PL-19-1995Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date:
Location Address Parcel Number
175 NW 98TH ST, Miami Shores, FL 33150 1131010240120
Contacts
Permit NO.: PL-0&19-1995
Permit Type: Plumbing - Residential
Work Classification: Alteration
Permit Status: Approved
Expiration: 03/03/2020
David Foley Owner INDIRA RAD GUTIERREZ Owner
17598
Home: 3056080714
R & I PLUMBING SERVICES Contractor
RENE GUZMAN
7898 NW 174 TER, MIAMI, FL 33015
Business: 3058236911
Other:7864136365
Description: PERMIT TO REPLACE PLUMBING FIXTURES Valuation: $ 1,700.00 Inspection Requests:
Total Sq Feet: 1,896.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$1.20
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.40
Permit Fee
$50.00
Scanning Fee
$3.00
Technology Fee
$2.50
Total:
$111.10
Payments
Date Paid Amt Paid
Total Fees
$111.10
Credit Card
08/28/2019 $50.00
Credit Card
09/05/2019 $61.10
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 construction.and zoning. Futhermore, I authorize the above named contractor to do the work stated. I
Authorized Sbnature: Owner / Applicant / Contractor / Agent
Date
September 05, 2019 Page 2 of 2
Miami Shores Village c ED
Building Department uG 8 2 19
10050 N.E.2nd Avenue, Miami Shores, Florida 33138��
Tel: (305) 795-2204 Fax: (305) 756-8972 BY:
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING Master Permit No. 2�? — b�S'?g'l0G_3
PERMIT APPLICATION Sub Permit No. Pt- o'6-7�1 'I iol S'
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [—]RENEWAL
)5NLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
Qi- CONTRACTOR DRAWINGS
�
JOB ADDRESS: l / S /
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO -
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):--L 0d2x, �� [�l Q , C2,2 Phone#:
Address:
City:
State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: V IAA G°� lL Phone#:
Address: Ct%
City: 4/ Alay_tl State: Zip:
Qualifier Name: 6 L"7J-/ LA-) Phone#:14
State Certification or Registration #: Certificate of Competency #: Q 3
DESIGNER: Architect/Engineer: Phone#:
Address: City: State:
Value of Work for this Permit: $ L� �� Square/Linear Footage of;Work:
r,,
Type of Work: ❑ Addition Alteration ❑ New Repair/Replace
Description of Work: -
Zip:
❑ Demolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $
Technology Fee $
Training/Education Fee $
DBPR $
Notary $.
Double Fee $
Structural Reviews $
(RevisedO2/24/2014)
Bond $
TOTAL FEE NOW DUE $GPI
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 and a reinspection fee will be charged.
Signature
O NER or AGENT
The foregoing instrume t was acknowledged before me this
1Z7 delay of (� 20 by
�r TlQC1 .Gu4;er who is personally known to
me or w)taJhas pro4asgd t\kP r l 1 (qaY as
tidenticationnd ho di' take an oath. �tl►►nn
C• ' "Y �.0
$
Q, �.A ' ►•► .
y y •;Z 7268
a'►Q ,`C �39� : a e o�'.:
� undo
Seal: //,STKi��Fo�
Signature ✓%��l�Lb ! �' YV
CONTRACTOR
The foregoing instrument was acknowledged beforemethis
_ day of j �- , 20 f / by
[� rJZ!-~/Buell who is rsonally known
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal:
ss*s*s**sssss*ss***ssssssssssssss*s*s*sss*ssssssss***ssssssss
APPROVED BY lC� g /Qj �' Plans Examiner
as
ELAMIS T CARTAYA Notary Public - State of Florida
` Commission # FF 982555
My Comm. Expires Apr 17, 2020
s s itik,*M * * sgostt!Ye4liaor�tr"ielisrwMNulesyrA6srs s s s s s * * * * * * * *
Zoning
Structural Review
(Revised02/24/2014)
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 Owner —Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the I-lorida Statutes, Fla, Stat, 4 440,05
allows corporate officers in the construction industry to exempt themselves from this requirement fir any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Worker%' 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 ofliccrs
or members of a limited liability company (IA..C) in the construction industry may elect to be
exempt if:
I. The officer owns at least 10 percent of the stuck 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 I•or 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, pan -time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
tT er
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this 0_ day of Z , 20,C1.
By nk,10 .4T � who is pers n to me or has produced
https:Hmail.google.com/mail/u/O/?tab=rm&ogbl#inbox?projector=1 1 /1