EL-19-1394Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
278 NE 103RD ST, Miami Shores, FL 33138
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Permit NO.: EL-06-19-1394
�Permit Type: Bectrical - Residential
,. L' work Classification: Addition/Alteration
Permit Status: Approved
Issue Date: 07/12/2019 1 Expiration: 01/08/2020
Parcel Number
1132060134860
HB Growth Properties LLLP Owner
278 103
KLEAN POWER ELECTRIC INC Contractor
GUILLERMO ALONSO
6601 SW 80 ST, MIAMI, FL 33143
Description: GARAGE CONVERSION INTO LIVING AREA. Valuation: $ 8,200.00 Inspection Requests:
KITCHEN & BATHROOMS REMODELING 305-762-4949
TotalSq Feet: 600.00
Fees
Payments
Date Paid Amt Paid
jAmount
50% Renewal Fee
Total Fees
$143.50
Credit Card
07/12/2019 $143.50
Total:
Amount Due:
$0.00
Building Del:(a ment Copy
In consideration of the is ante 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 ermit 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.
Authorized Signature: Owner
/ Applicant / Contractor / Agent
Date
July 12, 2019 Page 2 of 2
BUILDING
PERMIT APPLICATION
Miami Shores Village KECL -0
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949 �1
FBC 201'1
Master Permit No. l
Sub Permit No. L—CLO —q " 139A
BUILDING ❑E ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
F—IPLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHA WE OF CANCELLATION ❑ SHOP
CONI'R1kCTOR DRAWINGS
JOB ADDRESS: 278 NE 103 St
City: Miami Shores County: Mie 1m-Dade Zip: 33138
Folio/Parcel#:11-3206-013-4860 Is the Buildh ?WistoricallyDesignated: Yes NO x
Occupancy Type: Load: Construction Type: F)od Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): HB Growth Properties LLLP Phone#: 954-774-4616
Address: 17071 W Dixie Hwy
City. N Miami Beach State: FL Zip: 33160
Tenant/Lessee Name: na
Email: azorapropertymgt@gmail.com
CONTRACTOR: Company Name:
Address: 45 101 5u
City
Phone#:
Phone#: 9& `,COL 07,6 L
Zip: 121t; Il f
Qualifier Name: PrI[QUh7 (9l)(110'V1ti'47 *V (oW Phone#: _
State Certification or Registration #: r-G( 5a?wb6 Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#: _
Address: City: State:
Value of Work for this Permit: $e 2-Cq2 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Description of Work: @v@N1WeA@Wk
6kmj, , ter, oc t- ►,, L)4ly v kA N
Specify color of color thru tile:
Zip:
❑ Demolition
Submittal Fee $ Permit Fee $ — - CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $ _
TOTAL FEE NOW DUE $ % ► 3
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable) na
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.
Signature
��iii
• •
1
The foregoing instrument t),,as acknowledged before me this
NOTARY PUBL'
Sign: "
Print:
Signature
,Z
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of � MU O1 v 20 , by
,, («'A4J I who is peVsonally known to
me or who has pr uce it as
K identification and a%0 E INE PIN EIRA_ ON # 079431
NOTARY PUBLIC: a s 21
In urance
Sign:
Print:
Seal: Seal:
*******r*****�****s***********s**********r*************•*rtt*******�***s*rs********s************************
APPROVED BY 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 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.
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;
The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
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. -00,
State of Florida
County of Miami -Dade
The foreg g was acknowle ge before this day of , 20.
By w o is personally kn wn to me or has produced
Notary
SEAL
ORK2N1
n tst Bute mum"
on.
04/02/2019
State of Miami Dade
Miami Shores Building Department
Before me this day appeared, Alonso Guillermo who being duly sworn, deposes and say:
That he will be the only person working on the project locates at 278 Ne 103 St.
/eanPower Electric Inc
Guillermo Alonso