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CHANGE OF OWNER i�mi hor�s iII� � � � :� ¢ .����.� � �ild�n epar�trnent ` '� 4 � �'`� �.� �� 10050 N.E.2nd Avenue, Miami Shares, Florida 33138 � F `� -, Tel: {305}795-2204 Fax:(3QS}756-8972 INSFECfIQN LENE PHQNE NUM�ER:(305}fi62-4949 F � 20�� ��� U11.D1 Master P�rmit No.���-`��� ��� ���'``�-� PERMIT �PPLICATIQN s�a����,�� �,�. �,�� -������ � `��� ui�Qo�r� � E�Ec-r��c ❑ Rt}C�FING � R�v�s�ory � �x���s�o� �����wa� �RLUM�IRIG ❑ MECHANICA� ❑PUBlIC WORKS � CHANGE t}F � CANCEL�ATION � SH(JP CC?NTRACTOR DRAWINGS aoa a��R�ss. ���t� � � ��.�� �� Citv: Miami Shores County: Miami Qade Zip: �`"��'� � Falio/Parcel#� ��--^��� ����� ' �'g � 1s the Bui6ding Historically Designated:Yes NQ Occupancy Type. �oad: Construction Type: Flood Zone; BFE: FFE: OWNER: Name(Fee Simple Tit{eholder}; � �' � � �°,� � Phone#; ������'�� �� Address: �� �� � � ' � ����`�` City: State: Zip: TenantJ�essee Name: Phone#: Email: � `� � ��t �°°�� �� �..� , �'�^� �,, coiVTRaCroR:�ompany Name:���i�i a� rl� - .5��� 4���t�,`� Phone�: ��� ! �'�`� �`�;�'`� Address; �s ��� ��~� � � ��� �� City:����"�� �State;��- Zip: �� �� QualifierName: e��`�� � � �t°�'?���F"� Phane#:����,�t����"���� State Cer[ification or Registration#: C�� �"� ���E�a�;°`��""�,.> Certifieate of Competency#. DESIGNER:Arehitecfi�Engineer: PhQne#: Address: City: State: Zip: VaPue of Wark far this Permit:$ ���'�'� Squarejline�r Foatage of Work: Type of Work: ❑ Addition ❑ Alteratian ❑ New ❑ Repairf Replace ❑ Demolition Qescription of Work: t� �'`�" �" � �` �� � �`�- . <�e� � � � Specify colc�r of c�f r thru ffle: � su�m�ttai Fee$ Permit Fee� ccF� co/cc$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Dauble Fee$ Structural Reviews$ Bond$� TQTAI FEE NOW DUE$ (Re��seda2�z4/2oin} Banding Company's Name(i�applicable} Bonding Company's Address _ City State Zip Mortgage Lender's Name(if applicable) M�rtgage Lender's Address City State Zip Application is hereby made to obtain a permit to da the work and installations as indicated. I certify tnat na work or installation has commeneed prior ta the issuance of a permit and that ail work will be performed to meet the standards of all laws regulating eonstructian in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLU(Vt�ING, SIGNS, POOLS, FURNACES, �OILERS, HEATERS,TANKS,A!ft CON�ITIONERS, ETC..... �WNER'S AFFIDAVIT: 1 certify tF�at all the foregoin� information is accurate and that ail work will b� done ir� camplianee with all ap�alicable laws regulating eanstruction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NQTICE QF COMMENCEMENT MAY RESULT IIV YUUR PAYING TWICE FOR IMPRt)VEMENTS TQ YQUR PROPERTY. IF Y�U INTENQ TO OBTAIN FINANCING, Cf3NSU�T WITH YQUR LENDER C?R AN ATft)RNEY BEFORE RECt}RDING YOUR NQTICE OF CQMMENCEMENT." tVotice to App/icant: As a eonditron �o the rssuanee of o building permit with an estimc�ted vatue exceeding$25QQ, the applieant rrrusc prorrrise in go�d faith that a eapy of the notice of commencement and constructian tien law Brachure wilt be delivered to £he person whose praperty is subject ta attachment. Alsa, a certified copy af the recarded notice of commeneement must be posted at the job site for the first inspection whlcir occurs seven (7J days after the bui(ding perrnit is issued. tn the absence caf such posted natice, the inspection witl not be approved and a rernspection fee wrtt be charged. '� iJ�� "�� � P� �i�nature `,�`` Signature' �� ���^ �_' � � ���, � O ER or AGENT � ./ (�NTRACTOft fore�oi instrument was acknowledged before me this The foregoing instrumen was acknowledged before me this day of � �F� ,20�_ �, by � day of � �.-�� 20 � bY ��'����... �'��� � o is persanally known to ����� � �1,���w�t�s persanaliy known to m�or who has produeed �`����� ���— as me�r wha has produced ��� ' � -����� as idenCificatian and who did take an oath. identifieation and who did fiake an oath. --,,� N4TARY PUBLIC: NCITARY PUBLIC: � +�t ��"� �����t6�9df�4lf4dr������� �� ,- �. :'i ��""`_ �� ����`�'�'�`�� � �'�``-"� 1��80t@4 ��fd�� � ��', "'��,��„„�.��` e,� A k}` �� n@�� �s`�t y.-^" � Sign: � � -� Sign: � t�. Print: $ � ;;�Print: ��\ h u-�� ��V V Seal: � � ���Seal: � ' >l `� ,r .,` �a ", r, ,� � � u �.� � � �� ���, � � ������ � � � � �**���*�**���**�k**x���**���****� *�**��z*����k�����������**��*�**�*****��������*���:���c#���**�**��x*�***�**�***�*�*�x�� ' " ,..'i,`' i � i g ��Y tf;9� , A,PPROVEI�BY �� '�� �� Plans Examiner Zoning � ��'� � � Structural Review Clerk (Revised02J24J2414) ���r � �. �� � `����`�,� � ��� LiNCiINF L;RI I�SY�`PI��I�S SC)I.CJ`I`IQil7S I,I..C' 7352 SW�t Street Mian�i FL 33155 f'h 3Q5-909-4&1I Fax 95�-671-68QS I��1TE: f?c�c�h�t�I5� 2015� �it�te c��E�,t«z-icla �"u�flty of�ade I,3esus C,arrrienate,will be tl�e anl}=�ersc�n w=e�rkiz��oc�the praject at: i90 NVv'97°,St�-eet,Nli�z��i Shores FL 33150 �ince 1�y, p �mm f' 4i atur �. � �:.��� ��, C��' � �'rint��r7�e �tate of I;lc�rida Co�nt�=ofl��iami-I�acie ��,�`' �, �„- 13cfc>r•e zx�e,ttiis �� c�ay of�`,Y.� q���>��ersc����11y appe�red�����1� ���'���'�����.'�c��d�� ��E�c�exec�zted tl�e£c�re��igz�instrun�ent,�nd aek��e?�led�ed before r��e ttlat��ne was exect�ted fc>r ttie pucposes ther�i��ex�r�ssed. � � fr���,-�_ , � ��� � �����t��a9t�€t���,=��� ��—�. (SFi-�.L,) €��,�� �°�'*°�� � -��`�p�rsc�i�all}f Kno�n _��'`r 1'roeiuce Id n ifieatic� �.'�,tr ��,�,'�, �-� � �r= �.,{ w_.. r. �i�ziaiire ol'N<�taryr r�i_' +, ..p ��.l n �.'s d�p ��P" ��. 3a ~�'� � .{ �`. ���F����i?�£F�'�t�''$s�'t�9s ������$ � � �� iar�i h�r�� ili�g� �'.� ��- "'°.� ���Idin D� �rtnn�nfi � � ����.-��� �oo�o �.E.��,a ,�u��,�,� �r `�'�* Miami Share�, Florid� 3313� ���R� �r��. ��a�> 7��.��o� Fax; (3Q5} 756.8972 ��� � f�,.'P' — � �' Gt" ' � S �1 � � S Ca�11G �� �1 1 � � ` ���` i` �` t' ,,� �' s �' , `�i� v � ' �?� si�, � � `?��� � g��� �a�h,���� �' ' �4, ,'��,,���;z� ��`� 3 �'�� Y� � �t;, `� ti 1. �.a� 3��� i����z' }� f�� .�' � .����� ���5����� �.�,��?���k;z � � Flc�rida Law rec}uii•�s Gkorkers9 �oinpznsation insut-�nee ca�erage unc�er Cha�ter �=�(� of the Ffarida STatutz�. Fl�. Stat. � 44�?.C}� , 1 �Ilo�vs cc�r�aaratz offieers in th��;c�nstructiUn in�ustiy ta exempt themselves f�-orn this rec�uirenzent For an�� construction projeet prior to j �E�tainir�a a�uilding�erz2�it. Pursuaelt to the Florida L)ivision of W'ark�rs' �ompensation Emplo�er Facts Brochure: r�,n employer in ti�e construction industry who ernpioy°s one �r n�ore part-ti�t�e or ttzti-xirnz emplo;��es, includin�the c�wner, m�ut obtain workers' compe��sation covera�e. CoPporate afficers � or meJnbers c�f a iitnited liability compan�� (LLC� �n tl�e const�-uctic�n indust�y ma�:� ��ect t� be exempt if: i i 1. The afficer o���7s at I�a�t 1Q ��rcent of the st�c(c of the cor�aoratioil�or in t1��e casz af � a�1 LL�,a statement attesfiz��ta t2i�minirtlum 10 pereenz o�nership; � 2. The �fficer is Eist�d a5 an af�iaer of th� eor��ration in the recarc�s �z ttle Flc�rida i De�artmant af State, L)ivision af Corporations, and i ;i. The corpc�ration is �-e^isterec� and 1isEecl as active with tl�� Flarida Department of ; ( i State, Division of Corporations. �?o mare than thre� corporaee offieers per corporation or lirnited liabilitv cocnpany n�errlbers are i allowed to be ex�m�t. Constructio�l exemptic���s are valid for a period of two years ar until a volunta�•}=re��o�.atia�� is filed or the Exemption is re4°okecl by°th�Divisiarl. � YoGtr contractar is requestiii�a z�erznit under this���orkers' eompensatioz�exei�lption and has acknoevledge t[�at he oz•she�4i11 noC use dav lak��r,�ar-E-tir��e emplc���ees or sc�bc�ntr�ctors for yo�ir praject.The c�ntract�r has pr��vided an affida�it st��in�,�tt1�t he or she 4vi11 ; be the ot�ly person allowed ta i��ork on ti�our project. In[hese c irculnstat�czs,�Iiami Shores��ill��e does nat require verificatian�f � �uorkers' GQmpensatiotz insurance e�tierag� fr�m the coi�tract�r's comp�ny for day� labc�r,part-time employees or subcontractors. ! E3Y �IG'�ItiG BEI.C?�t' �'OL <=�CK'v0�'LEDGE TI-I:�T `�"OL' �I<�VE RE.aL� "I'I-IIS �QTICE :�'.�D t;�DER�T.1�D ITS ' i {C}tiTE\TS. � I �L � Si�r _ '`� _ � - �-�, --- �bv � ; S e af Flc�rid i ! � Counn� of Miaz7u-Daae ; 'The fore�oing was acknowledge befc�re tne this �� day of � �—` � .Zt} �-� . ' ; 13y�����--� �������—��" � — --��ho is persoiza�iy kno�n to m�c�r has produ��d ; � �� --- - ' �__�,�.��l�� _ - �� �356 � -- _ . - ident�� �fi��� 8�tt�l����, � ��. ��� ��: :, ��� �'1 a � � "�^�, �. � �," r�. � .� '�;Q�aF'�': ��_ f` , 1 �'�' `°'� .��°`"�; - -- - __._ _.....---__. r _ 'i. � � a,-„. �...,.��w""'".�,•'"�� � •�5� �1� ��:��... ..'.'✓`i ".�}� , n„F � t. �. 4� ��,��i a Y_� 4 �§�� ��� '� �-� t'��"' ����1�d�6��6�is���