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RC-19-958Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 i Issue Date: 06/03/2019 Location Address Parcel Number 1249 NE 100TH ST, Miami Shores, FL 33138 11320SO080060 Contacts Permit NO.: I G-U5-79-955' Permit Type: B#ding (Residential) Work Classification: Atterabon Permit Status: Approved Expiration: 12/02/2019 KURT BESECKER Owner 1249 NE 100 ST, MIAMI SHORES, FL 33138 Home: 3033784394 LASORSA ENTERPRISES INC Contractor ANTHONY LASORSA 2071 SW 70 AVE G-19, DAVIE, FL 33317 Business: 3057765109 Description: REMOVING DOOR & BLOCKING IT UP Valuation: $ 3,037.50 Inspection Requests: 305-762-49 TotalSq Feet: 38.00 Fees Amount Application Fee - Other $50.00 CCF $2.40 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.80 Permit Fee $50.00 Scanning Fee $9.00 Structural Review ($45) $45.00 Technology Fee $2.50 Total: $163.70 Payments Date Paid Amt Paid Total Fees $163.70 Credit Card 05/01/2019 $50.00 Credit Card 06/03/2019 $113.70 Amount Due: . $0.00 Building Department Copy 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 inforrpetign is accur e a that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize t abcjve named ontrac r o do the work sued. Authorized Signature: Owner / Applicant / Contractor / Agent l Date June 03, 2019 Page 2 of 2 Miami Shores Village Building Department 100SO N.E.2nd Avenue, Miami Shores, Florida 33138 13Y Tel: (30S) 795-2204 Fax: (30S) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION %BUILDING ❑ ELECTRIC ROOFING AY FBC 20, �Q I Master Permit No. T ) 6S Sub Permit No. REVISION ❑ EXTENSION MRENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS F_� CHANGE OF ❑ CANCELLATION [� CONTRACTOR JOB ADDRESS: 19 NO Folio/Parcel#: .v0f"' DOB+'0060 Its the Building Historically Designated: Yes NO Occupancy Type:*(Pqload: Construction Type4nJreFlood Zone: BFE: FFE: 1 OWNER: Name (Fee Simple Titleholder): K u r { &2 -ccor— Phone#: j 3 3D Y7 C6 Y y Address: 1 24 City: State: Zip: Tenant/Lessee Name: Phon Email: CONTRACTOR: Company Name: �A-_Ibpso � .�i�i�• Phone#: Address City: --1 Qualifier Name: State: FIL Zip: — 3 3 2 Phone#: 6S' V D State Certification or Registration M C1 6031 y7 Certificate of Competency #: Q DESIGNER: Architect/Engineer: �N�� i��T/Q/A%/� �'� �'�� Phone#: ��l/ �S- Address: 33q- Sw a" Afgju,E fg�;IfG �/ City: A11AW1 State: f` Zip: 3SI-3 i Value of Work for this Permit: $,?�.�(0-9 - S D Square/Linear Footage of Work: Addition U Alteration ❑ New ElRepair/Replace ❑ Demolition Type of Work: ❑ Description of Work: �-► ' -:�f ��� �' �' f3G 4Gi'Gt- LLB ��� ' Specify color of color thru tile: Submittal Fee $ —<0 =Pn'A Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews DBPR $ 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 City M. 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: 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 estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien low 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-, t N Signature Signatu OWNER or AGENT The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this � day of _, 20 l9 by day of . 20, by who is personally known to who - who ' personally kn o me or who has produced _ as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: G Print: •�.�. ,Seal: APPROVED BY DIANE SCHWARTZ Notary Public - State of Florida Commission # GG 142572 My Comm, Expires May 6, 2020 Lam% identification and who did take an oath. NOTARY PUBLIC: Sign: / Print: Seal: Plans Examiner ;•'�,� DIANESCHWARTZ r . Notary Public - State of Florida Commission: GG 142572 aT' My Comm. Expires May 6, 2020 #*#..,q!'•iM*#�Y'lMik�kli�'Sk9YW1F'M�YP�si`�Y�rIYIF* *#**#*** _ �c7 Zoning (Revised02/24/2014) S / It Structural Review Clerk Lasorsa Enterprises, Inc. 383 S.W. 12t' Street Boca Raton, FI 33432 305-776-5109 20 l Date: State of ;A County of Before me this day personally appeare 1 \�6�+ �00*5Kwho, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: r' Lk � ©Q iIFL I V �' K - W Contractor SignaCure Sworn to (or affirmed) and ubscribed before me this L day of 20—L� By Personally know Or Produced identification Type of Identification Produced ZL44t�- VMC—aA Print, Type or Stamp Name of Notary D�` SCHWARTZ s'o`~"�� 4, •; r Nota•yo c -State of Florida . COrr r;55:o'1= CC 142572 cam: y` ,,,,,, M Comm. Ex:) e5 May 6. 2020 y Boded fvxti„rtl M1c[try Assn, 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 CONTENT . Signature: a wner State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of 201�. By/goy who is personally down to me or proTuceT SEAL DIAY: SCHN'ARTZ i Notary Pub" c _ c'Tl r4 �'o' 48 • •"`_ • ;y„en-�GGy2iz2— My Comm. ExP;'e> ^''' i 2020 fxI8cr thr^ucrniticrt twtryAW. 6cation.