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RC-07-19-1576, 1298 NE 95th St (5)Miami Shores Village ENTERED 14 "I, Building Department JAN 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BYs Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 b FBC 20 1� BUILDING Master Permit No. �G— D PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [-]PUBLICWORKS [P/CHANGE OF [-]CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 12 ` g / lI C q -S City: Miami Shores ,/�2County: Miami Dade Zip: /-V Folio/Parcel#: 1 � _ 3! 0 6 - ®11 403 Is the Building Historically Designated: Yes NO I-' Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): [ uc /14 OQgL4J Phone#: '305- Address: -302- NE % 2 -S % City: 14 I ,4141 4500 2 &� State: EL Zip: 3�/ 3d� Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: did j ,5> Phone#: (1.7`�K S �Z�� ��b � Address: /J©� 71�v � �'`'� / r City: �"!/ 4/ Y/ State: 1'Y- Zip: .33 / (QJ Qualifier Name: Phone#: 2Z 770 State Certification or Registration #:1� GTE 5��%� Certificate of Competency #: / �7, DESIGNERR1:IArchitect/Eng�iinneer: '� Iv A fV� �i(t�i � A i�,�-r )��o�v���hone#:(J/�� 5� Z'�-I� Address: `W3 �' 06 WA &r, `��l `�� City: � ) (� � � State: (�� Zip: Value of Work for this Permit: $ �� 23 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition Description of Work: 6� Z Z Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Permit Fee $ CCF $_ Radon Fee $ DBPR $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CO/CC $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ _ (Revised02/24/2014) V Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Len4r'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. e absence r ch posted notice, the - inspection will not be approved and a reinspection fee will be charged. 1 .1 Signatu OWNER or AGENT Signatu The foregoing instru*nt was acknowledged before me this The foregoing instrument was acknowledged before me this day of �) �,. J'�� 20 by 1� day of ✓" `�: 20 2 C) , by CJ who is personally known to �hS1� 5 who is personally known to me or wh as produced L Ora-. ,<g ! as me or who has produced �L �` L w as identification and who did take an oath. NOTARY PUBLIC: Print: �AION Seal: �C)s _ to no•y.= . ay.4�i40.� . APPROVED BY "° Plans Examiner identification and who did take an oath. Structural Review ############################ Zoning Clerk (Revised02/24/2014) 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: I . 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 day of 14" 201 . By �V Q-� rAD'ZAt -j who is personally known to me or has produced -1,J&Z . N as Notary: C0Y ��1/� S SEAL: �a7. Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. �C- Q ? - ` ( f 5 lb Owner's Name : Fee Simple Title Holder ,r 05- ( P ) I, (��2 [ O'Ql�i (. GS Phone #: T%o Owner's Address: z �a NG G ' _ 7"-1 City: _ A i am i State : _ FL- Zip Code: Job Address (Of where work is being done): �Cl q N C 1 5 5 % City: Miami Shores State: —Florida Zip Code: Contractor's Company Name: - Address: 9 MiE 4 -� c Phone #: 305 .3-150—zfi3 City: State: Zip Code: Qualifier's Name:. -A ,sir,. E7>y Lic. Number: CG e— Architect! Engineer of Record Name: '- Dt1 h 2) n! ,i .) AQ "r-ta T-zZtA&Phone #: Address: City: State: Describe Work: Ajl Zip Code: hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the iami Shores harmless of all Signature U—L-,� Owner r Agent The foregoing instrument was aknowle ged beforeme this � day of 20%�'w ?by�Qoy 1 264z-L- Who i sonally k own t me or who has produced Signature !\�asay /jcation. Notary V blic: \>``���a?�d1oN iii��'' Sign: a.�,�o� C, —3 Seal: c., involvement. 1 Contractor or Architect The foreg n instrument was aknowledged before me this A— Jay of 203byS��� who p� iss personally known to me or who has produced 4C, C--.rzA vi�.i eil4egification. Notary Public: Sign: Seal: ON��®i`✓e • ''.; r�i r�oN h a e w Date: State of )t�G 010) D 4 County of DAI/ Before me this day personally appeared S� �QS'�7 who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: / � �—/' aA42f A;�11�zlvl FA11f6_S /-"--z- 3,3/op r SiAnature S orn to (or affirmed) and subscribed before me this rS day of 202D by ' a y • m ; p : Personally Know 7-3 av'pF'iv usP'�� ��a0€Produced Identification Pc' ,• c ��nJ OT F R\� ��s A.P011 % of Identification Produced P ' or Sta p Name of Notary