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RC-11-2117Miami Shores Village Building Department 10050 N.E2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: BUILDING JOB ADDRESS: /02 5- /' t ) 01 5 City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: /42 / 3,6 004 O3 ra Is the Building Historically Designated: Yes FBC 20 Permit No. Master Permit No. R 6 - 11-1 l °P-187 ROOFING NO Flood Zone: OWNER: Name (Fee Simple Titlehol4 I Ze- 7 " leC . Phone#: 7KTI 2 %7 j 2— Address: / ?5 City:' Tenant/Lessee N Email: ' n u State: Zip: Phone#: CONTRACTOR: Company Name: Phone#: Address: City: Qualifier Name: i'hone#: State: Zip: State Certification or Registration #: Certificate of Competency #: Contact Phone#: Email Address: DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ Aci 40 6 e ' Square/Linear Footage of Work: Type of Work: DAddition DAlteration ONew Repair/Replace ODemolition Description of Work: ia df�6-6 Fry 1•1" /1 ,/ "� 4-� Al . ./AV ail New Plooi 4 /4 44 7, j / • /tep, �5900e- 9i ,64,,-1,? A94,®,,,4i . Color thru tile: **** *** ** * *** ** ***** * * **********/ *** ***F ey * *** *** *+��x****** * *e�a�**** wax *e��x�xe��xe��x**** **** Submittal Fee $ Permit Fee $ / 00 , 00 CCF $ CO /CC $ Scanning Fee $ 5 r0 '3 Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ (� {� Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 r ' ec fee will be charged The foregoing instrument was acknowledged before me this day of 1 . 20 a by 4 iwi i® &ti ei � d� , who is, onally NOTARY PUB Sign: 144 MICHAEL J FABIANO cO2RNOitvli@tdierSithiel My Comm. Expires Nov 1, 2015 Commission It FE 140447 .,1 Througr . 5c'.ao .assn Print: ,Ie Jk 144 i My Commission Expires: Signature Contractor The foregoing instrument was acknowledged before me this day of , 20 _, by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: ***+ k*** **+ t< ***+ k**** fl= **+ k****** ******N+ **+ k********* *+ R+ F**e **+ b** **** *****+ b*****+ 1•+ 1,e **ts+ k**+ A*+ k+ k*****ee+k***+b******+N**** APPROVED BY Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Zoning Clerk Au# 5811571 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCT/ON INDUSTRY LICENSING BOARD SEQ# L1110050225 LICENSE NBR *10/05/2011 117019502 RF110675 Os. 4 The PLUMBING CONTRACTOR Named below HAS REGISTERED Under the provisions of Chapter 489FS. Expiration .date: AUG 31, 2013 (INDIVIDUAL MUST MEET ALL LOCAL, 431:1,ENsiNo REQUIREMENTS PRIOR TO CONTRACTING' ZN ANY .,411110 FALLON, DENNIS PATRIC 1400 NE 133 RD SUPERMAN PLUMBING, INC. NORTH MIAMI FL 33161 RICK SCOTT, KEN LA WSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW JEFF ATWATER CHIEF FINANCIAL. OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. 12 -08 -2011 EFFECTIVE DATE: PERSON: FEIN: 12/08/2011 FABIANO 202844443 BUSINESS NAME AND ADDRESS: SUPERMAN PLUMBING INC 1400 NE 133 RD MIAMI FL 33161 SCOPES OF BUSINESS OR TRADE: 1- PLUMBING EXPIRATION DATE: 12/07/2013 MICHAEL * IMPORTANT: Pursuant to Chapter 440. 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 QUESTIONS? (850) 413 -160 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE: 12/08/2011 EXPIRATION DATE: PERSON: MICHAEL FABIANO FEIN: 202844443 BUSINESS NAME AND ADDRESS: SUPERMAN PLUMBING INC 1400 NE 133 RD MIAMI, FL 33161 SCOPE OF BUSINESS OR TRADE 1- PLUMBING 12/07/2013 F IMPORTANT O Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover .benefits or compensation under this D chapter. H Pursuant to Chapter 440.05(12), F.S., Certificates of election to be Rexempt.. apply only within the scope of the business or trade listed on the notice of election to be exempt E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. CUT HERE QUESTIONS? (850) 413 -1609 * Carry bottom portion on the job, keep upper portion for your records. )WC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 MIAMI-DADE COUNTY BUILDING AND NEIGHBORHOOD COMPLIANCE 11805 SW 26TH ST. SUITE 207 MIAMI FL, 33175 (786) 315-2880 CONTRACTOR'S BUSINESS CERTIFICATE OF COMPETENCY ISSUED MARCH 15, 2007 THIS IS TO CERTIFY THAT SUPERMAN PLUMBING INC CONTRACTOR CERTIFICATE NO.: 07P000248 TRADE: PLUMBING CERTIFICATE EXPIRATION DATE: 09/30/2013 HAVING MET THE CODE REQUIREMENTS OF MIAMI-DADE COUNTY, AS AMENDED, IS CERTIFIED AS A CONTRACTOR IN THE FOLLOWING CATEGORY(S): 0001 PLUMBING WITH ALL WORK TO BE DONE UNDER THE SUPERVISION, DIRECTION AND CONTROL OF QUALIFYING AGENT FALLON DENNIS S.S.N. - -2083 ALTERATION, REPRODUCTION OR TRANSFER OF THIS CERTIFICATE IS PROHIBITED. SUPERMAN PLUMBING INC 1400 NE 133RD RD NORTH MIAMI CHARLES DANGER, P.E. SECRETARY, CONSTRUCTION TRADES QUALIFYING BOARD FL 33161 FEE FOR THIS CERTIFICATE WAS PAID ON PROCESS NO. T2011113293 FLP CERTIFICATE OF LIABILITY INSURANCE OP ID KT DATE(MM/DD/YYTY) 07/26/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 13• - .1' : = ce ' sate of . er s an • • DI • `F ` -I R • , the po c es must . - en • ors - • . l I : - • A • ` '' r • , su • act to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER • Newman Insurance Agency, Inc. 5700 Stirling Road Hollywood FL 33021- Phone: 954- 963 -9626 wN r At, r NAME: PHONE FAX rIC , Ext): (NC, No): ADDRESS: PRODUCER CUSTOMER SUPEPLU INSURER(S) AFFORDING COVERAGE NAIC 0 INSURED pe Superman NE 133 Riling, Inc. N Miami FL 33161 INSURER A: Atlantic Casualty OCCUR INSURER B: INSURER C : 05/23/12 INSURER D : EACH OCCURRENCE INSURER E : PREMISES (Ea occurrence) INSURER F : ■■ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR - TYPE OF INSURANCE AUU INSR - WVD - POLICY NUMBER POLICY EFF (MMIDD/YYYY) POUCY y (MM/DD/YYYY) LIMITS A GENERALUABILITY X COMMERCIAL GENERAL LIABILITY X OCCUR L0400017850 05/23/12 05/23/13 EACH OCCURRENCE $ 1000000 PREMISES (Ea occurrence) $ 100000 ■■ CLAIMS -MADE MED EXP (Any one person) $ 5000 PERSONAL &ADVINJURY $ 1000000 ■ GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE UMIT APPLIES PER: X POUCY JET T LOC PRODUCTS - COMP/OP AGG $ 1000000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ ■ UMBRELLA LIAR EXCESS UAB ® OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ■ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVEn OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below / A WC STATU- OTH- TORY LIMITS ER EL EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION Miami Shores Village Hall 10050 Northeast 2nd Avenue Miami Shores FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE jj�j�,rl.p� ©1988- 2001�,CURb CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD MIAMI -DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 1st FLOOR • MIAMI, FL 33130 2011 MUNICIPAL CONTRACTOR'S 2012 TAX RECEIPT MIAMI -DADE COUNTY - STATE OF FLORIDA PURSUANT TO COUNTY CODE SEC. 10 -24 EXPIRES SEPT. 30, 2012 THIS IS SIC T A BILL - DO NOT PAY RECEIPT NO. 30-6278642 CC NO: 07P000248 BUSINESS NAME / LOCATION SUPERMAN PLUMBING INC 1400 NE 133 RD OWNER :SUPERMAN PLUMBING INC SEE BACK OF RECEIPT FOR A LIST OF NON — PARTICIPATING MUNICIPALITIES Receipt holder must register in the city where work is to be done. PAYMENT RECEIVED MIAMI -DADS COUNTY TAX co.42 �22/2Q11 02240048001 000200.00 FIRST -CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RECEIPT HOLDER MAY DO BUSINESS AS A CONTRACTOR AS SPECIFIED HEREON. PLUMBING CONTRACTOR DO NOT FORWARD SUPERMAN PLUMBING INC MICHAEL FABIANO PRES 1400 NE 133 RD NORTH MIAMI FL 33161 lil t= D�1DE`COU . 'MX DQLL€'i7OR 140 W. FLAGLER ST. :1st FLOOR MIAMI, FL 33130 2011 i OC A1: BUSINESS +T ik I 20t2 M(4(- OiWECOURITY gi4WWOFFWR(GG EXPIRES SEPT. 30, 2012 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 601800 -6 RUIF'sEsOW iffffigING INC 1400 NE 133 RD 33161 NORTH MIAMI °8J'ERMAN'PLUMBING INC sec1leffAVING CONTRACTOR THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CRIES. NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE HOLDER'S QUALIFICA- TIONS. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLE`TOR.O 7 / 2 5 / 2 011 60000000422 000045.00 SEE OTHER SIDE FIRST - CLASS AftgrAdE PAID MIAMI, FL PERMIT NO. 231 RENEWAL CC iECW/ 'iiW0248 627864 -2 WORKER /S 1 . DO NOT FORWARD SUPERMAN PLUMBING INC MICHAEL FABIANO PRES 1400 NE 133 RD NORTH MIAMI FL 33161 i,I li,,,11,,,,11,11, :,,,11,1„1,1 „1,111„ !la.11,,,lll $I 1 .1 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 al 1 r , ' • .....4.4unatan INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC 20 RECEIVED DEC 0+6 011 Permit No. Master Permit No. 1 I `3101- Permit Type: BUILDING �/ ROOFING p OWNER: Name (Fee Simple Titleholder): NI" b v. +t) t? (,? P4 Phone #: ?a, . (/2 7 ( 20 Address: f ZS' Ae. t C)G 57"-` city: fli (/ in i -5 tie 12 US state: FL- Zip: 33 / 3 Tenant/Lessee Name: AIM Phone#: Email: .41)4Q 1`1-6- c/ V e 5 ACf CO lil 1-e (sct.fo c c w JOB ADDRESS: 2 3— A-) E / 0 6 6 7 City: Folio/Parcel #: Miami Shores County: Miami Dade Zip: 3.3/ 36‘ // 21 3 0 6o3 So NO t' Flood Zone: A Is the Building Historically Designated: Yes CONTRACTOR: Company Name: #1-1147 1-* Li eS4C& Phone#: b `12 (2-0 2. Address: / 23 A) 5' /0g s4 City: ni 4i 5 1-fo State: !� L Qualifier Name: /1-0717 E O (ee A) State Certification or Registration #: Certificat Contact Phone #: Email Address: DESIGNER: Architect/Engineer: Zip: 3 3 / 32? Phone #: Value of Work for this Permit: $ °ter a 03 Square/Linear Footage of Work: Type of Work: DAddition DAlteration DNew DRepair/Replace DDemoliti n 1 Description of Work: L4�LC P �`c (2 % V` �F W (— - i LE (9 k) f� err-t-4 12zko w.s -- a) -play w e-c K PPI-r /P r k.) *******+ a* ***+ x*****+ x* ************+x**** **Fees******a *** ***** ******* **************x ***a * ** Submittal Fee $ Permit Fee $ a CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ ?‘ Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State 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 FLF.CTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 occur en (7) days er the building permit is issued. In the absence of such posted notice, the inspection will not be approved a reinspection fee w'll be charged. Signature Owner or Agent Signature Contractor trThe foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of I eL,, , 20 t i , by 4t° , day of , 20 _, by who is personally known to me or who has produced ' `mil who is personally known to me or who has produced As identification and$$$o� did tttaketat'q th. as identification and who did take an oath. �`, . . NOTARY PUBLIC: NOTARY PUBLIC: , ��a . . b = cn ::. LL. S: (3:::////1:1 I I 1 Sign: Print: My Commission Expires: Sign: Print: My Commission Expires: **** * *** ** ****+xw*********** *************** ****+ x**+ x* *+ x+ x** *+x*******+x+x+x **+x**x * ******+x***** ****** ** x******* * *** APPROVED BY L J /f( Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) tity1411-W1411A volgto z sii Miami Shores Village rut, �. '')crt'ks Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 W ' 1' UMDE4�7 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUI ING PERMIT APPLICATION FBC 20 Permit Type: BUILDING ROOFING OWNER: Name (Fee Simple Titleholder): / ir? Address: / Z ,5 Ai et. /0_6 577 IZECEIVED NOV 15 2©11 Permit No Pei 1-2I I R" Master Permit No. hone #: -2C ° Y-0 7-1 2-O `Z City: 790 r State: i I- Tenant/Lessee Name: 741-- �,� Phone #: Email: f��� € ;Pi + 444 Gcm JOB ADDRESS: Zip: 3 3 f a g City: Mianyi Shores /� County: Miami Dade Zip: 33(3? Folio/Parcel #: J/ t` r 3 b 0 0 6 0 3 'S4) Is the Building Historically Designated: Yes NO Flood Zone:. e CONTRACTOR: Company Name: A (."95,110/4- Address: [ 2 AJ - City: ex 14L, 41 Qualifier Name: Phone #: 7-81 (Z }` liz 2 Phone #: Zip: 33/55 State Certification or Registration #: Certificate of Competency #: Contact Phone#: Email Address: DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ tX / T6,1 e Square/Linear Footage of Work: Type of Work: ❑Addition DAlteration • []New ,Repair/Replace ODemoliti Description of Work: i'0 t6104e- -r CNCL'd' 17/47-c.-3' C - / c-e 64y OM // 7' k Y /0 /2 ,,, ,,:a✓, /dt'74'is / 'Ar , i I1 ** * * **** x *********** *** * * * * ** x *** *+x, * ** Fees * *** **** ********* *: x*******x:***** * *****+z***** Cu> Submittal Fee $ Permit Fee $ loo CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ • r Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) R 1 b N.) t5 As% 0g-7-64-6 6 Mortgage Lender's Address 7Q �Se l/ C> 2 3 / -�/ City OP-41/1U6 , State (74-t—/ /2%LJ) I1 Zip'2 ?5 3 (s!t , 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 roved and a reinspecti:. ' :1 be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this day of 40V , 20 B/ , by i., .'.- Poole who isCpersonally know) to me or who has produced As identification and who did take an oath. APPROVED BY //-A Signature Contractor The foregoing instrument was acknowledged before me this day of ,20,by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Sign: Print: My Commission Expires: Zoning Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 OWNER BUILDER DISCLOSURE STATEMENT NAME: #00)1,0 fl) % (i6/Y-D//- DATE: / `�. - /7 ADDRESS: ('5 Ai i / 0 l 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 jnay 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. I 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, my own contractor with certain restrictions even though I do not have a license. Initial 2. I 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. 3. I 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 - hampers on permits and contracts. Initial 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I may also builo 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 ;;, ^tantially improved it for sale or lease, which violates the exemption. 5. •i I understand that, as the owner- builder, I must provide direct, onsite supervision of the construction. Initial 6. I 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. 7. 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. 8. I 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. Initial 9. 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. I 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 850.487.1395 or http : / /www.myforidalicense.com /dbor /pro /cilb /ind l Initial 11. I 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: Initia 12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the informatio have provided on this disclosure. Initial tI Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does n . 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 day of ,old - , 20 (Y. By l4Orne ki IUc,a who was personally known to me or who has Produced there Licens �� `� �� D °33 O---Ga�idi'ication. OWNER \ \ \a00‘1111111 ll, ,,, /i '4. � LY.®= _ ' m moo'; „St "''rarrrrtlllllt�>0v NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO. /? 4/114-€2 /47 TAX FOUO NO. '1213400 6035 + STATE' OF FLORIDA COUNTY OF MIAMI -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 11111111111111111111111111111111111111111 I CFN 241 1R10802084 OR Sk 27909 Ps 4782f "(les) RECORDED :11 /30/2011 10:38:20 HARVEY RINIH, CLERK OF COURT IIIAMI -OADE COUNTY p. FLORIDA LAST PAGE' MC n Spec above reserved for use of recording a i3 Legal description of property and street/address: %� S`�Ale /G�Ca 571 1 /NA** 51krCS fL 33138- � o/PB3 p B e-- G �Cs s, � G °Jof.Imrov go' Y S ei3Owner(s) name and address: d or/ terest in property: e and address of fee simple titleholder: ntractor's name address and phone number .Sine 40.✓ /9 /e, *&i✓f - -'v - /23•S°-,s -- Aye /3 020o 3' 7f61-.2054Z 5. Surety: (Payment bond required by owner from contractor, if any) Name, 'address and phone number: Amount of bond $ 6. Lender's name and address: 7. Person within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713:13(1Xa)7., Florida Statutes, Name,laddress and phone number: tie 8. In addition to himself, Owners designates the following person(s) to receive a copy of the Uenor's Notice as provided in Section .713.13(1)(b), Florida Statutes. Name, address and phone number: • 9. Expiration date of this Notice of. Commencement: (the camfratIon date is 1 year from the date of recording unless a different date Is specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER'713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPER A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST. INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY 'BEFORE COMMENCING WORK ,..stpR RECORDING YOUR NOTICE OF COMMENCEMENT. Si• s of Owner( ed Officer /birector/Partner/Manager Tide/Officell STATE OF FLORIDA COUNTY OF MIAMI -DADE The foregoing instNment was acknowledged before me this L day of . 1 By 4,e.4• -/ individually, or l7 as Personally known, or CI produced the following type of identifon; tignatlre of Notary Public Print Name: (SEAL) `VERI CATION PURSUANT TO SECTION 92.525. FLORIDA STATUTES Under penalties of perjury, [declare tit'at I have read the foregoing and best of my knowledge and belief. .sthorized Officer/Director/Partner/M Prepared By Print Name Thie/Office that the facts stated in it are true Signattire(s) • er(s) or er(s,'ss� ,;. r:s, � smart O f'ADE HERESY CERTIFY that mis is a true tOP? of P.ne • or rig rn ins oil on V o0 IUYoO ll A 20 :'rTNESS my Nino and 7`rciel Seal_ HARVEY RU rcu6 „red County Courts �' D.C. PERMIT : i2.0.A1 —;:)(i74, Miami Shores Village APPROVED BY . . DATE ZONING DEPT BLDG DEPT / 1 ' tiobi l/ SUBJECT iO CCMPLIANCE WI ni ALL FEDERAL STATE AND CCIjN iY riL,LES rD REGULATIONS l Z -17rt/ BATHROOM RECEPTACLE UN AND G.EI PROTECTED • �x t'rr) g Z. 54 c 5 m 0 Owe OO ea tf (0 eft ADD SMOKE/CARBON MONOXIDE DETECTORS ANY AND ALL CLOTH AND RUBBER INSULATED CONDUCTORS TO BE REPLACED `V 78b -2`