REV-17-2036BUILDING
PERMIT APPLICATION
`BUILDING ❑ ELECTRIC
Miami Shores Village RECEIVED
Building Department V
2017
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 �I
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 S -h
FB/C 20P
Master Permit No.
Sub Permit No._���
❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL
❑ PLUMBING 0 MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1460 1D 1uy-
City: Miami Shores County: Miami Dade Zip: 1
Folio/Parcel#: 1I -- 3 — b31— bad Is the Building Historically Designated: Yes NO
Occupancy Type: Load
OWNER
Address
Construction Type:
Flood Zone: &E-- BFE: FFE:
City:�I ou t w - - d State:
Tenant/Lessee Name:
ne#:
S's—
Email:
'—
Email: CL -n c j tip, rG i� cx n % Gr►t.L
CONTRACTOR: Company Name: �p rIwl of fVLlPA Phone#:
Address: � IIS'V% h i o)-nA
City: YVI4OAuc_k,
Qualifier Name: -1�
Zip:
Phone#:-45-�,6 ^2--�''qv
State Certification or Registration #: 1- Certificate of Competency #:
DESIGNER: Architect/Engineer:_ Phone
Add
Value of Work for this Permit: $ :A g 0 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
zip: 3 30 (o
❑ Demolition
Specify color of color thru the:
Submittal Fee $ Permit Fee $ —9'S ' G) CCF $ CO/CC $
Scanning Fee $ 7 Cn Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews
(Revised02/24/2014)
DBPR $
Notary$1; • 66
Double Fee $
Bond $
TOTAL FEE NOW DUE $
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. 1 understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... j
r`
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 wAe
a value xceedin 500, the applicant must
promise in good faith that a copy of the notice of commencement and cyen law br, h will be elivered to the person
whose property is subject to attachment. Also, a certified copy of the recof comme ement must a posted at the job site
for the first inspection which occurs seven (7) days after the building ped. In he absence such posted notice, the
inspection will not be approved reinspection fee will be charged.
n Signatur Signa
OWNER or AGENT CONTRACTOR
The foregoing instrumen was acknowledged before me this The frum/�ent was acknowledged before me this
day of u 20 1by -7 Vday of ft o ss - 20 1- by
o l t c who i ersonally nown to ADSL M Ovn-r i who is personally known to
me or who has produced as me or who has produced r, ✓'P If i `erase as
identification and who did take an oath. identification and who
NOTARY PUBLIC: NOTARY PO—BL-fiCk
Sign: Sign: A sJ z d
P ,, AY 40LOMAN
ri Print: 0►n ►'r
• Commission # FF 228649 --
Seal: N Seal:
My Comm. Expires May 10, 2019 :;a :'? ADYPRIETO
Bonded through National Notary Assn. MY COMMISSION M FF 214031
:•'a EXPIRES: March 25, 2019
Bonded ThruNotary PublicUndermriters
************************* ***************************************
BY
APPROVED yr Plans Examiner
0 l
Structural Review
(Revised02/24/2014)
Zoning
Clerk
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to uwner - 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:
ner
State of Flor1 a
County of Miami -Dade
The foregoing was acknowledge before me this /6 day of f , 20/.
Bwho i personally known me or has produced
as identification.
fare of Fl&ida-Notary FUMI
Commission # GG 118087
My Commission Expires
June 22, 2021