31490PERMIT APPLICATION FOR MUNICIPALITIES OF DADE COUNTY
(OWNER TO RETAIN COPY)
Date 7 Job Address 4 :5 7 02?. 4 :5 7 02?. Al E. cie6 51 Tax Folio // 3206 / ' 6'
Legal Description Sae_ P / ®- f Th vt rr� gLik, ( ?/6 Master Permit # ✓�� /�
/ Lessee / Tenant
Owner's Address 6o c E,51-!
Contracting Co. ,,/
Qualifier (,p f� ! \.. / Q4(. 5 er Phone
Phone
0 f 1- ec.1-»c inc. Address 1 q3 au:
State # (; qg5 Competency # 3:6
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING, MECHANICAL PAVING FENCE SIGN
WORK DESCRIPTION
-4 - �1M 1
gnature o Owner an• /or ondo P esident
Date 47-- ! Rotary Public. State of Floridan
/ My Commission Expires Der.
r,. 1, 199
Nota as to Owner and /or Condo res Mite.
My Commission Expires:
* * * *
PERMIT FEE: APPROVED:
1
*
Fire
5
Not
My
Phone
Ins. Co.
omission Expires:
sit * *
Other
75 -4 9'
94 —i 373
®
Square Ft. Estimated Cost 1) 004.00
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 OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN 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). I 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 ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING, and MECHANICAL work.
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 gulating construction and zoning.
Furthermore, I authorize the above -named contractor do he work stated.
S'.gnature of Contractor or Owner - Builder
Dater ? -if -R/
Roffiy PuMfQ tats of Florida
My Cone issioa Expires Dec 1
!a " mm tiwo anc Inc.
y as to Contractor or Owner Bui�.dex
Zoning Building
Mechanical Plumbing Engineering
CONSTRUCTION INDUSTRY
NOTICE OF ELECTION TO BE EXEMPT FROM
TIM PROVISIONS OF THE FLORIDA WORKERS' COMPENSATION LAW
MAIL TO: Department of Labor & Employme ecurity,
Bureau of W.C. Compliance € t,S . = - o%,„.1
2728 Centerview Drive, 100 Forrest$)'d'g' . , `' -
• Tallahassee, Florida 32399 -0661 ..:
f,.
Carrier Address
Policy Number
InSUrance (Ago cy)
Agency Address
PLEASE TYPE OR PRINT:
/4/ 7kZ
Position: Proprietor _/Partner — /or /Officer (Title)
IMPORTANT: Individual exemption filing fee, pursuant to Section 440.05, F.S., is
payable only by money order or cashier's check, to W.C. Administrative Trust Fund.
request and t ifiationc.
re rf W. J. 0..1110
� ' SWORN TO AND SUBSCRIBED BEFORE ME THIS
(Zip)
7 DAY OF
STATE USE ONLY
POSTMARK DATE /_W 961)-
This notice shall be i_ t/ r in effect for two (2) years from
date of3 i3until . ! •
or until revoked. whichever comes first.
Nana of Sole Proprietorship. Partnership, or Corporation) , (D/B/A If Applicable)
'l ®K � �e' y a-r / Y 4i1- . r7- -
N� ■+■■�■■■a
Address) (Street Address. if different!
•
Sael
(CRY) (State)
4-9 aro 7o /Iv
(Rand Employer Identification Number) ° • i a s
J • • s
Nature of Business o r T r a d e : /l. a ' �v . Jn �" • .t 1/ • • a e ,
As of 12:01 a.m. 30 days following the date of the mailing of this form. you are hereby notified that tbe flixtWing.koJeltoprieto
Partner or Corporate Officer of the above named business does elect to *exempt from the provisions Of the Floridi Wgr.kers' •
Compensation Law. I understand that by this iction I am not entitled to benefits under chapter 440, Flerkintatutes.„tty.filing this
form I have not exceeded the exemption limit of three Partners or three Corporate Officers. I further cePtifrthat anf eviteyees of the
business named above are covered by workers' compensation insurance. • • •
the following are the certified or registered licenses held by me pursuant to chapter 489 Florida Statulegelflone, sta state): • "
INSURANCE CARRIER INFORMATION (If Applicable): A construction industry employer with one (1) or mote employees must
maintain Workers' Compensation coverage. Failure to comply will result in a five- hundred dollar ($500) fine and a one - hundred
dollar ($100) fine for each day of noncompliance (see section 440.43, ES.).
Name of Carrier o" 6 / —�- 5 4 �
EFFECTIVE DATE pi 1 -'. e / q 9/
Social Security Number C � {9 / /#.22 - 6
seven dollars and fifty cents 17.50) and is
Failure to enclose fee will result in
NOTARY PON. rr ur 1ODA
@1S, tiia
lam-