MC-06-19-1234, 9353 NE 9th AveL��giuC
Miami Shores Village
1IECEIVITIID
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
JUJ 04 2019
BY: A,
F8C 20
BUILDING Master Permit No. 11(i--06- 1 -1 ` -
PERMIT APPLICATION Sub Permit No. H(-\ -- 06 ► 9 -17 - y
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING EIIECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
DRAWINGS
JOB ADDRESS: a( 1 ` 1 9 A % �5 f/
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder):�``�. ((y,Y'< E Phone#:
Address•.
4
City: , � � la C1 Z � l 1 State: r' t--- Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: i i" 'i', ; ir) it _1 ,* 7 (". Phone#:
Address: % �.J :3 C%
�a
City: ea CA State: Zip:
Qualifier Name — t� ` Phone#:
State Certification or Registration #: i ; XL J �J?WS 5 -, Certificate of Competency #;
DESIGNER: Architect/Engineer:
Phone#:
City: State: Zip:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration 91 New ❑ Repair/Replace ❑ Demolition
Description of Work: P to S-t-vl ((-e 0 k.X 1' U 11 C-t- - -O n S r n J -�L-,, j n
Specify color of color thru tile:.
Submittal Fee $,,A-v, '
Permit Fee $
CCF $
CO/CC $
Scanning Fee $
Radon Fee $
DBPR $
Notary $
Technology Fee
Structural Reviews $
Training/Education Fee $
Double Fee $
Bond $ _
TOTAL FEE NOW DUE $ -&140
(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 _ 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. 1 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. i f
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of I �( V 20 by
C0icA 0 W, , wh is er^ sonally kn known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign;
Print:_ E\/1110 601(clq
MC
The foregoing instrument was acknowledged before me this
11 day of 20 i'1 by
(s personallykn9wn to
as me or who has -produced
identification and who did take an oath.
:lei F_1X/011.1RDA
Sign:���
Print: �Ueiyll �"iG11 L Vie{
as
Seal Seal:' a+ 71.4;
otary Publk State of Florida RNotary PuhNc State of Fbrid&welyn garciaavalyn flarciay Commission V I )JS 4xpires 05/04/2021 MY Comm"fon OG 101334
*sps#s*s�ssf****ss*s *ssssss*s**
1
APPROVED BY Plans Examiner Zoning
Ity L91 -0 1 T�;--
Structural Review Clerk
(Revised02/24/2014)
na 'r
IvIlliami %*Shares
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.
I . The officer owns at least 10 percent of the stock of the corporation, or , in the case c
an LLC, a statement attesting to the minimum 10 percent ownership; 46 6�0
2. The officer is listed as an officer of the corporation in the records of the Florid
Department of State, Division of Corporations; and
3 The corporation is registerec, and listed as active with the Florida Department o
State, Division of Corporations.
A A
No more than three corporate officers per corporation or limited liability company members at
allowed to be exempt. Construction exemptions are valid for a period of two years or until
voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a pertnit under this workers' compensation exemption and has acknowledge that he or she will not use
day labor, part-time employees or subcontractors for your prcject. 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:
I -
County of Mlatnr Dade
The foregoing'me this 5'*day af
By_ i,,p (Who k personal