PL-19-2785Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
l�U'Cru��5�
Issue Date:
Location Address Parcel Number
257 NE 91ST ST, Miami Shores, FL 33138 1132060133450
Contacts
Permit No.: PL-1 1 -19-2785
Permit Type: Plumbing - Residential.
work classification: Aiteradon
Permit Status:
Expiration: 06/15/2020
IARA COLTRO Owner K.A. STAR CONSTRUCTION INC Contractor
257 NE 91 ST, MIAMI SHORES, FL 33138 KEVIN HERNANDEZ
Business: 3055357656 12640 COUNTRY CLUB LN, MIAMI, FL 33167
Business: 7862609420
Ins
Description: BATH REMODELING (UPSTAIRS KIDS ROOM) Valuation: $ 1,800.00 Inspection Requests:
762 4949
TotalSq Feet: 55.00
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
Check # 3053
12/17/2019 $111.10
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/�I�/Ay/IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating( s u ion and zoning. Futhermore, I authorize the above named contractor to do the work stated.
Owner / Applicant / Contractor / Agent Date
December 17, 2019 Page 2 of 2
Miami Shores Village F TSnIE
Building Department NOV 2.1 2019
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
FBC 20
Master Permit No. QC— 2�(o to C%
Sub Permit No.u,- I) 19 Z-iB5
❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: ^ 5
City: Miami Shores County: Miami Dade Zip: 551136
Folio/Parcel#: ( f® -?)20G ~ 09A 0 3 4 SU Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 37�Ac C.� .i44Q Phone#: S-
Address: ?-S+ 1l39- '% S
City: h; NM s-4-Df1 s State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: N`A- S+:,- Phone#:
Address: ® '
City r Ct-LCA nstate: Zip:
Qualifier Name: :lQ dAe , / Phone#:
State Certification or Registration #: c F'C 4-9 -I D_` Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: A.1� 1 ,_p
Specify colds of color°tlilrirfle:
Submittal Fee $,- Permit Fee $. CCF $ CO/CC $
Scanning Fee $
Technology Fee $.
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ Q 0 I ' (0
(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 on estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature446HQ
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of lQ®c"enom-V.— 20 t' by
I:A-� !..JQ\+A� who i
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Signature
_ 0
CONTRACTOR
The foregoing instrument was acknowledged before me this
2Z$b� day of 1N^.,Je,--�QN 20 ti by
16LV I ^, �wPuVJ4y C2 , who is personally known to
me or who has produced DLA K,% Se)=Pa$-34-40- as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign: '
0
Print• Print: lv•2`
tra IVWWRINOJ.
Seal: MYCOMMISSION # GZ610
7Seal: AM'" ; VICTOR O J. LUCERO
EXPIRES:Aprd 8, MYCOMMISSION# GG 167510
a1 p•? EXPIRES:
April 8, 2022
'toy i `P� BMW TIVU N..v./ Pu & UNWWrPom9
100111vowwwww
APPROVED BY r,/e �_ Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)
Proof of Coverage Page 1 of 1
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Employer List Page
This database was last updated Tuesday, November 26, 201912:08 AM.
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Federal Employer IQ Number Information
1 records found for federal employer Id number 463522403.
Click the links below the Employer Name column for more detailed Information.
Record lEmpioyer Name lEmpioyer Address
1 I K A STAR CONSTRUCTION INC 1 12640 COUNTRY CLUB LN, MIAMI, FL 33167
1 records found for federal employer Id number 463522403.
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Cov Exam
Cov Exem
—r-j f�'T� q Pj
https://apps8.fldfs.com/proofofcoverage/EmployerList.aspx 11/26/2019
Proof of Coverage Page 1 of 1
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Employer Detail Page
This database was last updated Tuesday, ;November 26, 2019 12:08 AM.
Carrier Location Information
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Employer Information
Employer Name Employer Type NAICS Code
IK A STAR CONSTRUCTION INC (CORPORATION IN/A
Coverage History
Governing Class Effective Detailed Coverage Carrier Office Policy Wrap
Code' Date Information Number Up
Detailed FRANK W
05551 (Jan 25 2016 Informationverage NSURA CE INCN CRUM IWC201600000 INO
`Represents the Governing Class Code associated with the Named Insured on the policy,
as reported by the insurance Carrier, and is not validated as correct.
Exemption Listings
Exemption Haider Name - Click on the name(s) below to view more detailed information
KEVIN HERNANDEZ
Owner Election Listings
No Owner Election of Coverage Listings
Employer Name History
Employer Name Name Type Change Date
LK A STAR CONSTRUCTION INC I Legal I Oct 4 2013
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https:Happs8.fldfs.com/proofofcoverage/EmployerDetail.aspx?EmpID=X000483 87 11 /26/2019
Proof of Coverage Page 1 of 1
WC !Mobile App We Home Search Our Data CFO home
Exemption Detail Page
"this database was last updated Tuesday, November 26, 2019 12:08 AM.
Return to Previous Page I
Exemption Details
Name Title
Effective Date ,'Termination Date
Exemption Type 1"Business Activities !Employer Name ,
KEVIN
. ..........................._..._...._......._,....._.
__..._..__....................._........._._.._ .....__....--'---..— __.____.._____.....__....__..
Click Here to View K A STAR
HERNANDEZ
Jun 5 2018 Jun 4 2020
Construction Activities Listed on € CONSTRUCTION
Exemption INC
KEVIN
Click Here to View K A STAR
HERNANDEZ
PR
Jun 52016
Jun 52018
Construction Activities Listed on € CONSTRUCTION
Exemption INC
KEVIN
A
—�
Click Here to View K A STAR
HERNANDEZ
PR
Jun 6 2014
Jun 5 2016
Construction i Activities Listed on CONSTRUCTION
Exemption INC
KEVIN
Click Here to View K A STAR
HERNANDEZ
PR
Oct 4 2013
Jun 6 2014
Construction Activities Listed on :CONSTRUCTION
Exemption INC
"Termination may be through the revocation of the exemption, or expiration of the exemption.
"The exemption only applies to the business activities listed on the exemption.
Return to Search Pagee-]
https:Happs8.fldfs.com/proofofcoveragelExemptionDetail.aspx?pr_person_id=X00037993 11 /26/2019
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 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: b�1�
Owner
State of Florida
County of Miami -Dade //
The foregoing was acknowledge before me this b day of De Cesw , 20 (C j .
By r'arC, (•} ra' who is personally known to me
Notary:
W"- 0
SEAL: VICTORINO J. LUCERO
MY COMMISSION # GG 167510
Sono,�R Thru Notary Publk Underwriters
IWAINT01101"I ik,
12640 COUNTRY CLUB LN
M IAM I ,FL 33167
Date:12/16/19
County of Miami Dade
Before me this day personally appeared Kevin Hernandez who, being duly sworn deposes and say:
That he will be the only person working on the project located at: 257 Ne 91" Street, Miami Shores, Fl,
33138.
Sworn to (or affirmed) and subscribed before me this 16' day of December, 2019, by Kevin Hernandez.
Personally known
Notary; W-L4Z
IULWI
VICTofallo J. LUCERD
W COMM" # GG 161510
EXPIRES: APO 8. =
Bottled Twoo .Pd-r"-L44e
KA STAR CONSTRUCTION
12640 COUNTRY CLUB LN
MIAMI ,FL 33167
Date:12/16/19
County of Miami Dade
Before me this day personally appeared Kevin Hernandez who, being duly sworn deposes and say:
That he will be the only person working on the project located at: 257 Ne 915L Street, Miami Shores, FI,
33138.
0ntractor Signature
Sworn to (or affirmed) and subscribed before me this 16`h day of December, 2019, by Kevin Hernandez.
Personally known
Notary:
e
VICTORINO J. LUCERO
MY COMMISSION # GG 167510
EXPIRES:APN 8,2022
Bonded Thru Notary Pubrrc Unftotm