RC-18-71 (2)aN 1
BUILDING
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
__Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECT I N LINE PHONE MBER: (305) 762-4949 /
FBC 20
Master Permit No. W (l t i — • O
PERMIT APPLICATION
OUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING [—],MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS:
Sub Permit No.
❑ EXTENSION ❑ RENEWAL
CHANGE OFI) ❑ CANCELLATION ❑ SHOP
CONTRACT( DRAWINGS
City: Miami Shores County: Miami Dade Zip:S' (?JL}
Folio/Parcel#: f 1 - ' e0 f 3 .'3q-S_C] Is the Building Historically Designated: Yes X NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): we� >�r�Ki� Gc� Phone#: � & —�6
Address: QS_7 APE '/ ST = 7teer>_
City: 14 aAY1(' S LX212,&-.s State: V:7 Zip:
Tenant/Lessee Name:
Email:
CONTRACTOR: [Co'�
Company Name:
15 rvl C��s
Address: C -,o ` 0 �� Lvc(t� AVC
City:
Qualifier Name:
ne#:�rg" G S/-57),5—
State Certification or Registration #:_ 3 Certificate of Competency #:
DESIGNE : Architec /Engineer: 1 1 l/(L �'tf�lnl�(S�� L.L. A(L�,t �Te[� Phone#: gV, 19
Address: 2'f 3 t�� �� `tJ�lit'tiS City: jl/ AMI Sidi' 'i5tate: P-L. zip: ;13�6
Value of Work for this Permit: $_ Square/Linear Footage of Work: 17 00 � t�
Type of Work: ❑ Addition (122NI Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
�0170A
• A i
Specify color of color thru tile: s
Submittal Fee $ PermifFee $ CCF
Scanning Fee $ • �7 Radon Fee $ L� SO DBPR $ G '__ Notar $ Oa
Y �.
Technology Fee $ (—Z. 00 Training/Education Fee $ 3 ' Double Fee $
Structural Reviews $ Bond $
�E- ��(I I�p� • �V , OO TOTAL FEE NOW DUE $ 3 IG Q • 2.S
(Revised02/24/2014)
1
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 on esti ted value exceeding $2500,�►the applicant must
promise in good faith that a copy of the notice of commencement and constructi lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded no ice of commencement must belposted at the job site
for the first inspection which occurs seven (7) days after the building permit is 'ssued. In the absence of ,such posted notice, the
inspection will not be approved and a reinspection fee will be charged. /--/
4 Signature Sign
OWNER or AGENT
The foregoing instrument was acknowledged before me this
-I6- day of 20 1�? by
P)E� X'q who is personally known to
me or who has produced (.- C , as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
%w�r
Print: CAA5C
Seal: ' �;�......
CHASE CAMPBELL
MY COMMISSION t FF 200055
• +
EXPIRES: February 17, 2019
r
Bonded Thru Notary Pubk Underwriters
R
The
efforegoing instru n was acknowledged before me this
e5 d�ay Owe , 20 , by
A�Af2D •who is per nally known to
me or who has produced as
identification and who did take an o th.
NOTARY PUBLIC:
Print: ► !
f .° `
Seal _ My COMMISSI #FF11488
.`�+ �•g° . EXPIRES April 21,
2018
(407) 398-0153 FloridaNOtaryService.com
*****************************************************
APPROVED BY Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)
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.
Signature: C v
l-fek.Y We
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this ► day of F , 20 1 c6 .
By who is personally known to me or has produced
P-01- 5 !;-3%9- V 6- as identification.
Notary
DALE C. OSTROMa
MY COIW►gWM t FF IUM
tbro Notary Pubic tin
Qo
CONSTRUCTION
F
Date: February 15Y, 2018
State of FLORIDA
County of MIAMI DADE
v.
Before me this day personally appeared /" ghdyv who,
being duly sworn, deposes and says:
That he or she w' I be the only person workbb'ng on the90""M/
ject located at:
25 � clly sr 1Lj/arrN ft
Sworn to (orAffirmed) aggI d subscri ebefore me this /9F day of Gta
2018, by ail 90
C
Personally know
OR Produced Identification ✓
Type of Identification Produced ,U .Jll&
NAYMA AGUIgglom LA1asa2
2018
398.0153