DS-19-1385� RIECEINP-JE)
Miami Shores Village JUN Building Department BY:�S4
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
0 Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 d
BUILDING Master Permit No. `4 -2 1 z(�
PER IT APPLICATION Sub Permit No. - 30 S
UILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION RENEWAL
F-IPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS: N too S l �
City: Miami Shores County: Miami Dade Zip: 33
Folio/Parcel#:Is the Building Historically Designated: Yes NO
I
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): r�stlPt-t-� l-;' C _Phone#: -3L-5-s7:7-2 q-"Ai3
Address:
City: M (ir'M �} �fL-�'S State: Zip: 33 l5�
i
—Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: ST' _ 1 C Phone#:
Address: \�(o'> 0 s+
City: �f"A State: Zip: -27
Qualifier Name: Phone#: --?i� & ZC) 9 �15
State Certification or Registration #: C6• I Certificate of Competency #: Vt 2 31 --�-O b
I
DESIGNER: Architect/Engineer: Phone#:
Address: Ii City: State: Zip: r,
Value of Work fbr this Permit: $ 3�C�C'� `a v quare/Linear Footage of Work: �OD Sy�IT
Type of Work: ❑ Addition ❑ Alteration New U Repair/Replace ❑ Demolition
Description of Work: ids ►> '-K -)-Z� �ti">~� G 12 r '► -(L_ - 'x VL�J {
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Specify color i f .&1b1'th?--U tile:--.'
Submittal rtm ; ....... Pptlnit F4 $ _
Scanning Fee $
Technology Fee
Structural Revieinrs $
4
Radon Fee $
Training/Education Fee $
CCF $ .C.0/CC $
DBPR $ Notary
Double Fee -$$
Bond $ P)C-10
TOTAL FEE NOW DUE $ 1 / 1 . 3-3
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
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 build;nq permit is issued. In the absence of s4 ^o, }!ce
inspectior► will not be appFoved and a reinspection fee will be charged.
Signature nature
The f regoing instru
6 day of
OWNER or AGENT CONTRACTOR
wasacknowledgedbefore me this
Z1-1J1. 20 by
is personally known to
me Ir who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign: 1
PrinCGZI! D �2
Seal ..�.�Y �.. BETSY 0. PEREZ
W,—o
l Notary Public - State of Florida
Commission N FF 182380
My Comm. Expires Apr 3, 201
s4%(i`+r�i**Ddltl
APPROVED BY
The foregoing instrument was acknowledged before me this
t-7 day of �� SAP•-� 1 20 by
4A w.., 5 who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Print: \Oc-Y J r 1-'% u
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Seal: .N»•"� , - BAWROS0INRIN0
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+� e Expifts: ¢ebpmy 3, 2023
':To: �?•'-Randal �1MufJet=YPuYe°tli�dMwriMa
****************** *********
Plans Examiner Zoning
Structural Review
Clerk
(Revised02/24/2014)
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f; MY COMMISSION # GG 296168
EXPIRES: February 3, 2W
°F s BMW Thru Notary public V �
Notice to Owner - Workers' Corn
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:
I . 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:
Owner
State of Florida
County of Miami -Dade
h
The foregoing was acknowledge before me this day of 1l n�i 20) f
By ' `( `�� '� ' '" who is personally known to me or has produced
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f�a �'� �1 as identification. ��\���,pY
Notary: a � � Z� ��'`• �.
SEAL: 4W0gr •#�
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OWN4 W N 'ems