DS-9-16-2520, 166 NW 110th St`yNurses r,� Miami Shores Village
e� 10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
"F:rsC` Phone: (305)795-2204
<ORltl
Permit Iva DS-9-16-2520
Permit Type: Driveways/Sidewalks/Slabs
Permit Work Classification: New
Permit Status. APPLIED
Issue Date: 9/15/2016 1 Expiration: 3/1 2017
Project Address Parcel Number
166 NW 110 Street 1121360030140
Miami Shores, FL 33168- Block: Lot:
Owner Information Address Phone
JOSE LUIS HURTADO 166 NW 110 ST
MIAMI SHORES FL 33168-4321
Contractor(s) Phone Cell Phone
HOME OWNER
Approved: In Review
Comments:
Date Approved:: In Review
Date Denied:
Type of Work: FRONT DRIVEWAY.
Bond Return
Scanning: 3
Fees Due
Amount
CCF
$1 20
DBPR Fee
$2 00
DCA Fee
$2 00
Education Surcharge
$0 40
Permit Fee
$125 00
Scanning Fee
$9 00
Technology Fee
$1 60
Total:
$141.20
Additional Info
Classification: Residential
Applicant
JOSE LUIS HURTADO
Cell
Valuation: $ 2,000.00
Total Sq Feet: 792
Pay Date
Pay Type Amt Paid Amt Due
Invoice #
DS-9-16-61306
09/15/2016
Credit Card $ 91.20 $ 50.00
09/13/2016
Credit Card $ 50.00 $ 0.00
HvauaDie inspections:
Inspection Type:
Final
Foundation
Review Planning
Review Building
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 AFFIDAVIy� 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 zon ng. ) 1 core, I authorize the above -named contractor to do the work stated.
September 15, 2016
Authorized Sihature: Owner / Applicant / Contractor / Agent
Building Department Copy
September 15, 2016
1
Miami Shores Village
Building Department RECEIVED
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (30S) 762-4949.{._
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC ❑ ROOFING
FBC 201(q
Master Permit No. DS-9-16-2520
Sub Permit No.
❑ REVISION 0 EXTENSION ❑ RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 166 NW 110th St
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: 11-2136-003-0140 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Jose HUrtado Phone#: 786-252-8932
Address:166 NW 110th St
City, Miami Shores state: Florida Zip: 33168
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: Phone#: -
Add ress:
City: State: Z
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #: _
DESIGNER: Architect/Engineer: Phone#: -
Address: City: State
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Description of Work: Driveway
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
Permit Fee $
Radon Fee $
—Training/Education Fee $
CCF $_
DBPR $
1-3
rz
❑ Demolition
CO/CC $
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
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. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
2p day of Sr t%C+oob e/ 20 i�, by
\ �JV �1) , who is�personally VS--
to
me or who has produced +A I ICj2.,1 \ S as
identification and who did take an oath.
OTARY PUBLI
Sign:
Print:
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 , by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: Seal:
M
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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166 NW 110 STREET
FAMILIA HURTADO-BONILLA
CANDY HURTADO
KEY PLAN AND NORTH SIGN
DRAWING N.T.S.
REFER TO GRAPHIC SCALE
0 x
2x
1/X" = 1' - 0"
SCALE
RESIDENTIAL DRIVEWAY
LOCATION PLAN
SHEET TITLE :
PLAN A 10 0
SCALE: 1/16" = 1' - 0" 01 SHEET NUMBER
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(786)200-7325
166 NW 110 STREET
MIAMI SHORES, FLOMDA 33168
�RAF
HRIS Z-MENA
(305)098-2800
0000 STREET, SUITE 000 WEST
PHILADELPHIA, PA 09000
I FOR REFERENCE
KEY PLAN
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166 NW 110 STREET
FAM11A HURTADO-BONILLA
CANDY HURTADO
KEY PLAN AND NORTH SIGN
DRAWINGN.T.S.
REFER TO GRAPHIC SCALE
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1/X"
SCALE
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RESIDENTIAL DRIVEWAY
LOCATION PLAN
SHEET TITLE ;
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11 0
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110 STREET
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FEB 2016, NEW DRIVE WAY x
EXISTING SIDEWALK
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5'-0" Concrete Sidewalk 1 qs '
CONCRETE WALKWA
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5' 25 DRAINFI�ELD
2'-6" 13'
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(786)200-7325
166 NW 110 STREET
MIAMI SHORES, FLORIDA 33168
O
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1305189E-2808
0000 STREET, SUITE 000 WEST
PHILADELPHIA, PA 00000
FOR REFERENCE
KEY PLAN
166 NW 110 STREET
FAMILIA HURTADO-BONILLA
CANDY HURTADO
KEY PLAN AND NORTH SIGN
DRAWING N.T.S.
REFER TO GRAPHIC SCALE
x
2x
140 ,=1'-0"
SCALE
RESIDENTIAL DRIVEWAY
LOCATION PLAN
SHEET TITLE :
PLAN A 100
SCALE: 1/16" = 1' - 0" 01
I SHEET NUMBER:
BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department MAR 42017 i
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 20b
Master Permit No. PS— _I —16 —2s5 2-0
❑BUILDING ❑ ELECTRIC ❑ ROOFING
Sub Permit No.
❑ REVISION EXTENSION ❑RENEWAL
❑PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1 k AlG'i 1104h S4-
City: Miami Shores County: Miami Dade Zip: 33 1 6 0
Folio/Parcel#: 12 3 1/ D O r' C O Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): �c �4 u -V-ct ('yam Phone#: 2 5 3 C_
Address: 16 b N1 W U D S r
City: MI C'tn'I G►-VE)r-ei State: L Zip:
Tenant/Lessee Name: (_ Phone#:
Email: 120-4/'0/1 �. ' LJ� M q i` E L`7✓�'1
CONTRACTOR: Company Name:
Address:
City: State:
Qualifier Name:
State Certification or Registration #:
hone#:
Phone#:
Certificate of Competency #: _
p:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ Z,d U o Square/Linear Footage of Work: 2-
Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition
Description of Work: Dr V
Specify color of color thru the:
Submittal Fee $
Scanning Fee $
Technology Fee $_
Structural Reviews $
Permit Fee $ CCF $ CO/CC $
Radon Fee $ DBPR $ Notary $
Training/Education Fee $ 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
State
Zip
ME
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 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.
Signature00,� -
y ER o `- GENT
The foregoing instrument was acknowledged before me this
14 day of KLUC-ln ,20 I- by
1C��C L k rA-ctc�who is personally eknown to
;�
me or who has produced �1)6V e1, t lCLM `( as
identification and who did take an
NOTARY PUBLI
Sign:
Print:
Seal:
***************
APPROVED BY
(Revised02/24/2014)
YANADY PRIETO
MY COMA41SSICN # FF 214031
EXPIRES: March 25, 2019
Banded Thru Notary Public UnderN(N
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20, by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
as
*************************************************************
�112
Plans Examiner
Structural Review
Zoning
Clerk
Tuesday, March 14, 2017
Dear Director of Building & Health Services:
I am writing to request a time extension for permit number DS-9-16-2520 in order
to complete work on the new driveway. Due to unforeseen circumstances, I was
unable to complete the work.
Please extend my permit until 4/20/2017. 1 understand that this extension covers
items related to the scope of work approved under the current permit and I know
that I must complete this project by the date indicated above.
I can be reached at the address and phone listed below.
f MAR 1 20»
L-
Sin c rel ,
Jose Hurtado
166 NW 110tn
Miami Shores, FI 33168
786-242-8932
Miami Shores Village�°��'�'�
Building Department SEP 13 zoos
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 20H
BUILDING Master Permit No. Tc 1
PERMIT APPLICATION Sub Permit No.
k,'BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
10B ADDRESS: ! b 6
U ak?
i
City: Miami Shores County:
County: Miami Dade Zip:
Folio/Parcel#: 11 2j3.6 o O 3 C)
c ` t� � i, Is the Building Historically Designated: Yes NO (../
Occupancy Type: )i llrG r�^Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): T6r�e ICU,- Ld'9 Phone#: 7 , 2-5Z 5q2 2
Address: /-� 6 ) V LAJ i / v fh �ri'
City: N ( cy"1 i State: r C-
Tenant/Lessee Name:
Email: 7A_
t'
CONTRACTOR: Company Name:_
Address:
City:
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer:
1-1
Zip:
Phone#:
Phone#:
Zip:
Phone#:
Certificate of Competency #:
Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 2, o 00 Square/Linear Footage of Work:
_ 6
Type of Work: U Addition ❑ Alteration ❑-New ❑ Repair/Replace ❑ Demolition
Description of Work: i'ry •-t ¢
s� •
Specify color
ro�� of color thru We:
Submittal Fee $ cJPermit Fee $ B CCF $ 1 a Zo CO/CC $ _
Scanning Fee $ Radon Fee $ _Z ' JQ DBPR s 2 .00 Notary $
Technology Fee $ t(% C) Training/Education Fee $ .40
Double Fee $ _
Structural Reviews
(RPvisPdN/J4/')m 4i
Bond $
TOTAL FEE NOW DUE $ C� I . Z. V -
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 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.
Signature �e Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of S JC/ t' t 20 1 7 , by
1 hoIaA Ngt-,a�is p w o ersonally known to
me or who has produced r-k— -(-)a I U(;,a as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal:
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal:
as
************************************************************************************************************
APPROVED BY �0 3 i® Plans Examiner Zoning
Structural Review Clerk
10-4 4n1/')n Nn1 A
P.
Miami Shores Village
`cttORES
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
` E"may
Phone: (305)795-2204
f<ORIDP`
Permit NO. DS-9-15-2238
Permit Type: Driveways/Sidewalks/Slabs
Permit Work Classification: New
Permit Status: APPROVED
Issue Date: 9/17/2015 1 Expiration: 03115/2016
Project Address Parcel Number Applicant
166 NW 110 Street 1121360030140
Miami Shores, FL 33168- Block: Lot: JOSE LUIS HURTADO
Owner Information Address Phone Cell
JOSE LUIS HURTADO 166 NW 110 ST
MIAMI SHORES FL 33168-4321
Contractor(s) Phone Cell Phone
HOME OWNER
Approved: In Review
Comments:
Date Approved:: In Review
Date Denied:
Type of Work: FRONT DRIVEWAY.
Bond Return
Scanning: 3
Fees Due
Amount
Bond Type - Owners Bond
$500.00
CCF
$1 80
DBPR Fee
$2.00
DCA Fee
$2 00
Education Surcharge
$0.60
Permit Fee
$100.00
Scanning Fee
$9.00
Technology Fee
$2.40
Total:
$617.80
Additional Info:
Classification: Residential
Valuation: $ 2,500.00
Total Sq Feet: 58
Pay Date
Pay Type Amt Paid Amt Due
Invoice #
DS-9-15-56927
09/17/2015
Credit Card S 567.80 $ 50.00
09/02/2015
Check* 115 S 50.00 $ 0.00
Bond #:2841
rlvaname Inspections:
Inspection Type:
Final
Foundation
Review Planning
Review Building
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 AFFI .AVIT: erty that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constr ction an zoning uthermore, I authorize the above -named contractor to do the work stated.
'��'. September 17, 2015
uthorized S gnature: Owner / Applicant / Contractor / Agent Date
Bu ding Department Copy
September 17, 2015 1
BUILDING
PERMIT APPLICATION
Miami Shores Village 1
Building DepartmentP �0�5
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(lq
Master Permit No. V—::�� 5 — Q_Z8
Sub Permit No.
i
®BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
PLUMBING MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: (T `� 1 L 7�
City: Miami Shores Countv: Miami Dade Zip:
Folio/Parcel#: 11 2 13,6 00 2 0 > 7 0 Is the Building Historically Designated: Yes NO L—,-/
Occupancy Type:Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): Ju � -t ]J (- A Q J\3 Phone#: -7 8 6 2 o `D "�V 1 S
Address: 16 6 m mot/ ) ( o -1y, S �- II 3 ()-.> -j (0 / 0 93
City: um State: 1. Zip: 6
Tenant/Lessee Name: - Phone#:
Email: , 7,QQ k' I ino/ /
CONTRACTOR: Company Name:` :UC3 L _ �Whl -P Phone#:
L \
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #:
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address:
State: Zip:
Value of Work for this Permit: $ at J U� CC) Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration [] New ❑ Repair/Replace
Description of Work: —ro A >L cif ye "
Specify color of color thru tile:
Submittal Fee $ ` Permit Fee $ 10K) - 0`) CCF
Scanning Fee $
Technology Fee $
Structural Reviews $
Radon Fee $
Training/Education Fee $
DBPR $
s
❑ Demolition
CO/CC $
Notary
Double Fee $(\
Bond $ `��('W ��/��
TOTAL FEE NOW DUE $ _ r` V
(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
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 al) 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. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signatu
If
--OWNER or AGENT
The \ forego ng instrument was acknowledged before me this
y2 `day of 20 S , by
A O who is personally known to
me or who has produced(��
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of
me or who has produced
20 , by
who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal: Sindia Alvarez
My Cornmissi0n FF 156750 Seal:
�0,F`°aQ Expireso9103120A8
as
************************************************************************************************************
APPROVED BY Plans Examiner aL Zoning
Structural Review Clerk
(Revised02/24/2014)
OjjWNER_B%UILDS
E—
NAM62S ( LLG i-C Y %Q �1'
ADDRESS: 1,66 /' `'(/ 11O6;
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
RE STATEMENT
DATE:
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have
read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner
must appear in person to complete all applications.
State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption
allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the
construction yourself. You may build or improve a one -family or two-family residence. You may also build or improve a commercial building at a
cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or
lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built
for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make
sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on
your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and
with -holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all
applicable laws, ordinances, buildings codes and zoning regulations.
Please read and initial each paragraph.
1. 1 understand that state law requires construction to be done by a licensed contractor and have applied for an owner -builder permit under an
exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain
restrictions even though I do not have a license.
Initial � 1,
2. 1 understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and
is not hiring a licensed contractor to assume responsibility. \ `` Y ,
Initial J
3. 1 understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential
financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the
contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts.
Initial ff r
4. 1 understand that I may build or improve a one family or two-family residence or a farm outbuilding. I may also build or improve a commercial
building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may not be built or substantially
improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the
construction is complete, the law will presume that I built or substantially improved it for sale or leas i which violates the exemption.
Initial \�'
5. 1 understand that, as the owner -builder, I must provide direct, onsite supervision of the construction
Initial
6. 1 understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence. It
is my responsibility to ensure that the persons whom I employ have the license required by law and by
county or municipal ordinance. InitialI /—/
I understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner -builder permit that erroneously
implies that the property owner is providing his or her own labor and materials. I, as an owner -builder, may be held liable and subjected to
serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property. My homeowner's
insurance may not provide coverage for those injuries. I am willfully acting as an owner -builder and am aware of the limits of my insurance
coverage for injuries to workers on my property.
Initial \ #'
8. 1 understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the
work being done. Any person working on my building who is not licensed must work under my direct supervision and must be employed by
me, which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the
Federal Insurance Contributions Act (FICA) and must provide workers compensation for the employee. I understand that my failure to follow
these may subject to serious financial risk. J
Initial v �'
I agree that, as the party legally and financially responsible for this proposed Construction activity, I will abide by all applicable laws and
requirement that govern owner -builders as well as employers. I also understand that the
Construction must comply with all applicable laws, ordinances, building codes, and zoning regulations.
Initial'
10. 1 understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States
Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact the Florida Construction Industry
Licensing Board at 8S0.487.139S or http://www.myfloridalicense.com/dbpr/pro/cilb/index.html r
Initial 'l '
11. 1 am aware of, and consent to; an owner -builder building permit applied for in my name and understands that I am the party
legally and financially responsible for the proposed construction activity at the following address:
Initial{
12. 1 agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the information that I have provided on
this disclosure.
Initial '
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the
Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial
loss that you sustain as a result of contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or
employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner -builder
permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of
the contractor's workers compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and returned to the local
permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the notarized signature of the property
owner, or other type of verification acceptable to the local permitting agency is required when the permit is issued.
Was acknowledged before me this
Off— day
20
By rto5 T�� -�i�� who was personally known to me or who has
Produced there License or -i--> c-- t UDC -NSA as identification.
'I IY DV Notary public State of Florida
(— �ZO W N E R ARY =0`°9 °�� Sindia Alvarez
\ oq a FF 156750
Epom,on
09.1031201zire
•
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
SURVEY AFFIDAVIT
STATE OF (FLORIDA)
COUNTY OF (DADE)
The undersigned Affiant Just—, T J R.TA�0 does hereb attest that
9Y
(Property owner)
The attached survey, performed by LPrNror,s 4wz> 6F1-RGlq Fret. zjs-# Zoq 8
(Name of surveyor's company)
For address: 3, 1 A )eFizo q Xgrwm8 , IpRAL %ASo&r ! G 33 /3
Performed on I/" 0 N' 4 8 (date of survey) is an accurate representation of the existing conditions and
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property
without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to
remove or obtain permits for any structures which now may exist on the property which are not permitted or which
may violate zoning or building code regulations. The Affiant further understands that the existence of any such
structures may affect final inspections as applicable to this or other permits.
Fu er, Affiant �V�e na
Ppe y wner Signature Property Owner Print Name
SWO N TO AND SUBSCRIBED before me this c�?_ day of o Z
Affiant is personally known to me, produced —�- 63 43Z+r44610 as identification.
"-J-S�
Notary
Revised on 5/22/2009/ Revised on 6/12/09
OSO5�Y AVgt Notary Public State of Florida
Sindiia Alvarez
ee My Commission FF 156750
oie�op Expires09/03/2018
Mission": Rick Scott
Governor
To protect, promote & improve the health
of Fil people in Florida through integrated John H. Armstrong, MD, FACE
state, county &community efforts. HFALT State Surgeon General & Secretary
Vision: To be the Healthiest State in the Nation
August 31, 2015
Jose Hurtado
166 NW 110 Street
Miami, FL 33168
RE: Modification to a Single Family Residence - No Bedroom Addition
Application Document Number: AP1200688
Centrax Permit Number: 13-SC-1624700
166 NW 110 Street
Miami, FL 33175
Lot: 14 Block:219 Subdivision:
Dear Applicant,
. . .... ......
This will acknowledge receipt of a floor plan and site plan on 08/14/2015 for tile. . lPPPA of the ajistin
9.
onsite sewage treatment and disposal system located on the above referenced.pcoperty. Proposed : • • •':
new driveway. 000000 000000 .....
No objection letter was issued by C. Icaza on 08/31 /15. • • • • • • • • • • • • • •
00
This office has reviewed and verified the floor plan and site plan you submitteaefire he proposed
remodeling addition or modification to your single-family home. Based on thejnfo,matiorty";provided,
the Health Department concludes that the proposed remodeling addition or mbdlficItion is.notaddinvao0:
bedroom and that it does not appear to cover any part of the existing system or encroach c the
required setback or unobstructed area. No existing system inspection or evaluation and assessment,
or modification, replacement, or upgrade authorization is required.
Because an inspection or evaluation of the existing septic system was not conducted, the Department
cannot attest to the existing system's current condition, size, or adequacy to serve the proposed use.
You may request a voluntary inspection and assessment of your system from a licensed septic tank
contractor or plumber, or a person certified under section 381.0101, Florida Statutes.
If you have any questions, please call our office at (305) 623-3500.
Sincer
C los I
Eng eer Ilir
Department of Health in Dade County
Florida Department of Health www.floridahealth.gov
in Dade County - • , Florida TWITTER: HealthyFLA
PHONE: (305) 623-3500 FACEBOOK:FLDepartmentofHealth
YOUTUBE: fldoh
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166 NW 110 STREET
MIAMI SHORES, FLORIDA 33160
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0000 STREET, SUITE 000 WEST
PHILADELPHIA, PA 00000
FOR REFERENCE
KEY PLAN
166 NW 110 STREET
FAMILIA HURTADO-BONILLA
CANDY HURTADO
KEY PLAN AND NORTH SIGN
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REFER TO GRAPHIC SCALE
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MIAMI SHORES, FLORIDA 33168
pRAFTER
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(305) 198-2 808
0000 STREET, SUITE 000 WEST
PHILADELPHIA, PA 00000
FOR REFERENCE
KEY PLAN
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166 NW 110 STREET
FAMILIA HURTADO-BONILLA
CANDY HURTADO
KEY PLAN AND NORTH SIGN
DRAWING N.T,S.
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This property described as:
Lot 14, Block 219
MIAMI-SHORES EXTENSION,
according to the Plat
thereof, as recorded in
Plat Book 43, Page 40
of the Public Records of
Dade County, Florida.
.004
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Burtado Sr. Jose Luis and Hurtado,Edda
PROPERTY OF:Hurtado, Rubi Indira, 166 N.W. 110th Street, Miami Shores,
♦nl s.u.ulnlluuol IUFstcvtrul(F A BOUNDARY Florida 33161.
A -So I'llF omit: I.S.t 1. It %Isul sb:a 1. of
1'I.UtIIDA I.N. .11'N1 Y111N SURVEY
I nereby certify that the survey repre- I.ANNF.S . �11) (::1It(•1:1, I:\('.
`+.1 /'.0
%.Nu MArr" sented hereon meets the minimum 1 13 �1!Oi
technical standards set forth by the board
Of Land Surveyors in chapter 61G17-6 ti1;1t1F)OI S-,,NIAPIPF:121-I.a,`1) PI-A.S.NFItS
Florida Administrative Code hpursuant to ERNESTO E. ESPINOSA T42946
Section 1;:•027. fla. Statutes. ?here are no
encroachments, overlaps. easements
appearing on the Plat. other than as
shown hereto. OIfirc addrrss: J59 Alcatar :%%ruur• ( ural Gables. 1•lurida J.i 134
IJaJ51 Gblr-7119 19$11 �'_J-SbhJ
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