PL-19-24A
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
RECEIVED
Jto'. 3 2C}JGf
BY:ri Aa
Tel. taual 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 ( )
BUILDING Master Permit No.iL`9--
PERMIT APPLICATION Sub Permit No. L (�
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
MPCUMBING ❑ MECHANICAL PUBLIC WORKS
❑ ❑CHANGE OF ❑CANCELLATION ❑SHOP
f-�—
CONTRACTOR• DRAWINGS
JOB ADDRESS: 6 r i / % D�
Folio/Parcel#: the Building Historically. Designated: Yes NO
Occupancy Type: �/ = Load: Construction Type: Flood Zone: �_ BFE: FFE:
OWNER: NamefFeeSimpleTitl holde 1:_ • d1) n &)-,V of Q
// ) S _-vim Phone#-, / 2 �3
City:
Tenant/Lessee Name:
Email:
State:
Name:%
Address: Id ILI �( t- �.�
City: {� S e:
Qualifier Name: �h 7 Phone
State Certification or Registration #: Wy l) Certificate of Competency #:
DESIGNER: Architect/Engineer: / 7 / Phone
305-
3()/
Address: City: State• Zip:
Value of Work for this Permit: $ `?S ,
. Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ AI ration Mew ❑ Repair/Replac Demolition
Desviption of Work:
1
s ,iTZ
Specify color of color thru tile: -7T
Submittal Fee $_ ao � Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ V
w
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
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 building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
f,
I
Signat
OWNER orAGENT
The (foregoing instrument was
acknowledged before me this
day of .IQJMb 20 16 by
I� >• `LIVY 11 who is personally known to
me.or who has produced as
Signature 4 CONTRACTOR
TT egoing instrurgent was acknowledged before me this
day of 20 ►8 by
b�V, cr)I�ceyz- who is personally known to
me or who has produced �L(— ' ea
_ MY COMMISSION # GG065755
NOTARY PUBLIC r'�� EXPIRES February 28, 2021
Print:
Seal:
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APPROVED BY a I� Plans Examiner Zoning
Structural Review Clerk
(Rev1sed02/24/2014)
Forever Gas Corp
18111 NW 68th Ave.
Miami, Fl. 33015
November 29, 2018
State of Florida
Miami Dade County
Before me this day personally appeared Robert Gonzalez who, being duly sworn, deposes
and says:
That he will be the only person working on this project located at:
161 NE 101 St., Miami Shores, Fl. 33138
Contractor Sizeeiture
Sworn to (or affirme and subscribed before me this day of,
20 1 &
Personally know
OR Produced Identification
Type of Identification Produced: 0(—.-
:��Y:°,; MONICA L SANTANA
•: MY COMMISSION # GG065755
'+ta;rya' EXPIRES February 28, 2021
Print, Type or Stamp Name of Notary
4
Miami shores Village
Building Department
10050 N.E.2nd Avipnue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.6972
Nonce to Uwner — WorKers' compensation Insurance Exem
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.
Signature:
Owner-L;
—;
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of QeQ1 ;l\GiW , 20 LE) . �\\\11111IIIIl/l/j
����� c,MINE T//i,
By,31'n � � who isQersonally known to me or has produced �� �MISSI�N •.
:�c,�,ot�atY »ati•
as identification.
IFF Z4799 . r,
Notary: AM_ :;';`
�y�,�,� %99 • r ended thN �,•: OQ�
�9..Ca � �1Y1r2.. � �1r� '�i f" �'•'�;�a;�.Mssn. t��.���
SEAL: ///�/ /C
f
�ForeverG-as
18111 NW 68 AVE UNIT I-105
Hialeah FI, 33015
305- 298 -0193 Cell
305- 331- 2572 Office
Forevergas@live.com
£L--o wm - z I
DROP TEST CERTIFICATION
PERMIT NUMBER: P1-y1-l9-ZL1
NAME: Jo�N �VI'�-�tij� DATE: 2- % `7
ADDRESS 161 N zy �7� CITY fA)ejtji 4W3 ZIP
THIS LETTER IS TO CERTIFY THAT FOREVER GAS CORP. COMPANY PERFORM A DROP TEST TO
CHECK THE WHOLE GAS LINE.THIS DROP TEST HAS A THIRTY DAY WARRANTY FROM THE TESTED
DATE
TYPE OF INSTALLATION: X, NEW ❑ EXISTING
THIS IS FOR A: ❑ WATER HEATER JYZAS GENERATOR.
❑ STOVE/RANGE ❑ OVEN
❑ BARBECUE
E 0:
XNATURAL GAS:
SYSTEM PRESSURE FROM METER: �_
WATER COLUMN: -3
TEST DURATION: lilou4c
DATE OF TEST: 2 > %
❑ POOL HEATER
❑ OTHER
❑ PROPANE GAS:
SYSTEM PRESSURE FROM TANK
WATER COLUMN
FLOW
PSI LOCKUP
TEST DURATION DATE OF TEST:
IF Y , H E ANY FURTHER QUESTIONS, PLEASE CALL 305-298-0193
DATE:
BERT O ZALEZ
CONTRA TOR (QUALIFIER)
bkjMACkj d.>"-PA . DATE: I
SIGNATURE OF NOTARY PPBLIC
r;•"Y"•,; MONICA L SANTANA
A.
`= MY COMMISSION # GG065755
EXPIRES February 28, 2021
STATE #: 28379
CC # LPG 28379