PL-18-1254y�`
Miami Shores Village
`yNOREs
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
F><ORIDp'
Permit No. PL-5-18-1254
Permit Type: Plumbing - Residential
Perlill't Work Classification: Addition/Alteration
Permit Status: APPROVED
Issue Date: 8/2/2018 1 Expiration: 01/29/2019
Project Address Parcel Number Applicant
68 NE 91 Street 1131010200020
Miami Shores, FL 33138- Block: Lot: ROBERT IRWIN FLOYD GONZAI
Owner Information Address Phone Cell
ROBERT IRWIN FLOYD GONZALES 68 NE 91 Street (305)492-9763
MIAMI SHORES FL 33138-2808
68 NE 91 Street
MIAMI SHORES FL 33138-2808
Contractor(s) Phone Cell Phone
DOCTORS PLUMBING INC (305)602-0400
/pe of Work: PLUMBING AS PER PLANS
/pe of Piping:
dditional Info:
and Return :
lassification: Residential Scanning: 1
Fees Due
Amount
CCF
$1.20
DBPR Fee
$2.25
DCA Fee
$2.00
Education Surcharge
$0.40
Notary Fee
$5.00
Permit Fee
$150.00
Scanning Fee
$3.00
Technology Fee
$1.60
Total:
$165.45
Valuation: $ 2,000.00
Total Sq Feet: 0
Pay Date Pay Type Amt Paid Amt Due
Invoice # PL-5-18-67502
08/02/2018 Credit Card $ 115.45 $ 50.00
05/11/2018 Cash $ 50.00 $ 0.00
Avauame i
Inspection Type:
Top Out
Final
Review Plumbing
Underground
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
constructian aAd zoninm Futhermore, I authorize the above -named contractor to do the work stated.
August 02, 2018
Authorized -Signature: wne / Applicant / Contractor / Agent
Building Department Copy
August 02, 2018
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
FBC 20
BUILDING Master Permit No.���
PERMIT APPLICATION Sub Permit No. P(_Iy —1-2 L-;'�
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
]PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: O 'yC (S+ �; �•
Folio/Parcel#: It " 31 O I — C)20 — ()O?Z Is the Building Historically Designated: Yes NO
Occupancy Type: Load
OWNER: Name (Fee Simple Titleholder):
Address: I
City: ' u,N^'cS kotx-
Tenant/Lessee Name:
Email: %4[-)V12CA(0
Construction Type: Flood Zone
iA(o� G KZ��PS
S-�
State:
ctc) I, c z
BFE: FFE:
ne#: �J -C6 2— 9 76 -3
ne#:
ip: 3 313
CONTRACTOR: Company Name: D Oc� �s y"-� "I �Ci" `1 Phone#:
Address: (I 3 (L S L-J I SI -ie r✓
City: Lit 1 Q State: ip: 3 J 7
Qualifier Name: Re (h)C �j ✓,: 6 l Sr Phone#: % 04 Z gt ' N y5
State Certification or Registration #: (! r-e. - I L j Z 531 / L / Certificate of Competency #:
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $
Type of Work: 0 Addition
Description of Work:
one#:
City:
Square/Linear Footage of Work:
❑ Alteration ❑ New ❑ Repair/Replace
Zip:
❑ Demolition
Specify color of color
thru tile:
Submittal Fee $ `'� Permit Fee $ CCF $ CO/CC $ TT
Scanning Fee $ Radon Fee $ DBPR $ Notary $L V� /
Technology Fee $ Training/Education Fee $
Structural Reviews $
Double Fee $
Bond $ S
TOTAL FEE NOW DUE $
(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 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 $1500, 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 Si ure
OWNER or A UEN CONTRACTOR
The foregoing instrument was acknowledged before me this
—I day of t 20 �J by
,��� w�-- 0 1 o is personally known to
me or who has produced :0 � as
identification and who did take an oath.
NOTARY PUBLIC:
The foregoing instrument was acknowledged before me this
41/ day of aJZ,,20 / , by
g/� e— j ho is personally known to
me or who has produced % ���✓ ? �'�'� as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print'. 1 LEZ It Print:
Seal: MY COMMISSI�Oember(202 202 Seal: '"Y:: Eji7!,FCULTO
EXPIRES: N Underwriters °*• +: MY C0%,�; +wSiCA # PF 113884
BondedThruNotery�+b ? A EXPIRES:,lune 14, 2018
or h,r Bonded Tnru Notary Public Undenvdtsrs
s**s*rr****s#*ssrr**s*s*sx*r*rss*assss*****************rss**ss*s**r+ks*ss**rsss**#ss*st*srss*sssss*srs******s
APPROVED BY r�� / Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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, comaensation insurance txemnon
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:
l . 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.
,,,�,�C���
Signature:
Owne
State of Florida
County of Miami -Dade_
The foregoing was acknowledge before me this
day of , 20
By rr l, +UI 1 `7✓1` W
who is personally known to me or has produced
�n ,
cwr) as identification.
o=
z b
ado•
Nota
Q Q 4t z
SEAL:
W o y N
O
O
N
DOCTOR' S PLUMBING INC.
Date: UC /Z / //6
State of- Ro r i 4
County of- ►-�( <-"-4-�
Before me this day personally appeared
deposes and says:
cerN)e,'.)&
who, being duly sworn,
That he or she will be the only person working on the project located at:
6 6 to F 41 SI' (-%cSSI.-o,(e)
Contractor Signature
S to (or affirme ) and subscribed before me this d lday of JOAL 20 y,
by A�ux�-,c.d o *c- 4-
Personally know
Or Produced Identification
of Identification
Print,��Ap� or)Stai�A N
MY COMMISSION # GG 20dW
EXPIRES: April 18, 2022
BonW Tiw Notary Pdit UnderwrUere