DEMO-17-225Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date:10/19/2018
Permit NO.: DEMO-1-17-225
Permit Type: Demolition
Work Classification: Plumbing
Permit Status: Approved
Expiration: 04/17/2019
Location Address Parcel Number Project
1569 NE 104 ST, Miami Shores, FL 1122320320160 <NONE>
Contacts
ALAIN & CARLY GONZALEZ Owner ALAIN & CARLY GONZALEZ Applicant
1569 NE 104 ST, MIAMI SHORES, FL 33138 1569 NE 104 ST, MIAMI SHORES, FL 33138
Mobile: 7862779756 Mobile: 7862779756
ORIGINAL PLUMBING INC Contractor
HARRIS HAUGHTON
Business: 9542743041
Description: MISC. PLUMBING DISCONNECTS Valuation: $ 350.00 Inspection Requests:
4949
Total Sq Feet: 0.00
Fees
Amount
CCF
$0.60
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.20
Permit Fee
$100.00
Scanning Fee
$3.00
Technology Fee
$0.80
Total:
$108.60
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$108.60
Credit Card
10/19/2018 $108.60
Amount Due:
$0.00
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 t e oing information is accurate and that all work will be done in compliance with all applicable laws
regulating constructs Futhermore, I au orize the above named contractor to do the work stated.
Authorized Signature: Owner / Applicant / Contractor / Agent
Date
October 19, 2018 Page 2 of 2
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
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
JAN Z 7 2017 1
0-571
FBC 20Iq
Master Permit No. o � S
Sub Permit No.he ' c) 1---I -?_ S
❑ REVISION ❑ EXTENSION ❑ RENEWAL
PLUMBING ❑ MECHANICAL` [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
.CONTRACTOR DRAWINGS
Q
JOB ADDRESS: Is( P T
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load:., Construction Type:. Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):_ AA Xs0 '(1>0 fJ- Z- Phone#:
Address: (S CP 9 GJ el i ck S 1
City: !al , -,q � I 6> V only _S State:
Tenant/Lessee Name:
Email
Phone#:
2
CONTRACTOR: Company Name: _DfLA��NA�� i✓(,cJ,.�r� l�L- Phone#:�C'
Address: jYl�,�
City: State: Zip: (o! .
Qualifier Name: S' 14 A c q 6-A Z J Phone#:
State Certification or Registration #: ( L e> S W Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ j4 35 Z) Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace El Demolition
Description of Work: t, i Su C_ P rho,;3 Yam. � Ca'J'T' 7-� s
Specify color of color thru tile: FF,�,
Submittal Fee $ 2 Permit Fee $ 6 / CCF $ d (0O CO/CC $
Scanning Fee $ 3 Radon Fee $ DBPR $ 0- Notary $ ^---
Technology Fee $ . 80 ' Training/Education Fee $ 2 C ^ J Double Fee $
Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ / I
08 - ro O
(Revised02/24/2014)
Bonding 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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 Signature=21q='
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this
day of F�, 201-) , by Ja%A.,3 l//6c,0 ZdtVL ,
who is ersonally known t e or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign: Z"
The foregoing instrument was acknowledged before me this
day of -T.44Vhr7l 20 %2, by //a /LIZ/ S t%' A4 /q
who is personally known to me or who has produced
as identification and who did take
v
Print: Gll(
My Commission Expires: ;1 7 BARBARA A ESTEP
4. .: MY COMMISSION # FF 073975
J! :a EXPIRES: March 29, 2018
Bonded Thru Notary Public Underwriters
***************************
APPROVED BY ' Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
NOTARY PUBLIC:
Sign:
��
Print:
My Commission
10 '496 4-7
*************************************
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JEFF ATWATB2
CHIEF FWINCIAL OFFICER 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: 1/21/2017 EXPIRATION DATE: 1I21/2019
PERSON: HAUGHTON HARRIS
FEIN: 201030278
BUSINESS NAME AND ADDRESS:
ORIGINAL PLUMBING INC
18001 N.W_ 2ND PLACE
MIAMI FL 33169
SCOPES OF BUSINESS OR TRADE:
LICENSED PLUMBING
CONTRACTOR
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win dm scope of tm beaNn m trade Ysbd on aw mbe of election to be asen 0 Purwad Is Caspler 440.05(13� F.S , Hoboes of akrmn to m
Um p � e nob a nMow to be �m bnyer nra requ arrmft of On ssacbon for ksow� u ofcwbk. s. The depsrbrsd sfW rewke a
DFS-F2DWC-252 CERTIFICATE OF ELECTION TO BE EXEMRT REVISED 08-13 _... - QUESTIONS? (850)413-1609
Page 1 of 1
ORIGINAL PLUMBING INC
CFC057806
18001 N.W. 2N' PLACE
Miami, FL 33169
TEL , 954-274-3041
Date
State
County of oc rt_
Before me this day personalty appeared r 2 +1 c.yLwho, being duly swan, deposes and
says
That he or she will be the only person working on the project located /yG— i
Sworn to (or affirmed) and subscribed before me this day of 164wif 20by
0
Personally know.
OR Produced Identification
Type of Identification Produced
t►RY C(,
CHI L. M
* * MY COMMISSION A FF
EXPIRES: March t ,
of Fttir�O! Bonded Thru Budget Notary Services
Print, type or stamp Name of Notary