RC-19-1210 (2)R]�C I E
1 1� Miami Shores Village = AY s A 19
I
Building Department BY:
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
Q BUILDING ❑ ELECTRIC ❑ ROOFING
FBC 20
Master Permit No.&-- 6s —I Z
Sub Permit No.
❑ REVISION ❑ EXTENSION EJRENEWAL
PLUMBING ❑ MECHANICAL 0 PUBLIC WORKS ❑ CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 278 NE 103 St
City: Miami Shores County: Miami Dade Zip: 33138
Folio/Parcel#:11-3206-013-4860 Is the Building Historically Designated: Yes NO x
Occupancy Type: Load: Constr, ion Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleh0cle
Address: 17071 W Dixie Hwy
City: N Miami Beach State: FL Zip: 33160
Tenant/Lessee Name: na Phone#:
Email: azorapropertymgt@gmail.com
. CONTRACTOR: Company Name: *-:S}-b C N 9-p G ^ N V� Phone#:
Address: IO 612,2 G�►� to V
City
HB Growth F perties LLLP Phone#:954-774-4616
3�1�4�1
Qualifier Name: ,0b6e,*[ bV Q,& &jQS 1 Phone#: ,
State Certification or Registration #: c GG l3 �! Ilia Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $� Square/Linear Footage of Work: 600
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:}-t� "ffk assoeia�ithaaw-pael a9wpoAQ&;@d•wRd@r-@xp++ iF@d plei;Fnit #
r (1�i'QrsSi i 0 1 `i j, t�lilk0l �, It iCN �' L��Yf YY1S
i✓ New wi4 0W S a ct 6 00Y, `� � d.r(�1ACV- yo;0P ?Z2 MIT
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
Permit Fee $
Radon Fee $
Training/Education Fee $
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ °
0Zsx
(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
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 charaed.
Signature101, '—
OWNER or AGEN
instrument was acknowledged before me this
The foregoinIi
S— day of 20 y by
1'pC VL4rVVJV%—'i , who is personally known to
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
nn __
10 day of Ne , 20 IV by
e4V Q 6CSSL, who is personally known to
me or who h s produced as
identificati and . take an ath.
NOTARY P LIC:'
Sign:_
Print:
Seal:
s* **7�71-
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
x
(Revised02/24/2014)
R� b GoNTeAcTi iJ 6 (qe UV
01/24/2019
State of Miami Dade
Miami Shores building department
M Y 2 8 2019
BY: �1
Before me this day personally appeared Robert Burgess who, being duly sworn, deposes and say:
That he will be the only person working on the project locates at 278 Ne 103 St.
Robert
RJB Contracting group
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.
Signatur
Owner
State of Florida
County of Miami -Dade
The foreg ng was a'c+knowledge efo a me this I day of 'S>�•.� , 20 % I .
B fOJ4V " " who is personally known to me or has produced
/X,--
.:'� as i e ification.
Notary:
ka
SEAL:
��9hrs�r��2i
Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date: 07/12/2019
Location Address Parcel Number
278 NE 103RD ST, Miami Shores, FL 33138 1132060134860
Contacts
Permit Afo.: RC-05-19-1210
Permit Type: Building (Residential)
Work Classification: Garage Enclosure
Permit Status: Approved
Expiration: 01/08/2020
HB Growth Properties LLLP Owner RJB CONTRACTING GROUP Contractor
278 103 ROBERT BURGESS
1089 CHESTNUT ST, CLERMONT, FL 34711
Business: 9549934780
Inspection Requests:
Inspec ion Re
Description: GARAGE CONVERSION INTO LIVING AREA.
Valuation:
$ 32,800.00
49
KITCHEN & BATHROOMS REMODELING NEW WINDOWS AND
DOORS.
Total Sq Feet:
600.00
TO REPLACE EXPIRED PERMIT RC-11-15-2870
Fees Amount
Payments
Date Paid
Amt Paid
50% Renewal Fee $492.00
Total Fees
$492.00
Credit Card
07/12/2019
$492.00
Total: $492.00
Amount Due:
$0.00
Building Dep il�mt Copy
In consideration of the is uance 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.
Authorized Signature: Owner / Applicant / Contractor / Agent Date
July 12, 2019 Page 2 of 2