fee
$300.00
Scanning Fee
$3.00
Technology Fee
$4.00
Total:
$318.50
Phone
Cell
Valuation: $ 5,000.00
Total Sq Feet: p
Pay Date Pay Type Amt Paid Amt Due
Invoice # PL-3-18-66648
04/04/2018 Check #: 2556 $ 268.50 $ 50.00
03/02/2018 Credit Card $ 50.00 $ 0.00
Avauaore inspections:
Inspection Type:
Top Out
Final
Review Plumbi
Underground
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 addAoRiN. Futhermore, I authorize the above -named contractor to do the work stated.
April 04. 2018
Auth6rizecl Signature: Owner / Applicant / ontractor / Agent
Building Department Copy
April 04, 2018
1
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
Miami Shores Village
Building Department JARO 2 2018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY.
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 r:�G
Master Permit No. I=-C.I a - 1 z
Sub Permit No.-PL (P- �q3
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
OPLUMBING ❑ MECHANICAL [:]PUBLICWORKS
1080 NE 92N D Street
JOB ADDRESS:
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip: 33138
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): GUCo Holding LLC Phone#: (305) 926-0977
Address: 2700 SW 3rd Ave
Miami FI 33129
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email:
Juan@cpcoin.com
CONTRACTOR: Company Name: A ST0.'/ Phone#: Co 2co / Y
Address: / 6 l ry f'l
i V
City: AJ I V
Qualifier Name: G
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Certificate of Competency M
Zip:
Address: City: State:
Value of Work for this Permit: $ �500d • cv Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace
Zip:
❑ Demolition
Specify color of color thru tile: 40-7
Submittal Fee $ E0, M Permit Fee $ 300- CCF $ CO/CC $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
DBPR $
Notary $
Double Fee $
Structural Reviews $
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE $ �O
ding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
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 k—
OWNER or AGENT
The foregoing instrument was acknowledged before me this
_0 _ day of NA ( C �A 20 ( cf by
7u rnke C who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal:
.s
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
p0 k_ dayofOk&v L(n 20 l & by
V�E�Ld\ tJ 11QK�e`� who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
17—"� Sign:
Q'AA Print: A GtPA D
Mayra Carolina Montero Seal: o,X'P?.. 4 Mayra Carolina Montero
Commission # GGOM10 ' �Q.. `�� Commission GG077310
Expires: Feb. 27, 2021 =� "� Expires: Feb. 27, 2021
..
Bonded thru Aaron Notary "'��; . Bonded thru Aaron Notary
APPROVED BY I` U Plans Examiner
as
Zoning
Structural Review
(Revised02/24/2014)
Clerk
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Local Business Tax Receipt
Miami -Dade County, State of Florida
-THIS IS NOT A BILL - DO NOT PAY
7161311
CFC-2
CER+ {I-
4RNAN
�r.
K.A. _ Y ,r,
.'er e provi,ion- �: Cit 439 FS
W-Qwr
5 T r 0; Lvjz�EL rt
t:'Of T RACTO"R
d.rt NA : E , KE' ,f44
K.A._ SiAI? (3iiJi`iC, 1
IS CERTIFUED under the prov;s;or.s of Ch 489 FS
BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
KA STAR CONSTRUCTION INC RENEWAL SEPTEMBER 30, 2018
12640 COUNTRY CLUB LN 7439106 Must be displayed at place of business
MIAMI FL 33167 Pursuant to County Code
Chapter 8A - Art. 9 & 10
OWNER SEC. TYPE OF BUSINESS
KA STAR CONSTRUCTION, INC 196 PLUMBING CONTRACTOR PAYMENT RECEIVED
C/O KEVIN HERNANDEZ, PRESIDENT CFC1428924 S7 TAX COLLECTOR
Worker(s) t 5.00 07/18/2017
ECHECK-17-187103
This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license,
permit, or a certification of the holders qualifications, to do business. Holder must comply with any governmental
or nononvernmental reaulatory laws and requirements which auoly to the business.
JEFF ATWATER
CHIEF FINANCIAL OFFICER
I*.
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 6/5/2016 EXPIRATION DATE: 6/5/2018
PERSON: HERNANDEZ KEVIN
FEIN: 463522403
BUSINESS NAME AND ADDRESS:
KA STAR CONSTRUCTION INC
12640 COUNTRY CLUB LN
MIAMI FL 33167
SCOPES OF BUSINESS OR TRADE:
LICENSED GENERAL LICENSED PLUMBING
CONTRACTOR CONTRACTOR
Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a ceMcate of election under this section
may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only
within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be
exempt and certificates of election to be exempt shah be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate,
the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shah revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609
KA STAR CONSTRUCTION
Date:
State of FLORIDA
County of MIAMI -DADE
Before me this day personally appeared KEVIN HERNANDEZ who, being duly sworn, deposes
and says:
That he or she will be the only person working on the project located at:1080 ne 92"d St Miami
shore
Contractor Signature
w Prno(or affirmed) and subscribed before me this 1 day of MARCH .2018 by
Personally know
OR Produced Identification
Type of Identification Pro
��?i/b,, Mays tero
Commission # GGOM10
Expires: Feb. 27, 2021
r
Bonded thru Aaron Notary
Print, type or Stamp Name of Notary
Notice to Owner — Workers' Com
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
nsation 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:
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;
The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
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: ��" -k
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this O k day of GULL Vx 1 20j_&_.
By ` YC nD (76tQS who i em: nally kno o me or has produced
as identification.
Notary: a
SEAL: `,ok��?� ?�!�.,, Mayra Carolina ntero
= `�' Commission # GGOM10
s,. Expires: Feb. 27, 2021