PL-19-1230Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
T�2a
Issue Date: 06/20/2019
Location Address Parcel Number
29 NE 109TH ST, Miami Shores, FL 33161 1121360040600
Contacts
Permit No.: PL -05-19-1230
Permit Type: Plumbing - Residential
Work Classification: Gas
Permitstotus. Approved
Expiration: 12/17/2019
JACQUELINE GONZALEZ Owner ELITE GAS CONTRACTOR INC Contractor
29 NE 109TH ST, Miami Shores, FL 33161 RICHARD HARVEY
Mobile: 3052818409
Business: 7863330679
Description: NEW GAS LINE FOR STOVE Valuation: $ 500.00 Inspection Requests:
05-762-4949
Total Sq Feet: 593.50
Fees
Amount
Application Fee - Other
$50.00
CCF
$0.60
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.20
Permit Fee
$50.00
Scanning Fee
$30.00
Technology Fee
$2.50
Total:
$137.30
Payments
Date Paid Amt Paid
Total Fees
$137.30
Check # 109
06/20/2019 $137.30
Amount Due:
$0.00
Building Department Copy
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
pertaininghereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. Inccepting 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
re a in nstruotion and zoning. Futhermore, I authorize the above named contractor to do the work stated.
re: Owner—T—/ Applicant / Contractor / Agent
June 20, 2019
6(,/2o/2i�q/
Date
Page 2 of 2
Miami Shores Village
REC'777",TED
Building Department J�; i15
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 BY: AQ
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 1-:1 ofi
BUILDING Master Permit No C.R
10 - I� "-30 I
PERMIT APPLICATION Sub Permit No1- (_--(j l 123
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKSHANGE OF F-1CANCELLATION [—]SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 01 POE 10 1 S�-'�
�r `
City: Miami Shores County: Miami Dade ( Zip: 331 a l
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): kliah (91/i,"Z Phone#:
Address:
^( I� L I�� c.zk r"u
City: State: I Zip: 33[(a
Tenant/Lessee Name: Phone#:
Email:
't t2,11A(V
1-- '1eob 1.7 b 4
CONTRACTOR: Company Name:LI
-
t
'
Qp�+ice-c7r,�
r
Phone#:
Address: / S�ZS" 14J 3S- P/-
City:
G
City: f///9 [El If State: zip: 3.9 e12
Qualifier Name: /?! C HAA6 #*,e ✓E y Phone#: 7,N^ 333 _m 6 79
State Certification or Registration #: 2 `f `f 3 7 Certificate of Competency #: Z
DESIGNER: Architect/Engineer:
Phone#:
Address: ' City:
Value of Work for this Permit: $ �D Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace
M
❑ Demolition
t Description of Work: 1?,VW i4 V,47Z112*Y Ad HAM= )IZWAY' E'x15n t/6 A14 ff7Altr- 601 -V&y0'7L"0
__ %� C�.f/.t/�Y" s3 �.✓K�S ct,�,gT� �6�6�L, �wC /zs�D2 /2.d�/6�' Fyiy.�E .�N�1
Specify color of color thru the:
Submittal Fee $ Permit Fee $
y Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
CCF
DBPR $
CO/CC $ .
Notary $
Double Fee $ _
Bond $
TOTAL FEE NOW DUE $ 13-p 30
.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 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved an reinsp ' fee will be charged.
Signature Signature
R or JGENT ONTRACTOR
The foregoing instrument was acknowledged before me this
day of c J u w% -Q— . 20 19 by
who is personally known to
me or who has produced (4KO L t as
identification and who did the an oath.
NOTARY PUBLIC: �►
Sign: (;l�(� �2 ALUO(V `0AXe kO
Print: �����00 AAe, r0
Seal:
The foregoing instfument was acknowledged before me this
00 day of 20 19 by
/rafi��i921��'% who is personally known to
me or who has produced
KV
identification and who did take an oath.
N��11UNIIIIIfI/�/��
NOTARY PUBLIC: G �Z
'VO�Y23,2 ip !�L
Sign:
Print: fG0 210ii60
Seal:
.'$'ye0�ead
+" JARDIEL ABREU ROMERO �y,�i9r •• " di
MY COMMISSION # GG064945
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami Shores Village RVCF,\jE®
Building Department kA N1 291010
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 �l'
FBC 20«
BUILDING Master Permit No. \D-1 5-W\A-
PERMIT APPLICATION Sub Permit No.? -C - Irl -1230
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
03 UMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
JOB ADDRESS: zo 4- e A
DRAWINGS
City: Miami Shores County: Miami Dade Zip: 3316
Folio/Parcel#: � 121 �5>� 004 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): (r L Phone#:(3051 O IOC�
Address: a N f_ ( d-1,
City: State: =F l o C Zip:
Tenant/Lessee Name:
Email:
KAN
v ' I
CONTRACTOR: Company Name: _FOE�p y �U Tc?-C:1�-V1 -S CO 4V - Phone#:3QL- •/ —7 2
q p"
_1 %
Address: J�O JAVV�A- C� L� iZ_-
City: State: Zip:,!^ �] ��
Qualifier Name: �1 rnM V CA-� U 1=/LD � Phone#: 3l,c.�I 'l, 6 T-�(�
State Certification or Registration #: (5, Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:,�pp City: State:
Value of Work for this Permit: $ :b5 QO Square/Linear Footage of Work:
Type of Work: L!_I Addition ❑ Alteration \ ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:�„�'
Zip:
Specify color'of, color'thru tile: "
Submittal Fee $- - Permit•Fee $ CCF $ _ , CO/CC $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
DBPR $
Notary $
Double Fee $
_ Bond $ _
TOTAL FEE NOW DUE $ (3l - 30
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
E.
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 approked and a reinspection fee will be charged. n
Signature( - /\Ilt Y \ I Signatu
ER or AGENT l _ '/ / / CONTRACTOR
The foregoing instrument was acknowledged before me this The fckegoing in rumennt�w{as acknowledged before me this
day of � 20by day of 'v` 20 by
J mem — N!:2ho is personally known to2,/who is personally known to
me or who has produced. 7�f17C� u���s me or who has produced C-4✓b'421-1d .393 0 as
identification and who did take an oath.
NOTARY P
Sign:_
Print:
identification and who did,take an oath.
NOTARY PUB
Print:
Seal: SINDIA AIVAREZ Seal::►"'•. JACQUELINE GONZALEZ
MY COMMISSION N GG 238273'i MY COMMISSION # GG092580
o EXPIRES: September 3, 2022 EXPIRES April 10, 2021
I .•.P ,'x.11
ndedThruNotaryPublir.UncSerarltars
****************** ********
APPROVED BY ��� Ci ��/Q_ Plans Examiner
Structural Review
(Revised02/24/2014)
Zoning
Clerk
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 YOUI ACKNOy TGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of �� 20.
who is personally know to me or has produced
as identification.
Notary:
SEAL: SINDIA ALVAREZ
_r°•' `?
MY COMMISSION # GG 238273
Bonded Thru Notary Public Underwriters