DS-20-515Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Permit NO.: DS-03-20-515
' Permit Type: Driveways/Sidewalks/Slabs
u(I
I Work Clossificaion:Hew
Permit Status: Approved
Issue Date: 03/17/2020 1 Expiration: 09/14/2020
Parcel Number
465 GRAND CONC, Miami Shores, FL 33138 1132060170320
Contacts
Julian Montero Owner
465 Grand Concourse
GARY BERNHARDT CONSTRUCTION Contractor
GARY BERNHARDT
7700 SW 114 ST, MIAMI, FL 33156
Business:3052597575 CRISTINA@ABPROFESSIONALSHUTTER
S.COM
Description: POURED SLAB FOR GENERATOR Valuation: $ 380.00 Inspection Requests:
Total Sq Feet: 0.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$0.60
Concrete/asphalt/pavers, slabs, dways,
$50.00
swalks
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.20
Planning and Zoning Review Fee
$35.00
Scanning Fee
$12.00
Technology Fee
$2.50
Total:
$154.30
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$154.30
Credit Card
03/17/2020 $154.30
Amount Due:
$0.00
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 cpntrar4or_to do thg/work stated. i
3
Authorized Signature: Owner / Applicant / Contractor /
Date
March 17, 2020 Z Page 2 of 2
Miami Shores Village
o aq a0l sk
og2oz Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
Ip�L�WENHUMBER: (305) 762-4949 Lv-�
BUILDING MAR 0 9 020 Master Permit No.-E�L p3-?'D513
PE IT APPLICATIONBY* -- Sub Permit No.� 5-N-10" S'S
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
C&P coo %e
P
City:
Miami Shores
County:
Miami Dade Zip:
Folio/Parcel#:
I — 3 206 " O i i -
O 3 to
Is the Building Historically Designated: Yes NO Y
Occupancy Type:
Load:
Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):
�Construction
i�� (( (tea..
�t
�N'_e
' (`o/eo Phone#: 3 2� le-Y lo3L
�Iit �
Cd
Address:
("ma>
'L-'CUie
S.0
City: M
/ 5-gip 5
State:
f'L Zip: v 3 / 3 tl
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name:
Address: 77by S�-J
City: rC'vC-
Qualifier Name. i
Khw
State Certification or Re ' tratio
hone#:
Zip: 1:6
Phone#: 3 %3 L/ 7-32-O
#: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ �_ quare/linear Footage of Work: 3
Type of Work: ❑ Addition Alteration New ❑ Repair/Replace Demolition
Description of Work:
Specify color of color thru tile:
S
Submittal Fee $ Permit Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
CCF $ CO/CC $
DBPR $
Notary
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 15 y - 3
(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 $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
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of ilAA41 20 by
J ho isqersonally know to
me or who has produced
as
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day f �"' �` 20 by
who ' �ersonallyn to
me or who has produced as
identification and who
t ke an oath.
identification and who did take an oath.
NOTARY PUBLIC:
+�'
:.:
A RIEL A MUSIBAY
NOTARY PUBLIC:
�? :':
MY COMMISSION # GG079337
q. , -1
EXPIRES March 05, 2021
d'1
Sign:
Sign:
Print:
—
Print:
Seal:
r
Seal: :�°'•'�' ARIEL MUSIBAY
�`= MY COMM SION # GG079337
e EXPIRES March 05, 2021
APPROVED BY
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review
Clerk
Gary Bernhardt Construction
7700 S.W. 114 Street
Pinecrest, Fl. 33156
Phone No: 305-934-7320
Qualifier: Gary Bernhardt
License: LPG32019
Date: March 9th, 2020
State of Florida
County of Dade
Before me this day personally appeared Gary Bernhardt, who, being
duly sworn, deposes and says:
That he or she will be the only person working on the project
located at:
465 Grand Concourse
' • r -
Contractor
Sworn to (or affirmed) and subscribed before me this 13th day of
March, 2020, by Gary Bernhardt
Personally Known X
W"...'1114b 1
Notarybiric
ARIEL A MUSIBAY
, �": MY COMMISSION # GG079337
''3o.n�?:�', EXPIRES March 05. 2021
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
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:
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: �Q, ' ' I��YI
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of 20
By�T"" Ire gc�'/NIwho i KEEEnown me or has produced
as identification.
Notary:''• ARtEU A MU5IBAY
LOP,•':
SEAL: MY COMMISSION # GG079337
� -s;., d
j oss.d`` EXPIRES March 05, 2021