PL-19-583Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date: 03/26/2€119
Location Address Parcel Number
160 NE 102ND ST, Miami Shores, FL 33138 1132060131860
Contacts
Perm€tNO.: PL-03-%M3
Permit Type: Plumbing - Residential
Work classification: Drain field
Permit status: Approved
Expiration: 09/16/2019
SUZANNE SPONDER Owner ALFONSO SEPTIC CONTRACTOR INC Contractor
160 NE 102 ST, MIAMI SHORES, FL 331382325 JOSE BOLANOS
Other: 3055393099 1391 W 36 ST, HIALEAH, FL 33012
Business: 7862514099
Description: INSTALL A 300 SQFT OF DRAINFIELD valuation: $ 4,800.00 Inspection Requests:
305=762
Total Sq Feet: 0.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$3.00
DBPR Fee
$2.52
DCA Fee
$2.00
Education Surcharge
$1.00
Notary Fee
$5.00
Permit Fee
$118.00
Scanning Fee
$9.00
Technology Fee
$4.20
Total:
$194.72
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$194.72
Credit Card
03/26/2019 $144.72
Credit Card
03/18/2019 $50.00
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 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.
re: Owner / Applicant / Contractor / Agent
Date
March 26, 2019 Page 2 of 2
( L br�— I q - 5s/�
�.� DIVISION Of
Environmental Health
`® Florida Health
Miami -Dade County
eQ� OSTDS/Well Division
11805 SW 26th Street • Miami. FL 33175
-� Inspector CR ��ls9/N? Da
c
.address ��--
Comments:
Signature
# 4610. / ocl�al l�
RECEIVED
Miami Shores Village
MAR 18 2019
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
FBC 20 l�
BUILDING Master Permit No.j?L b3 - I c _L---,93
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1%j - e- /02<�V-
City: Miami Shores County: Miami Dade Zio:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: _� Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 5�07 dm tin C f�h �Qc� r� Phone#:
Address: I &Q U E , 102 SCi'
City: "to gej r S bkla C State: Zip: R 31 3J�--
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: I�FCLS�l \I(C (O� n! Phone#: --�qj�
Address:
�
City: P lP (e aU- State: ��� Zip: 3 301-2
Qualifier Name:
ne#:
State Certification or Registration #: C—LA 7 I2:2 Certificate of Competency #: At& O /% l 1-97
DESIGNER: Architect/Engineer:
Address: /, City: State: �QnZip:
Value of Work for this Permit: $ 'z�� Square/Linear Footage of Work: ,
Type of Work: ❑ Addition ❑ Alteration ❑ New IN Repair/Replace ❑ Demolition
Description of Work: 300 S1 5 ('� (—o
ppedfVcolor of color thru tile:
Submittal Fee Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
I
DBPR $ Notary $ S
Double Fee $
Bond $ gv-�
TOTAL FEE NOW DUE $
6,4 l
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
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 charged.
Signature Signature
NER or AGENT C TRACTOR
The foregoing instrument was acknowledged before me this T e foregoing instrument was acknowledged before me this
L� day of h afL- 4L 20 t Gi by , 9 day of ����{ 20 I G1 by
who is personally known to \0� C, �C NZ), who is personally known to
me or who has produced as me or who has produced T�—M�� u-G�-N97 as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: qNOT.AUBLIC:
Sign: Print: s�
I Seal:SINDIA ALVAREZ
JOSE BOLANOS *: MY COMMISSION # GG 238273
i WIY COMMISSION # 00 231451 = � 'o` EXPIRES: September 3, 2022
{ E � EXPIRES: October 1046202't Bonded Thru Notary Public Underwriters
APPROVED BY 3Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014) p
Alfonso Septic Contractor, INC.
1391 West 36 Street
Hialeah, FL 33012
Alfonsoseptic@gmail.com
Date: March.12 2019
State of Florida
County of Dade
Before me this day personally appeared —Jose Bolanos who, being duty sworn,
Deposes and says:
That he or she will be the only person working on the project located at:
160 NE 102 St Miami Shores FLA.
Contractor Signature
Sworn to (or affirmed) and subscribed before me this
by I05���5
Personally Know
OR Produced Identification_ _
Type of Identification Produced
Print, Type or Stamp Name of Notary
SINDIA ALVAREZ
:,: ,_ MY COMMISSION # GG 238273
='; P EXPIRES: September 3, 2022
SWOCI Thru Notary Public Underwriters
day of .20 151
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
CONTENTS.
Signature:
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this 19 day of kAJtjeJA, 20�.
By':L7,o /ULh SPO who is personally known to me or has produced
Notary:
as identification.
JOSS SMANOS
UyCOA66MM f GG 23145T
EXPIRES: October & 20"
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APPROVED BY DATE
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