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MC-03-22-701, 9333 N Miami Ave (2)Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Parcel Number 9333 N MIAMI AVE, Miami Shores, FL 33150 1132060130350 Contacts PATRICIA N PENICHEIRO Owner Lemon City Applicant 9333 N MIAMI AVE, Miami Shores, FL 33150 Kamau Powell Other: 9167965773 tpenicheiro@yahoo.com 3634 Grand AVE, Miami, FL 33133 kpowell@lemoncity.com ACV-2 AIR CONDITIONING CORP Contractor JORGE LUIS ACEVEDO 901 NW 132 PL, MIAMI, FL 33182 Business: 3055461143 billing.acv2air@gmail.com Mobile: 3055861142 _....__. _.._. .._......... _ Description: NEW MINI SPLIT AC SYSTEM � Valuation: $ 5,400.00 Inspection Requests Total Sq Feet: 1,110.00 spa Fees Amount Application Fee - Other $50.00 CCF $3.60 DBPR Fee $2.84 DCA Fee $2.00 Education Surcharge $1.20 Permit Fee $139.00 Scanning Fee $3.00 Technology Fee $4.72 Total: $206.36 Building Department Copy Payments Date Paid Amt Paid Total Fees $206.36 Credit Card 03/25/2022 $206.36 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 inform 'on is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning:' Fuerrmore, I ayyF2jriz a above named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Date March 25, 2022 Page 2 of 2 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 on 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 fro he contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU �CKNOWI GE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS Signature: State of Florida County of Miami -Dade �� z The foregoing was acknowledge before me this j" day of , `�LG ✓ �/� , 20 By Pam, r i ei- ?tp-7, &[-,6k 9-<% who is personally known to me or has produced Y' v +� �� r t as identification. Notary: �•Z.t,1i�1Z v�.�tn��t SEAL: Netale9e N�ki Powell O-` A .`*4 Comm.:HH 159435 Expires: Sept.27,20H March 24, 2022 State of Florida County of Miami -Dade Before me this day personally appeared Jorge Luis Acevedo who, being duly sworn, deposes and says: That he will be the only person working on the project located at 9333 N. Miami Avenue, Miami Shores, FL for the company. -�� 4 A e� Jorg uis Acevedo ACV- Air Conditioning CAC1815085 Sworn to (or affirmed) and subscribed before me this 24 day of March 2022 by Charles Gibson who is Personally known to me. Notary Public My commission expires: NANO Nataki PO" �: cr Comm.:HH 159435 .,.:' Expires: Sept.27,2025 te Of FbAde %'K_c Notary Public • Sta t�� w �,y Review Building 45 Annt Paid Annt Due $ 50.00 $ 171.20 $ 171.20 $ 0.00 E: In addition to the requirements of this permit, there may be nal restrictions applicable to this property that may be found in the records of this county. 'HERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OTHER :ZNMENTAL ENTITIES SUCH AS WATER MANAGEMENT ICTS, STATE AGENCIES, OR FEDERAL AGENCIES. Miami Shores Village 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 FBC 20 *', 2 BUILDING Master Permit No. KCs PERMIT APPLICATION Sub Permit No. Mn ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING (MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP a A` CONTRACTOR JOB ADDRESS: I 1 4 a A ji. DRAWINGS City: Miami Shores County: Miami Dade Zip: 3 Sp Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: �12-toad: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): fAk(;606 PAR LY�+uia Phone#: U (O " 1 I� Address: 15?) tj' M 1 40y%1 " City: At xm ( -`0 State: r I ,.. Zip: wS� Tenant/Lessee Name: Phone#: Email: �T2r�IC��r�e7La �fGtl.Uc). LcrM CONTRACTOR: Company Name: (I w �" i i ; 0VJ <' %11*A0 Phone#: t3% S�' c, 1'9 2- Address: Ci l A-) City: State: 1— 1_ Zip:�- Qualifier Name: e V i�t(c Phone#: ,�� State Certification or Registration #: Levi �1 z� S- Certificate of Competency #: DESIGNER: Architect/Engineer: //r1�r4 P0O 14A A 1/ Phone#: Address: 2D0o Dqt.% f L. City: State: -IPLZip: 32SiO4I Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Permit Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) 'i�tMD�N6 wa-n� To Ow�i?- 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 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 c tified copy of the recorded notice of commencement must be posted at the job site for the first '�beappjvedbnd h o en (7) s after the building permit is issued. In the absence of such posted notice, the inspectio will a rein ecti ee will be charged. OWNER dt AGENT The foregoing instrument was acknowledged before me this day of 20 `'' by who is RgEiiino to me or who has produced identification and who did take an oath. NOTARY PUBLIC: �31 Signature CONTRACTOR The foregoing instrument was acknowledged before me this h14 day of 20 . _. by ?�<f07'1 6 to is personally known to me or who has produced f ��c{ L; c as identification and who did take an oath. NOTARY PUBLIC: Sign: ��.� ��, Q ��-�` r Sign Print: Print: 'i�PY PV/Gj� Natelege Nalski — "r1zNate /,, Nalaki Powe Seal: `o: e�.% Seal: �t��►arPlrB�/J�J lege _`_: M Comm.:HH 159435 =� ' - in Comm.:HH 159435 s�o�,_.. �,Expires: Se t.21, 2025 Expires: Sept.21,2025 Notary Public - State of Florida ;�,� if%--5 /rrr; r Notary Public • State of FbMa APPROVED BY lans Zoning Structural Review (Revised02/24/2014) Clerk