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�uildir�� Q�par�fim�r�t
�.C?050 N.E.2nd Avenue,Mi�mi Shc�res,Fl�rida 33138 "��� ,� �.�,��� � �,,����
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INSRE�"f'I�M tINE FFIOME IVUMBER:(30S}T6Z-49A9
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�L I M�ster R�rmit No ,����� �� `tte� .A�°�����`�
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�os�����ss: _L`� � � c� ��, �
Crty: Miami Shares Countv: Miami Dade Zip� "���`��
FoEiajPareel�:��"� ��l�- °�! !. Is th�Bui#din�H€stor'ccally D�swp,nated:Yes t��
Occupancy Type: Co�d: Construction Type: Flaod Z�ne: BFE: FFE:
OWNE�<N�me(Fee Simple Titlehalder�: � Phone#:�a � �a
Address.��, °��°, f��
City: ' C°� A State: �C_ Zip: �"�, �-
TenanC��essee Name: Phone#:
Emaif: Ga a �� t�.�!� f
CL�NT�A�'€QR.Cc�mpany Name: ���_;�`.�C'�'_c��s.�_�-*.,���.�� Phon�#:���-�`��'°�,����
Addr�ss:� �� �
City: �,�� State� `��:_ Zip: ��\���_e._.
QualEfEer Nam�e_� i s� � U`� t'� Phone#e
State�erti#Icatlon�r Re�istraticsn#: Certif�cate of C�mpetency##:
�ESIGiNER:Archite�jEngin�ee: Phon�#:
At�l'�P4SS: CIL�: �t�tt: ZI(a:
V�Eue af Wark for this Permit�$ � ��A�Squarejl'an�ar F�atage af UVtork:
Type af W�rk: ❑ Additian [� A(teration New ❑ R�pairJR�place ❑ �emolition
Descripti�n�f Wark: ��-.��C c� = � � -�,��° Zm �t,� --��
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S�r�eify c�lar of ealor thru tile»
s��m��c�i F��S �erm�t�e�� cc�S cc�/�c S
sc�nn�n�Fee$ ��a�an Fe�$ ��PR$ N�tary S
Techt�ology F��$ Teainin�/Educati�n Fee$ Double F�e$
Structural R�views§ �ortd$
TC}TAL FEE Nt�W DUE$ � ��"" ��
iR�viseaa��aa/ao��>
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�ondin�C�mp�ny's Narrte(if�pplicable�
Bondin$C�mpany's Address
City State Zip
Mor�a��Lend�r's Name(i€applicable)
IVE�r�����Lend�r's Addr�ss
�ity Stat� Zip
�pplic�ti�rr is h�reby made to ok�t�in a permit to dca th�uvark and inst�ll�tic�r�s as indic�t�d. 1 c�rtify that rrca work or inst��Eation h�$
comrn�need prior t� the lssuanc� of a permit and that all wor� �il! be perform�d to m��t t�e st�ndards �f alE la�rs re�ula2ing
construc�ie,n in tt�is ju�isdi�tic�n. i understand that a separat� permit must be seeured f�r ELECTRIC, PLUM�INC, SI{�P�S, PCiQ�S,
FURP���ES,QC?ILERS,HEATERS,�°ANKS,AIR Cf�NDITI�(�ERS,ETC.....
�VIIM1l�R'S AFFIQ��I1T: 1 certify that all the fore�oing informatior� Es ae�urate and that al# wc�rk will b� d�n� in complianc� v�rith all
�pplicable laws ee��l�ting construction and zonin�.
•`V1/AIRNING T°� �WNER: YOUlt FAILURE TQ RECt�R� A► Nt�T��E Q� +Ct7rl�lItV1EF��CE�tIIEI�fi MAY
RES�1l�1' IN Y�t�R PAYIIVG ICE F�R i11lIRFt��✓EMENT� TGl Yt�U� PRQPE� . I� YQU INTEND
TQ ��TAIN �I�IAIVCING, CQNSI��T WITH YQUR �EN�tER QR AN A �RNEY �EFORE RE��RDIt�G
YC3!!E� IVQTICE C?� CQ ENCE � ENT.,,
Matrce to Appiicgnt: As a eondttiarr to the issuance of ca building permif wrfh ar��stimoted vatue exeeeding�2.5tX1, the appfr`cant musr
prvmise in gaod faith that a copy of the notice of comrnencemenY and construction Pien laru brc�chure arritf b�d�livered ta iire�person
whase praperty is subj�ct t�attachment. Also,a certi�ed c�py�f the r�cc�rd�d natice�f amm�ncement must be poste�#at the jcab site
for che frrst ins,�ection which occurs seven (7) days after the bull�ing permit is issu� . In the absenc� of such pt�st�d notie�, the
inspectfan wif/not be apqroved and a reinspectic�n fe�wifl be charged. �,`,
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Si�natur� �-''"�� Sign�tur� � `� �.� � ', � �
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Th�f�regcain�instrument was acknowledged before me this The for�gcaing instrument was acknvwi�d��d bef�re me this
�'� day of �� � 20 �-'� ,by '�`� day�f ��C� 20 ��..� ,by �
�:e.,�-,�� .�n`��,v�F�o is persanally known Eo ��"`������ .. �who is pers�n�lly kn�wn to
me ar wha has pr�duc�d � � �s m�e�r wh�h�s pr4duc�d �.������ �s
id�ntificatic�r��nd who did take an oa . fd�ntifi�atiran�nd who did t�k�an�ath,
4cs�:�ilre\ .S�fituai�,.ti4 `it01 '.^,l",1m�kSa Y1raS' 1 aSii�tCt.k�i
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Print: .P¢, � � Print:
S�al. -�" � Seal:
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APPR�V��BY Plans Examiner Zoning
Structural R�view Clerk
(R€�visedQ2/24f 2014}
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IaCi'll hQC@� I��age
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�,�`'� 1005Q N.E.Zt1d AVetIU�
��I� �° Miam� �hores, Fl�rid� 3313�
� T�1: (305} 795.2204
Fax: (3Q5} 756.�972
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�`lorida L,aw requires Warkers' �ornpensatie�� insu�-anee ceaver��� cander Chapt�r 44E} af the Flc�rida Stat�ates. Pla. Stat. § 440.05
allows cc�z�pc�rate of�'icers in the ccans ccion industry tc�exernpt th�mselves from thi�requirem�nt for az�y constructican proj�ct prior ta
obtainin�a bui�din�pertnit. I'ursuant to the Florida Division of�orkers' Compensation Employer�acts Brachur�:
An employ�r in the canstructian industr}� who cmplaya one or more part-time or fizll�time
emplayees,including the owner,must obtain workez�s'compensatian coverage. �orporate officers
or m�mbers of a limited li�bility co�pany (LL.C} in the constrztction industry may elect to be
exe�rtpt af:
l. The offic�r owns at lease 20 percent of th�stack c�f the corpor�tio�x or in the case o�'
an L,LC,a st�tement att�sting to the minimum 10 percent awn�rship;
2. The officer is list�d as an affieer af the corparation in the reeorcls af th� Florida
Dep�ent af Stat�,Division of Corparatzons;and
3. Th� corporatic�n zs registered d tist�d as active with the Fiorida I?ep ent af
�i�Eee,L}ivisic�n of�orporations.
No mc�re thazz thr�e corporate o#�ieers per cc�rporation ar limited liability campany z�embers are
allc�wed to be �xempt. Gonstruction exemptians axe valid far a period of two years or uritil a
voluntary r�vocatian is filed or the exemption is revoked by t�te Iaivision.
Your ec�n ctar is requesti�z�a permit under t1�is workers'coznpensation exemptic�rt��zd h�s acknowl�d�e that he or sh�wiil n�t us�
day Iabor,p��t-tizne employe�s�r subcontractars for your praject.Ti�e�ontract€�r has pgovided af�idavit statin�that h�or s�e u�il
be the only per�c�n allowed to work an your praject.In these czrcta�ns ces,Miamx Shc�res Viiiage does nat require verifiGatio�a of
r�orkers'compensatis�n insur ce covera�e frotn th�contractor's coznpany for d�y labor,part�Cime ea�zptoye�s ar subeontractors.
BY SIGNING BELC?W YOU ACKNQWL�DGE T T YC}U HAVE �D THIS NC}TICE UNI)ERSTAND ITS
CC}NTENTS.
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Si�nature:
C?wn�r
State of Florida
�ounty of Miami-Dade
The fare�cain�was acknowted�e before me this �� day of ,20 \.
By t �.,.t� _ c wha is personally known to m�or has produced
as idezatific�tioz�.
� :Q;r�Y'��;, i���A�A�taR��;a?ATO
;?'.»..�.;� Notary?ub;ic-StaEe af pi�r��a
Notary; '`�� �c":� Comm9sslon��tH rt923aQ
� �'�c�°�' tay Comm.Expfres 9ct 2E.Z025
SEAL: `
r�.���..��°�°"�` 3and�Q through r��tfar�e;Norary�,ssn,
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� a � x � � ���
C}ecemb�r 1C�, 2021
State af Florida
Caunty�f Mi�mi [��de
Be�ore me this day p�rs�n�lly app�ar�d �4nteani� �uvara whc�, being d�ly s�carn, depos�s�nd says:
That he II b��he only persan warkin��n the pr�aject located �t 123 NE 99 S�T.
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�` Contr�ctor Signatur�
Sworn t� ar�d subscribed before me this 10 d�y af D�eember 2021 by Antonic� Luvara.
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P�rsonally knaw ��
C�r Produe� fd�r�t�#ic�tic�n
Typ�af Od�ntifi�ation Produc�d
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