PL-19-914Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date:
Location Address Parcel Number
1020 NE 93RD ST, Miami Shores, FL 33138 1132050150140
Contacts
Permit NO.:''PL-04-19-914
Permit Type: Plumbing - Residential
Work Classification: Alteration
Permit Status: Approved
Expiration: 12/18/2019
1 LANE MIDDLETON Owner
1020 NE 93 ST, MIAMI, FL 331382939
FOREVER GAS CORP Contractor
ROBERTO GONZALEZ
18111 NW 68 AVE 1105, HIALEAH, FL 330153989
Business: 3052980193
Description: LOW & HIGH VOLTAGE WIRING FOR NEW Valuation: $ 1,800.00 inspection Requests:
NATURAL GAS FIRED GENERATOR WITH WHOLE HOUSE 305-762-4949
AUTOMATIC TRANSFER SWITCH Total Sq 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
06/21/2019 $111.10
Amount Due:
$0.00
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that al Vtheo
' be done in compliance with all applicable laws
regulating construction and zoning. Futhermore, I authorize the abM:7
dostated.
t:
Authorized Signature: Owner / Applicant / Contractor v/ Agent Date
June 21, 2019 Page 2 of 2
- Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 79S-2204 Fax: (305) 7S6-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
RECEIVED
APR 2 51M
L-.4
FBC 20 h Master Permit No�V'LOA'p (p
l C2..
Sub Permit No2L-IZ$'A —I C1
❑ REVISION ❑ EXTENSION ❑RENEWAL
��LUMBINGI ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF CANCELLATION SHOP
g CONTRACTOR DRAWINGS
JOB ADDRESS: / d Z U I �` O
Folio/Parcel#: I/— 3 Q — / 1(0 Is the Building Historically Designated: Yes NO
Occupancy Type: 5F Load: Construction Type: Cn Flood Zone: J BFE: FFE:
OWNER: Name (Fee Simple Titleholder): /�-14 n 2 / "� ' �17t fL! UY? Phone#: 5 J 41-9 6 31/44
Address: /� �L d %�� (' `� 51 ))
City: S l� State: r C___ Zip: 3 7) -?
Tenant/Lessee Name:
Email:
i
CONTRACTOR: Company Name: 66-e I:e alc z Q Phone#: 305 2'5f 0/93
Address: I g 11 l 10 Gt ) (o Z 4 � 0 S—
City: /V Z
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
G
Zip: 3
Phone#:
e of Competency #: 6 �%
Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ ' 6o Squar C/Linea)Footage of Work: I,C
Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition
Description` of Work: ' Y s .- CC. 012-1
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
CCF
DBPR $
t
y J
:-r
.�r
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(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
Zip
City State 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: 1 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.
i
Signature I
_ OWNE or AGENT
(C _J
The foregoing instrume t was acknowledged before me this
day of e% 20 % 1 by
who is personally known to
Signature W41
O RACTOR
The foregoing instrum ntt was acknowledged before me this
7re
1 day of_ \A►'C k , 20 ( q by
me or who has produced as me or who as produced_
identification and who did take an oath. identificath in and who did
NOTARY PUBLIC: NOTARY PI IBLIC:
Sign: /JNl • Sign:
Print:/Q '"` S Print:
4 t�n
40
Seal:►sr' NADIAM. Seal:
Notar Pu i RAMOS si``R ""l 6
y. = Y bl c • State of Florida
Commission N GG 281067
Y Comm. Expires Dec 11, 2022 F
******** Bonde hQlitiQr4tleMat#1911*
APPROVED BY Plans Examiner
Structural Review
who is personally known to
Qv I Ccgyv q as
an
L
YRNADY PRIE 0
MY COMMISSION If FF 2141)31
EXPIRES: March 20, 2019
Zoning
Clerk
*
(Revised02/24/2014)
Forever Gas Corp
18111 NW 68 h Ave.
Miami, Fl. 33015
June 14, 2018
State of Florida
Miami Dade County
Before me this day personally appeared Robert Gonzalez
who, being duly sworn, deposes and says:
That he will be the only person working on this project
located at:
1020 NE 93 St., Miami Shores, Fl. 33138
U Iq
Sworn to (Qr affirmed) and subscribed before me this
dayof, , 20 IBC' .
Personally know _
OR Produced Identification
Type of Identification Produced:
-
Print, Type or Stamp Name of Notary
11
MONICA L SANTANA
MY COMMISSION # GG065755
EXPIRES February 28, 2021
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:
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;
The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
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: 1 ?�q�
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of J!? to , 20 /9
Byy "1�--� Mi`Q�GP� who is personally known to me or has produced
as identification.
Notary: NADIR M. RAMOS
Notary Public • State of Florida
;��• Commission M GG 281067
SEAL: 'for' My Comm. Expires Dec 11, 2022
Bonded through NatlonaI Notary Assn.