1036 NE 96 St (10)Square Ft.
ii
PERMIT APPLICATION FOR MIAMI SHORES ll�'�lri1,�
10050 N.E. 2nd Avenue • Miami Shores, Florida 33138 • Phone: 305- 795 -2204 U FaX 51756 - N'
Date4 5. 49.---03 Job Address 163G au ' ed yIr - -- Tax Folio
�t 1 O e+ OF -4 - tr L UP 3
Legal DescriptionLC 131-i q Ii. $l en Irf11M1 Snare- SS Designated:
p oc
Owner /Lessee /Tenet im109( Fe ire( Ns
Owner's Address 1 0 J `P q(6 5 ,e'r Phone r 30 ' `51 —' 1 i'3
Contracting Co. Address 12 1') 3 5 _,' 1/2- 1 -44- Z0 m o n 3 3i&
Qualifier ChuN 1 lct 1 j0l( b(Ss(. aN ss# 9 — n`232 -5 Phone 4 V ZW
State # cec 0 5e) '15 Municipal # Competency # Ins. Co. J
IF THERE IS NO PERMIT PACKAGE ACCESSIBLE ON THE JOB SITE FOR INSPECTORS TO VERIFY,
THERE WILL BE NO INSPECTION. RE- INSPECTION FEE IS $50.00 AND MUST BE PAID IN ADVANCE
BEFORE CALLING FOR ANOTHER INSPECTION.
Permit Type (circle one): BUIL ELECTRICAL '' /n-� PPLUMBING MECHANICAL ROOFING
J
WORK DESCRIPTION: S W rnl r� p O CJ ( W(J
� Vvvvv
se 7lTT(
)
C i�
�tY lf�lE� ' ( �1� re-iyvtni-
b ° `y , -,� ��G✓ ✓
q 200L 5'SL
Estimated Cost (value) �� U (�
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY RESULT IN
YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIIN FINANCING, CONSULT WITH
YOUR LENDER OR ANY ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). 1 certify that
all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits are required
for all disciplines.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulati g construction and zoning. Furthermore, I authorize the above named contractor to do the work stated.
Signature of owne d/o Condo President
Notary
My Co
Mechanical
VCO — ce)
!)
///
a
to
wner and/or Condo President
` %;:g y c RICK ZABIELINSKI
=ar '1.4,1 MY COMMISSION # CC 944522
EXPIRES: June 12, 2004
o oed Thru Notary Public Underwriters a
Jw
0
0
6. 101 1 ff
RICKZABIELINSKI
T , += MY COMMISSION # CC 944522
EXPIRES: June 12, 2004
Bonded Thru Notary Pub l ' 6 .: ti ers I,
...:
TO', ALD E
Electrical
S
APPROVED:
Zoning
• o, Plumbing
Date
S
Date Notary as
My Conn
C.C.F
Master Permit .73? 003 —. 'Ry
re of Contr
ontractor or Owner Builder
ssion Ex
' -
Yes
res
ner Builder
Structural Engineer ' 5/ 2 Z C C'�
o
Date
Date
Notary Public
Print Nntarv'c �i.,.....
ww-g. r Jntowsk' MO
vet l rrP gip; tiffellKitiotorst • �.4 �►
Mt9i�fthtt frft� �aaaa 1i' •7!•..
• art' tt I1.
i1.
1%14 & nrt ;Ft trntt • � r a n:r.Pot'"
1'llai3l'1 A �`- c -
L'
NOTICE OF COMMENCEMENT
PE1iUJT NO. TAX P UO NO. ,
STATE OF FLORIDA:
COUNTY OF DADE:
.THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with
• Chapter 713, Florida Statutes, the following Information is provided In this Notice of Commencement.
1. Legal description of property and street address: F/t - 1.O Fee* oCLc+ ) 5� 4- 4-II (1 1. f i..t/y. El is k= � .1
S`, 1r ' ,t fh vfv No,-g3 } = , , t J
� 1( t' U7C. cis YC'c�,'C! /AiC 1
ki
2. Description of improvement: 4I m m /n, `` pC]G ! S Q /} • - Pci, �i
J f
3.Owner(s) name and address: k 1 nr e t ) ^ 4- f ( (h) re ((e) i^U 5
I(7 N c. q(, Si(eeT" a/TM' Stfd
l
Interest in property: _ O.�I
Name and address of fee simple titleholder:
4. Contractors name and address: CK c 4 &A / c � r. ctrl i--15 ' - v n)
- w i ( LS - Treer - +# 2.6) (An F/i 33l
5. Surety:(Payment bond required by owner from contractor, if any)
Name and address:
Amount of bond $
6. Lender's name and address:
Signanire of Owner
Print Owners Name
Swotn to and subscribed before me this 2c,
day of , r , ;g "al.__,j
t Pr •- RICK ZABIELINSK
;:
•' 1 .1 MY COMMISSION # CC 944522
• EXPIRES: June 12, 2004
rimmtitu
CF114 2003R0400144
MS* TcIIJi to 777T4i nes
NEZIVIte U
lt 3f3M3 1$t$4 145
WIND N M.Is CMS Cr CtltNT
UNIT ME
tot. t tmm
7'4
9. Expiration date of this N - ' -- of Commencement: . expiration date is 1 year fmm the date of recording dnless different date is specified)
7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided
by Section 7 13.13(1)(a)7., Florida Statutes,
Name and address:
8. In addition to himself, Owner designates the following person(s) to receive a copy of the Lienors Notice as provided in
Section 713.13(1)(b), Florida Statutes.
Name and address:
Prepared by: h''(1' ? -? 1:),. i) i
175'1'73 /t ZS"1 -- _ ; 1 - 3zc►
Address: i l l Ft <1
Date 5
L
Miami Shores Village
Building and Zoning Department
Attention: Building Official
M 1 Ii( \1 S)-1(y
SWIMMING POOL OWNER'S CERTIFICATION
I certify that I am the legal owner of the property described as
a i (j r47t- f--
1 ; 114 6 la (.1C A Si4Gte>
C r Nz; e i 0 -� � , located at 103G E. j 7
In accordance with Section 33- 12(f), Code of Metropolitan Dade County, I certify that
I understand and agree that the swimming pool to be constructed at the above address cannot
be used or filled with water until a separate permit has been obtained for an approved safety
barrier, and such barrier erected, inspected and approved.
I further understand that this certification, however, does not eliminate the need for
obtaining a permit and erecting an approved barrier prior to final inspection and use of the pool.
Legal Owner/ lb, ��(;� l,'k. ` !+�(� ,t,% �
Note: This certification is to be submitted with a swimming pool permit application in duplicate.
PERMIT NO.
ADDRESS: .
MIAMI SHORES VILLAGE
BUILDING / ZONING DEPARTMENT•
SECTION
BY
DATE
ZONING •
ELECTRICAL
.,
MECHANICAL
PLUMBING
FIRE
PUBLIC WORKS
STRUCTURAL
BUILDING OFFICIAL
1. Subject to camp(lance vrlth aft Federal, State
County.Yatage rules told regulations. WILQe assume
no rosponslbWity for accuracy of /or results (roc
these plans.
2. Thls copy of plans must be available o
buHding site or no Inspection wfil be coadcctat
CRITIQUE SHEET
JOB ,ADDRESS 36, / v ' t-
APPLICANT ■ e ( S
PHONE #
APPUCATION root
SHEET OF
MISCELLANEOUS
DATE ZONING
COMMENTS
INITIALS
7 d j /00 L c/c - Cp s 6.6 ' ee
POOL G° ECNICENEM X00
Spa F CLOSING/ SELF LOWiN
GATES REQUMEO
FENCE: 1' MOH 0\444.4
AND NON-CM/BAKE
IF NrICH-lnf[ S 1=4L MfVP FPNco
WALL, OWNER MUST REPLACE
WITH A 4' FFNC[F f
OWNER'S PROPERTY
NOTICE OF REQUIREMENTS
RESIDENTIAL SWIMMING POOL,
SPA AND HOT TUB SAFTY ACT
I (We) acknowledge that a new swimming pool, spa or hot tub will be constructed or
installed at /O '4/ 9 ST/M iami Shores,. Fl., and hereby affirm that one of
the following methods will be used to meet the requirements of Chapter 515, Florida
Statutes.
;please initial the method(s) to be used)
The pool will be isolated from access from the home by an enclosure
that meets the pool barrier requirments of Florida Statute 515.29;
The pool will be equipped with an approved safty cover that
complies with ASTM F1346 -91;
All doors and windows providing direct access from the home to the
pool will be equiped with an exit alarm that has a minimum sound
pressure rating of 85 decibels at 10 feet;
All doors providing direct access from the home to the pool will be
equipped with self - closing, self - latching devices with'release
mechanisms placed no lower than 54" above the floor or deck;
I understand that not having one of the above installed at the time of final inspection, or
when pool is completed for contract purposes, will constitute a violation of Chapter 515,
F.S. and will be considered as committing a misdemeanor of the second degree, punishable
by fines up to $500 and /or up to 60 days in jail as establi -hed in Chapter 775, F.S.
CONTRACTOR'S NAME (PLEASE PRE NT) .
,p••
RICK ZABIELINSKI
V 1
• MY
f4 EXPIRES: June 12, 2004
- „ .. ` Bonded Thru Notary Public Underwriters
• • UBiil
BUILDING DEPARTMENT
10050 N.E. SECOND AVENUE
MIAMI SHORES. FLORIDA 33138.2382
TELEPHONE (305) 795 -2204
FAX (305) 759-8972
'S SIGN
NOTARY UB C
I 1 6 %)
& DATE
OWNER'S NAME ('LEASE PRINT)
6.o
LINSKI.
__ MY COMMISSION 4 CC 944522
EXPIRES: June 12, 2004
Bonded Thru Notary Public Underwriters
MIAMI SHORES VILLAGE
41 BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date ;0 & .3 Time
Type Insp' n : :: Qua ..A 9 ALP-a,
Permit No. 0 2
Name 1/S r
Address O (, U E % -
Company
Phone# 3 o� - 50-5- G8?-8
For Inspector 9 Q 10 'O3 Name & Date
Approved
Correction ❑
Re -Insp' n Fee
MIAMI SHORES VILLAGE
� BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date 10"8 Time
Type Insp'n C'IA.
Permit No. 03 3 �3 8
Name 1/C\ YY1
Address l O (c N € 9l - Sr •
Company
Phone # '3C J 5 3 (08;
For Inspector:S Q ‘O hk0..5 Name & Date
Approved
Correction
Re- Insp'n Fee
p O'
s it
2a
/38d
`/2 cd
I
J
, ,I
:,,41 S
-73,
Mph / �P ®•act ,.. _
G OVV Co-.c- err*
(3.5d
��mvE
-- 4' l / /cis
I b
n •
iz fr
/4%
• jfC(,y) -p
//0. 00 1 :
'.,r) 34.98
0
i t
I v 1
" d 4' ch i c,e
•
/5,7&
97d rioo Z 3,9�
CBS SAN ,`
o / /P / h'
rob a,
, 070 x2
ed7G
1,1
Nol VALID NTt . MAR flit Srt :AAnIDE
AND TIRE ORIC :NAL RADCD SEAL DE
ELAN IDA LICENSED SURV CYUR
.■nu .In erg
M;Aii11 - AO= CoVn,77
T/O ,t/ ,i,ij-
A BOUNDARY
L.F. ELEV. = ;D // /
Gar Elev X38
E.R.P.. Q '?Z
Ferreiras, Kimberly. M , and
PROPERTY OF: Ferreiras, Alberto C. , 1036
SuRVEy
t
hereby certify that the survey repre-
sented hereon meets the minimum
technical standards set forts by the Board
of land Surveyors 'n chapter 61C174
Florida Administrative Code pursuant to
Section x.1027. Fla. Statutes. The are no
encroachments. overlaps. easements
appearing on the Plat. other than as
. shown hereto
n. rim*. Alft'YY0. AND NAPPED NEE 5/747
4 -30 -03 "Recertified ", Certified
M >7 7.5.
denotes lowest habitable
door elevation.
Elevations shown refer to
N.G.V.D. 29
Lowest Adjacent Grade:
B.M. # 7? -AZ. ELEV. .7L'�
'30
This property. described as:
The East feet of Lct 15,
and all of Lots 13 and 14,
Block 81, MIAMI SHORES
SECTION NO. 3,
according to the Plat
thereof, as recorded in
Plat Book 10, Page 37
of the Public Records of
Dade County, Florida.
N.E. 96th Street,
Miami Shores,
Florida 33138
I.ANNE. .a`+D (.,>RCI.A. INC.
11•.x_098
SI;liVEYORS -,M, PIERS- 1.A•NI) PLANNERS
MIn4 # S Z3&
Uffirc address: 359 :Ucatar Avenue. rural Gables. Florida 33134
(305) -7909 (954) 523 -8663
FIEL D TE DRAWN BY
t5 /2 z /oz 'as Zoe
To revised.
4 . 3a• e3
Page 1 of 2
DRWC. NO
148931
D/
. o,v'
IN 'Z ' 41 ' k . 1 I
lq
IN
v x
1 1
5'conc : u�r%
/38d
, d (3,5d
/ 520
NI //
,, T , -r
J •
_ 8 / 45 6 - _ % Gre ~ Yt;.: g
FOU NTA/ 117 �•
^ C`
)
/ /O,
¢' L,2 /cb
nl
a7d Ir 0 ci
` cBS F� AN7L dC
d f//9//z i'
a l A /`lob D,
, Q /5,7&
N °^
/Z,Sr 1 74°7
3 4'98
/0,98
oj1,
44, •
wlt .n ' .� - •C� Iiv •K n`
• -J
ro7 =� °��
GG- c cL.4 .. e✓� 7G•
P// NOV O.
PROPERTY OF:
NUT VALID WITHIN/1' rut SJC. UTtIRc
arm - nlc tutu:v.4s. AA Caro scat. or
►l.UKIDA LICENSED S'IUR %'Cl
.a. \D .%l P!•q
L
Gar4ge Elev., 9:38
E.R.P.. 4 4
Ferreiras, Kimberly- M., and
A BOUNDARY
SURVEY
1 Thereby cernh that the survey repre-
sented hereon meets the minimum
technical standards set forth by the Board
of lard Surveyors in chapter 61C17 -6
Florida Administrative Code pursuing to
Section 47207/. Fla. Statutes. The are no
encroachments. overlaps. easements
appearing on the Plat. other than as
shown hereto.
ff
IR. mew met. aumer a arm mamma
L.F. ELEV. = /0
denotes lowest habitable
floor elevation_
Elevations shown refer to
N.G.V.D. 29
Lowest Adjacent Grade: 730
B.M. # 72 -%Z ELEV. 52 7 ..' -
vl :giYl - AO= CO (../,.,7Y
Ferreiras,.'Alberto C., 1036 N.E. 96th Street, Miami Shores,
4 -30 -03 "Recertified", Certified To revised.
T 7? 0 1 - 1 4 'sr � 75. 75 .7 e - 3o .a�
This property,described.as:
The East 10.00 feet of Lot'15,
and all of Lots 13 and 14,
Block 81, MIAMI SHORES
SECTION NO. 3,
according to the Plat
thereof, as recorded in
Plat Book 10, Page 37
of the Public Records of
Dade County, Florida.
Florida 33138
LANNES .AND (:ARC1A. INC.
Lli. /t 2U9fl •
Nl :liVEYORs- M,kP1'E :KS -LAND PLANNERS
� �E hMirI4
*5Z38
Office address: 339 .-Ueatar Avenue. Coral Gables. Florida 33134
FIELD D TEI SCALE
.5/7 • °= 2o/
(305) 666 -7909 1 323.866.1
DRAWN BY
Page l of 2
DRWG. NO
148931
�x
V
u
4'
5'Gor�c : iciG/
I1
d
/2.60
U
0
z3,5
//35
•
55'
*per //
2c7 B'
/.0d
•
o,
4� G� /Gcs
old Y. /o0
cgs pc-4,4'7
1
R /5,76 ,
n
iz,3fr $7.°7
arc*
c(Cf k' 4' 6 A!cy'
I, /Om' (P)
G7a N ‘J
1b
. •
POOL G°ECTUOIAEME 78
SELF - CLOSING/ S LF- LOCKING
GATES REG IRED
FENCE: 4° GPI H (MIN.)
AND. NON-CLO SABLE
IF NI ,IGHBORS RE OVE FENCE/
TW .L OM g(R T 6R[EPLAeE:
WITH A 4'. OBE EON
OWNER'S PR RERTY
J
Z3,97
° 20
G,
A
o-
0n Q
.UT V41.0 Wrrllul? flit SIGNATURE
AND THE URI(. 1 VAI. RAISL'D Sr St. u►
/1.URIDA 1.( C4,ED.l'IPR\"tl'l1R
t
Q
L.F. ELEV. = /0
denotes lowest habitable
floor elevation.
Elevations shown refer to
N.G.V.D. 29
Lowest Adjacent Grade:
B.M. # 73 -!oa ELEV.
M , A,r - 1 `Aoc co �.,r7
Garage Elev., 9.3e
E.R.P.. Ct42
/14/4 v�, 96, 17, sr
ti
N/ �v
/7
/'
rr
/9
Zo
f
2/
� 6,4- 770 i c/
A BOUNDARY
Ferreiras, Kimberly M., and
PROPERTY OE: Ferreiras Alberto C.., 1036 N.E. 96th Street, Miami Shores,
St1itVE7
1 hereby marry that the survey repre-
sented hereon meets the minimum
technical standards set forth by the Board
of land Surveyors in dtapter 67077 -6
Florida Administrative Code pursuant to
Section Ciao. Fla. Statutes There are no
encroachments. overlaps, easements
appearing on the Plat. other than as
. shown hereto.
rt. TM
I. auet'tTO.t Awa I.Arv(j +a '747
0
Iv
N
7 ;O
This property .described as:
The East:10.00 feet of Lot 15,
and all of Lots 13 and 14,
Block 81, MIAMI SHORES
SECTION NO. 3,
according to the Plat
thereof, as recorded in
Plat Book 10, Page 37
of the Public Records of
Dade County, Florida.
FIELD D TE 1 SCALE
"5/22/42 /a, 20/
4 -30 -03 "Recertified", Certified To revised.
� % 4- 3o•e>
Page 1 of2
Florida 33138
LANN ES AND (;A RCIA. INC.
Lfl. 1i _U9K •
Sflit'E:YOKS- NIA M.:RS -LAND PLANNERS
t yM I ri+ # Sz38
Office address: 359 :Ucuar Avenue. ('oral (tables. } lorida 331!4
1305) 666 -7907 19,54) 523 -866.3
DRAWN 13Y
a, d
DRWG. NO
148931
c\
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 5/29/2003
Applicant: KIMBERLY
Owner: FERREIRAS
JOB ADDRESS: 1036
Contractor
Local Phone:
Parcel # 1132060143550
Signed:
In consideration of the issuance to me
conformity with the plans, drawings, st2
done by either mysel my agent, serval
Signe
a
0
NE 96
PAY
TO THE
ORDER OF
FOR
riBankUni
Building Permit
Permit Number: BP2003 -840
FERREIRAS
KIMBERLY
ST
Contractor's Address:
Fees:
FEE2003 -3243
Description
Building Permit Application Fee
Total Fees:
Amount
$60.00
$60.00
Total Fees: $60.00
Total Receipts: $0.00
1
Permit Status: APPROVED Permit Expiration:
Ct Work: FENCE AROUND PROPERTY. POSTS 4FT APART WOOD 5FT H.
Legal Description: 5 6 53 42 MIAMI SHORES SEC 3 PB 10 -37 E10FT LOT 15 & LOTS 13 & 14
11/23/2003 Construction Value:
VC PARTNERS, INC.
1250 E. HALLANDALE BEACH BLVD.
HALLANDALE, FL 33009
-k\o\Nt.l Shoe u
aft,eA woo- "frp
501 Golden Isles Drive • Hallandale Beacf lQr� 3009,
1- 877 - 779 -2 www.buexpress.com 3
m (� - gr2r ',tI -fkS
$3,000.00
Page 1 of 1
11'00L22711' 1:2670905941: 03299L
63- 9059/2670
32
10Q50 P.F. 2nd Avenue • Miami Shores, Florida 33138 • Phon •
3 Cif 103(o NE., q(0.(n 5+.
Date Job Address
Legal Description Historically Designated: Yes No
' LI X
I�
Master Permit # d �
Owner /Lessee/Tenet elm but l( - ,vyk9,1 03
Owner's Address X0302 ME q LQ4h J�•
Contracting Co. CV1 F'Ys{t. -.
Qualifier
State # Municipal #
IF THERE IS NO PERMIT PACKAGE ACCESSIBLE ON THE JOB SITE FOR INSPECTORS TO VERIFY,
THERE WILL BE NO INSPECTION. RE- INSPECTION FEE IS $50.00 AND MUST BE PAID IN ADVANCE
BEFORE CALLING FOR ANOTHER INSPECTION.
Permit Type (circle one): (BUILDING/ ELECTRICAL
WORK DESCRIPTION:
l
Square Ft.
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILIZRE TO DO SO MAY RESULT IN
YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH
YOUR LENDER OR ANY ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). 1 certify that
all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits are required
for all disciplines.
OWNERS 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. Furthermore, I authorize the above named contractor to do the work stated.
Si nature of owner .1 d/ it Condo President
My Commission Expires
Notary as to Owner and/or Condo Presi
FEES: PERMIT / RADON
APPROVED:
Zoning
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
/1��
� Building
Mechanical Plumbing
SS#
4, • +;t KELLENIota
S.
Notary Pub! - Stata of F . t
' = MyComma Expires Apr1
Commission # DD 109725
Bonded By Nar'onal Notary Assn.
Tax Folio
Estimated Cost (value)
Competency #
Address
C.C.F r41-1'651aA
t2r- ! 756 -8972
Phone (305) T"i„J J "` r ci t q
Phone
Ins. Co.
PLUMBING MECHANICAL ROOFING
3 000
Date Signature of Contractor or Owner Builder
h as to Contractor or Owner Builder
knmission Expires
NOTARY BOND
TOTAL DUI 6[J
Date /
Date
Electrical
Structural Engineer
c s -e ) fre,r 643 being the legal property owner, for the property
Located at: ( E
•
OWNER BUILDER DISCLOSURE STATEMENT
Legally described as
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 - nd I have read and understand 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 licensed contractors. You have applied for a permit under an
exemption to that 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 or a farm out - building. You may also .build or improve a
commercial building at a cost of $25,000.00 or less. 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 completed, the law will presume that you built it for sale or lease, which is a violation of this
exemption. You may not hire an unlicensed person as your contractor. It is your responsibility to make sure
that 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- holding tax and
provide workers' compensation for that employee, all as prescribed by law. Your construction must comply
with all applicable laws, ordinances, building codes and zoning regulations.
Proof of ownership provided ( -4--
Was acknowledged before me this ,6"
Produced
Owner
Fla. 6'13 7/ 3 .
,23 � Owner
VILLAGE OF MIAMI SHORES
BUILDING DEPARTMENT
W�rlD
DISCLOSURE STATEMENT
initial of reviewing clerk. The foregoing instrument
day of , 2003
By l &,('` ra 4 rets who is personally known to me or who has
as identification and who did take an oath.
Notary
Miami Shores Village
10050 NE 2nd Avenue
Miami Shores, FL 33138
Activity Log
Date of Activity
11/25/2002
Time of Activity: 12:00 AM
Activity Type: Application Filing Date
Activity Status: APPROVED
Decription One: Application Accepted By:
Decription Two:
Time of Activity:
Activity Type:
Activity Status:
Decription One:
Decription Two:
11/26/2002
12:00 AM
Last Edit Date
Last Edit By: Alicia
Time of Activity: 12:00 AM
Activity Type: Application Decision Date
Activity Status: APPROVED
Decription One: Decision By:
Decription Two:
Time of Activity: 12:00 AM
Activity Type: Fee Date
Activity Status: Paid
Decription One: Fee Type: Building Permit Application Fee
Decription Two: Amount: $60.00
Page 1 of 3
Printed On: 6/5/2003
Activity Log
Date of Activity
11/26/2002
Time of Activity: 12:00 AM
Activity Type: Fee Date
Activity Status: Paid
Decription One: Fee Type: Notary Fee
Decription Two: Amount: $5.00
Time of Activity: 12:00 AM
Activity Type: Fee Date
Activity Status: Paid
Decription One: Fee Type: CCF
Decription Two: Amount: $0.60
11/27/2002
Time of Activity: 12:00 AM
Activity Type: Receipt Date
Activity Status: APPROVED
Decription One: Receipt #: RCPT2002 -2101
Decription Two: Amount: $65.60
5/24/2003
Time of Activity:
Activity Type:
Activity Status:
Decription One:
Decription Two:
12:00 AM
Permit Expiration Date
Page 2 of 3
Printed On: 6/5/2003
Activity Log
Date of Activity
5/24/2003
Time of Activity:
Activity Type:
Activity Status:
Decription One:
Decription Two:
12:00 AM
Application Expiration Date
Page 3 of 3
Printed On: 6/5/2003