PL-18-3144i
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: (30S) 762-4949 &7
FBC 204-:
v(15- 3
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.?L- (o -ca -3144
BUILDING ELECTRIC ROOFING 12f REVISION EXTENSION RENEWAL
PLUMBING MECHANICAL [:]PUBLICWORKS [:]CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: ' ' /O _3 -S-,
City: Miami Shores County: Miami Dade Zip: 4 313 0
Folio/Parcel#: t 1 aa06 a 1 ' i 750 Is the Building Historically Desigpate : Yes NO —
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): f"wN-V0 *14N Phone#:
Address: I Z lou* ST
City: `J{CJ ,-St/ate: Tc— Zip:
Tenant/Lessee Name: (M K Phone#: 7ft -554 -061
Email: 1-i 1"
CONTRACTOR: Company Name: Z V Phone#3iDs
Address: p Nv c .
City: State: Zip: 25IN
Qualifier Name:=1z,.j\ Phone#:
State Certification or Registration #: C. F C Z 3 o Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: Uz r City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: Addition El Alteration New Repair/Replace El Demolition
Description of Work: Con etY uXh
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ L CCF $ CO/CC $
Scapning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ LID
Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
cr
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 () days after the building permit is issued. In the absence of such posted notice, the
inspection will n an a reinjpion fe j will be charged.
Signature Signature
OWNER or AGE T CONTRACTOR
The foreggjng instrum was ack wledged before me this
day of 20 l by
who is personally known to
me or who has produced 15P 4_ as
The foregoing instrument was acknowledged before me this
X
Sn
day of 20 by
1 V (C t who is ersonally known to
me or who has produced
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
as
Sign: Sign•
i/'
O Print n
A G Print: 1//Gti•4 (iVr
cotary Public, e o on a
Seal: Commission# FF 987414 Seal: EmyLRARDI
My comm, ®xplt®x Mliy 29; ?gig GG 140466
r 04,,2026,
APPROVED BY ' (- XXlo t Plans Examiner
Structural Review
Revised02/24/2014)
a-,
Zoning
Clerk
Location Address
Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
142 NE 103 ST, Miami Shores, FL 33138
Contacts
Permit No.: PL -10-18-3144
Permit Type: Plumbing - Residential
LWork Classification: Addition/Alteration
Issue Date: 10/17/2018
Parcel Number
1132060131750
Permit Status: Approved
Expiration: 04/09/2019
Project
NONE>
FERNANDO YANEZ Owner FERNANDO YANEZ Applicant
142 NE 103 ST, MIAMI SHORES, FL 33138 142 NE 103 ST, MIAMI SHORES, FL 33138
Other: 3055103348 Other: 3055103348
ZJ PLUMBING & AIR CONDITIONING, INC Contractor
DAVID GONZALEZ
Business: 3055456950 ZJPLUMBING@GMAIL.COM
Mobile: 3052194806
Description: ONE NEW BATHROOM & KITCHEN REMODEL Valuation: $ 5,000.00
Inspection Requests:
305-762-4949
Total Sq Feet: 530.00
Fees Amount
Application Fee - Other 50.00
CCF 3.00
DBPR Fee 2.63
DCA Fee 2.00
Education Surcharge 1.00
Permit Fee 125.00
Scanning Fee 3.00
Technology Fee 4.38
Total: 191.01
Payments Date Paid Amt Paid
Total Fees 191.01
Credit Card 10/11/2018 50.00
Credit Card 10/17/2018 141.01
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
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 constructipn and zoning. Futhermore, I authorize the above named contractor to do the work stated.
Applicant / Contractor / Agent Date
October 17, 2018 Page 2 of 2
zi
C O ME' CAL R_E 1
896 SW 70" Ave, Miami, FL 33144 1 (P) 305-545-69501 (F) 305-262-13891 License No. CFC1429736
October 15, 2018
State of Florida
County of Miami -Dade
Before me this day personally appeared _00%' L'ci 6.0 LtZ , who, being duly sworn
deposes and says:
That he or she will be the only person working on the project located at:
V-2 4167 /D 3 S -f• Alm",, 33/3(?
Contractor Signature
Sworn to (or affirmed) and subscribed before me this —PS -o' day of De -66-z,"_, 2018,
By )2vLcl leL—
ADRIANA GIRARDI
MY COMMISSION # GG140466
OF EXPIRES: September 04, 2021
Personally know
Or produced identification
Type of Identification Produced
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
tion 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 ACKNOWL$DGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS. it t
Signature:
State of Florida
County of Miami -Dade
The foregoing was ack dg before me this llJ day of , 20
By_ who is personally known to me or has produced
as identification.
t'"'i% DANAYS DIAZ
Not='t 'e MY COMMISSION # FF997536
EXPIRES June 01, 2020
SEAL: poi „tee o s3 FW4&NaUtySerAc@.com
R. liami c%hn- res VillaiaA
rUie !; g DeIar tmms, e
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tei: (305) 755-2204 Fax: (305) 756-8572
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
BUILDING ELECTRIC 17 ROOFING
OCT 11 X018
Master Permit No. '?vC, - 6 - 18 - 170 R
Sub Permit No-JUL9 — -3 1 LIq
I REVISION EXTENSION QRENEWAL
PLUMBING MECHANICAL 17 PUBLIC WORKS ['I CHANGE OF Ej CANCELLATION [—] SHOP
E C
j•.,•,
p
COUNTRAC f Vit DJ RNi 11NG?
s012 ADDRESS; ( 4 a , E, I L J 1 • Z.'efADDRESS;
City: - Miami Shores County: Miami Dade zip: 331 3 S
Folio/Parcel#: Is the Building Histo, scally Designated: Yes NO
Occupangj Type: Load: Construction Type: Flood zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Yr E1C'-1y j1ub6 Phone#:
Address: / 4 a /" , C - / 03 5r
SW a2. (s,
Tenant/Lessee Name: Phone#:
Email:
CONTRACTIOP: Company Blame: zz- P I u V 1 n nl,o„o#• 2>:1-2_1 l -HgQi0
Address: Sol (!O S W -?-0 kv-0- -
City: VA I A. IA I 5ta rt- yip •; Y 1
Qualifier Name: Phone#:
C'cc / 'a% -73 ;'i?7 7±d u ru "t,+Y .yy 4!•
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: S 5, 00() _ Square/Linear Footage of Work:
FJC vi iir, n. nuuLLi Ji, r ita-, aaivii j lit -4V L_) n LNilii/.iln idCe- LJ v'Z,, YivuLiaili
Description of Work-
Sped
ork:
specify color of col(o/rr thru die:
5uinfliLtdi Fee f'eftrl i Fee 4
Scanning Fee S
ic6ifio-logy FCC 4.
Structural Reviews S
Hevised02114/1U14s
Ration Fee S
Li:P
DBPR S
Luj i:L
Notary 5__--___--
rJou6m Pet: J
Bond S.
a
Yoncling Company's Name (it applicable)
City
Nl-rtgign1 nnrl roc Pliamn
Mortgage Lender's Address
C;ty
State
St atc
Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certifv that no work or installation has
Corni-nenced 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: 1 certify ffiat all the foregoing Information Is accurate and that ail work will be done ir. compliance with ail
applicable laws regulating construction and zoning.
1AlADNIN17- WN n%Jk11UVQ- Vn11D CA11 I $PC Tt-t ocrnon A T RAAYN97kTIrCnCCnRfiRACNrllZRAVN
i i Iii ----• R P A Y I iii -3 7 ii i -A-- E F 0 ii i I-V' I P i i U-41, E I-Vi E ii T 5 T V- -i V- 6, i i -rte...,_,_,..-._ . I F Y 0 U Iii T E ii U-
TO OBTAIN FINANCING,, CONSULT WITH YOUR LEINDER OR AN ATTORNEY BEFORE RECORDING
1^1 Fn ^Ir AA f1Ir&10brft Ar!fW "
Y 4 %* i m&. #c 6.
iVotice to Appdcaijt: As u coociiilon to tirie issuance Of - 0 ouji 0 . I
I
ny penz-it With, on estiniatea vai - ue exceeu I II oy , 25&a rhie uppi - j , c an c ii-jusr
plot rise hi goodi6i6i that a cupy of Me notice of commeaceitietit atid coastructior-i 1'1ea ;&w iLorochure wih'be 6eiiveired to the Person
Whose properry is subject to Greaclinie jt. Ais&, u ceiviied coplor pitiie I U U IIUL Ltf U) L i -I 1) JSLt u70, 1. . the J U U" site
Full) litJu- r the first inspectioll Which occurs sever, j71 du) -N uJITC
rje coGryea..
it ie bul ...... Pell IS --7, issued. iri the aiisence of such posteu" notice, tije
Ii . Ilispectiol't writAct Cle 6rIlpfuVeo Uilu a icillsVeLefull 1
Sionattirp
WNE-n uf AGENTT
U U.
Yc71/who is r -o Iv knowA--
as
identifica an 4 ;e an oath,
J,
JOSE
SIGN W9510112
E.1111ES: Apdl 2,2020
01` FIV BoNed Nu Budget NoWy Ser*n
cSi!ratore
CU-NTRACTIOR
The foregoing instrument was acknowlei$#ed before me this
2, ua)i or26 6y
who is npmonallv known to
ille of W1iii ;)aS Piotiuced as
identification and who did take an oath.
Print; Adrixv-A
ADRIANA GIRARDI
MY COMMISSION # GG140466
PI RES: September 04, 2021EXNE9
APPROVED BY Plans Examiner Zoning
1Revised04i24/2L)14)
Structural Review Clerk
0/9/2018 02:09 PM PDT TO:13057568972 FROM:3052621389 Page: 1
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33133
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION FORM
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS
SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION ;FOR A $30.00 FEE PER YEAR.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. ' COPY OF QUALIFIER'S STATE LIC CARD
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT)
D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICEOF COMPETENCY OF QUALIFIER
B.
T COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT
C. ` COPY OF LIABILITY INSU RACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPTI
D. _ COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION
YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
s•s ss s s sssss.•ssesssssssssssssssssssisssssssssssss
COMPLETE CONTRACTOR'S INFORMATION
BUSINESS NAME:
BUSINESS ADDRESS: V 6 S 1t) Ci '44t, CITY Allwl-
STATE ? ( ZIP CODE .a 3 / VW
BUSINESS PHONE: (395- ) 5_5/5"L- 6"? -EQ FAX NUMBER (__dS
CELL PHONE J;,05- ,,2/S- D QUALIFIER'S NAME: .v1 r N +
QUALIFIER'S LIC NUMBER: 4, Fc f $/.2 9> 3,&
E-MAIL ADDRESS (IF APPLICABLE): -Z- fb 46/ n t, "'
i
Cromd an SM 2109 BY MUN / RV 3126109 MLOv
0/9/2018 02:09 PM PDT
005979
TO:13057568972 FROM:3052621389 Page 5
0/9/2018 02:09 PM PDT TO:13057568972 FROM:3052621389 Page: 2
CER'T'IFICATE OF LIABILITY INSURANCE F"--m(m*1Oo`YYYY)
TYPE OR INSURANCE
ADOL
X COMMERCIAL GENERAL LIABILITI'
CLAIMS A1ADE X OCCUR
10/9/2018
THIS CERTIFICATE IS ISSU913 AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATWELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the P0II0y(le5) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on
this certificate does not confer rights to the certificate holder in Iielu Of such endorsements).
PRODUCER
XA Andy Rodriguez Jr
ANDYS ASSURANCE AGENCIES
1441 W Flagler St
PHONE
a' S( 0$$42 gQ7 FAX
30S 643-5969
ai oRess: andyjr6andyeassurance.com
Miami, FL 33135 INSURERS AFFORoINy COVeRA MAIC s
INSURERA: Wesco Insurance Co
INSURED
Zi PLUMBING & AIR CONDITIONING INC
INSURER 5: ^
INSURER C; _
C INE P 51NOLE'UMIT Is
INSuRER 0;
BODILY IWURY (Per 4cdpcnt) $
896 SW 70 AVENUE INSURER E:
Miami FI 33144 INSURER F:
r%cvr arvu nMmOr-rv;
0/9/2018 02:09 PM PDT TO:13.057568972 FROM:3052621389 Page
JEFF ATWATER
CHIEF FINANICAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF: WORKERS` COMPENSATION
CERTIFICATE OF ELECTION TO BE EXEMPT.FROM FLORIDA WORKeRW COMPEN541TION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Cgmpensation law.
EFFECTIVE DATE: 3/13/2017 EXPIRATION DATE: 3/13/2019
PERSON: GONZALEZ DAVID
FEIN: 813580741
BUSINESS NAME AND ADDRESS:
ZJ PLUMBING & AIR CONDITIONING INC
898 SW 70TH AVE
MIAMI FL 33144
SCOPE OF BUSINESS QR TRADE:
Licensed Plumbing Contrador Heating, veatoawn. Mr.
ContWoning and Refrigard%n
systems InstelstiM. Service
antl Repair„ Shop. Yard b
DF+vets
IMPORTANT, Pursuant to Chapter 440.06(14), F.S.. an officer or a corporation who elects Exemption) from this chapter by filing acfrrtlficata of election under
this section may rat recover benefits or oompensation under this chapter. Pursuant to Chapter 440,05(12). F.S., Certilicetee of el"n to be exempt... apply
only vAtnln the scope Of the business or trade [fated on the notice of election to be exempt. Pursuant to Chapter 440:05(13), F.S.. Notices of elw%on to be
exempt and certificates of elactiOn to be exempt shall be subject to rev=bon if, at any time•after the tiling or the nQtiee or the iss"noe.'of the oartifuata, the
person named on the notice or cgraficate.no longer mee(s the requtrements of this section for iL%woe of a certificate. The deperfjrrent shall remke a
Certificate at any ume• for failure Of the person named on the rrertift®te to meet the. requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-11309
I