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PL-19-2901Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 360 NE 91ST ST, Miami Shores, FL 33138 r—+—+. FD V Issue Date: 31/07/2020 Parcel Number 1132060190210 Permit NO.: PL-12-19-2901 Permit Type: Plumbing - Residential Work Classification: Alteration Permit Status: Approved Expiration: 07/06/2020 SAM RISSMAN Owner A YOUNG PLUMBING CORP Contractor 360 NE 91 ST, MIAMI SHORES, FL 33138 JUAN C HERNANDEZ Home: 5107172306 sam@sambr.com 740 NW 91 AVE, PEMBROKE PINES, FL 33024 Business: 3059242243 Description: INSTALL KITCHEN SINK, DISHWASHER, DISPOSAL Valuation: $ 1,050.00 Inspection Requests: 305-762-4949 TotalSq Feet: 0.00 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 Building Department Copy Payments Date Paid Amt Paid Total Fees $111.10 Credit Card 01/07/2020 $111.10 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 at all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above nai d cgatra for t Ao the work s�pted. Authorized Signature: Owner ! Applicant / Contractor / Agent Date January 07, 2020 Page 2 of 2 Miami Shores Village 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 BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC ROOFING DECENTERED A 6 2019 FBC 2017 Master Permit No.,01-0-1 Q-7R6-q/-4 Sub Permit No. PL- 12- 19 - 2901 REVISION ❑ EXTENSION 7RENEWAL 1PLUMBING ❑ MECHANICAL PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: v Occupancy Type: Load OWNER: Name (Fee Simple Titleh Address: City: -" a t o'- - Tenant/Lessee Name: Email: CONTRACTOR: company Name: City:l Qualifier Name: State Certification or Registration #: DESIGNER: Architect/Engineer: Address:_ � 1?26> Value of Work for this Permit: $ Type of Work: ❑ �a2 Description of Work: 1 v Is the Building Historically Designated: Yes NO Construction Type: e, Flood Zone: ��—BF�E:,--7 FFFE: State: �� hone#: _�o►�p Phone#: c/ Z Phone#: 4.�z � Certificate of Competency #: _ _Phone#: _/ NJ V L/"• vvp City:/ /-/I, ((A ' 6,00 Square/Linear Footage of Work: -ation ❑ New ❑ Repair/5eplace Specify color of color thru We: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF $_ DBPR $ Zipp�& ❑ Demolition CO/CC $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ (4- 1O SS (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 WE 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 ( Signat re OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this day of 20 20 by 04ho 'lk personally known to i me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Print:Seal: ;o`vp�e^ DIANESCHWARTZ ? .�:. Notary Public - State of Florida •; Commission # GG 142572 � F� ,9*@'��9f�4FasPiFeii4i��kiGk* Bonded through National Notary Assn. APPROVED BY 1c The foregoing instru ent was acknowledged befor me this day f , 20 by o ersona in to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign L Print: Seal: *********************** Plans Examiner — Structural Review _ °� '• DIANE SCHWARTZ Notary Public - State of Florida Commission x GG 742572 My Comm. ExpiresMayy6,20J2 tary Assn. as Zoning Clerk (Revised02/24/2014) A YOUNG PLUMBING CORP. 740 NW 91 AVENUE, Pembroke Pines, FL 33024 LICENSED PLUMBER RF-0067124, 98P000228 DATE: Jan 4, 2020 STATE OF FLORIDA COUNTY OF MIAMI-DADE Before me this date personally appeared, Juan Hernandez, who, being duly sworn Deposes and says: That he will be the only person working on the project located at: 360 NE 91 Street, Miami Shores, FL 33137 Sworn to and subscribed before me this day of , 26iq 7600 By Juan Hernandez Persony allKnown DIANE SCHWARTZ Notary Public - State of Florida • Commission # GG 142572 My Comm. Expires May6,2020 / �A •,��� h National Notary Ass {ordedt hrouSn. 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 CONTRNTS_ Signature: Owner State of Florida County of Miami -Dade /f h Th oregoing was acknowledge before me this day of 20 W . B who is personally known to me or has produced as id ntification. Notary: 7�� ;?o';��•:` DIANE SCHWARTZ ' Notary Public - State of Florida Commission k GG 142572 SEAL:=2�? My Comm. Expires May6,2020 oc �Bordld through NaMral Notary Assr.