FW-14-1369BUILDING
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
PRMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
JUN 2 5 2014
FBC 201®
Master Permit No. SI/— 13&
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑ RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 1 LGS313 K
City: Miami Shores County: Miami Dade Zi D:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: ], Flood Zone: BFE: FIFE: 1
OWNER: Name (Fee Simple Titleholder): ��C �`1 Phone#:® - �l
Address: l C�� We q4 g -j7
City:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address:'�E
City:
Qualifier Name:
k 1 IUA � S-Vka t�-s State: Pa • Zip: )'.3 W,
J
State Certification or Registraboh #: Certificate of Competency #:"
DESIGNER: Architect/Engineer: Phone#:
Address: City: State:
Value of Work for this Permit: $ Square/Linear Foota of Work: 111 J
or
Type of Work: ❑ Addition. Alteration ❑ New w 1 epair/Replace Q Qemplitioq
Description of Work:
Specify color of color thru tile:
Submittal Fee $� • Permit Fee $ CCF $ CO/CC $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
DBPR $
Notary
Double Fee $
Bond $
TOTAL FEE NOW DUE $
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 whic occurs seven (7) days the building permit is issued. In the absence of such posted notice, the
inspection will not be pro and a rein , n few a will be charged.
Signatre Signature
OWNER or AGENT CONTRACTOR
The f p%ulng instrun ent was acknowledged befo e e this4orwh
ns 0 t w acknowledged befor me this
#1-01 a o r 20 by of 20 by
kWh personally knowna tw' ersonally kno to
me or who has produced 101111111Jt0.,_ asproduced C as
identification and who ®yr[t�%/y�,",moi identification and ON 90 `t0;10
••��1SSl0�y °•. �/ �q •,� nRt� cVr`�.d :`�1 w
NOTARY PUBLIC: ` _ a%W, NOTARY PUBLIC: * e C c
•� CAi � Zi �
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® ®®® * e a ;2 18 969
Sign: = Z ° • S' 9 •° B Q -v
Print: .� °° '� e�noedthN �0H'Q�� Print: e•261:::::6fVh
I1011'.•
:.:.•• cam'\\\� i//lllll 11111ti���STATE u% ��\
Seal: ®/, (/r± cvnt� 4..a\ Seal: �
APPROVED BYrS Plans Examiner l Zoning
Structural Review Clerk
(Revised02/24/2014)
Notice to Owner - Workers' Compensation
Miami shores V
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project
prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees, including the owner, must obtain workers' compensation coverage. Corporate
officers or members of a limited liability company (LLC) in the construction industry may
elect to be exempt if:
The officer owns at least 10 percent of the stock of the corporation, or in the case
of an LLC, a statement attesting to the minimum 10 percent ownership;
The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
The corporation is registered and listed as active with the Florida Department of
State, Division of Corporations.
No more than three corporate officers per corporation or limited liability company members
are allowed to be exempt. Construction exemptions are valid for a period of two years or until
a voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you maybe
personally liable for the worker compensation injuries of anyperson allowed to work under this permit. Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner
Print Name:. r •
Signature:
State of Flon�ida
County of Miami -Dade) e��*��c„Q��S Rop �"
day
By
Contractor
Print Name: I `�
Signature:
..��1111111u...
FloridaState of S RO
County ofMiami-Dade) \\��;�O
Sworn tuandd subscribed befor
day of" ,?$
0.000
STATE OF (FLORIDA)
Miami Shores Village
Building Department
SURVEY AFFIDAVIT
COUNTY OF (DADE)
The undersigned Affiant, b° does hereby attest that
(Property owner)
The attached survey, performed by
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
r (Name of surveyor's company) �6'Foraddress: l� �i 1 cir 3� 30
Performed on (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 m ff ct final inspections as applicable o this or other permits.
Further, ants eth
roperty Owner Si ture Property Owner Print Name
SWORN TO AN UBSCRIBED before me this �ay ofl�k
Affiant is _personally known to me, produced as ide it tion.
Revised on 5/22/2009/ Revised on 6112/09
JEFF ATWATOt
O"X-M STATE
OF f "{
WARTMENT OF FRUMIAL
CERTFMTE OF f ' TO Be Xr, !: EFLAMUMIPORKERV
f
ThW Cerdfos #W the- indvWusl lided below has shkIed tD be: exempt ftm FbrtftL WoftW Compensation law.
EMECTWE DATE: ZS=14 EWIRATM� DATE: Mole
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Miami Shores Village
Building Department
WOOD FENCE DETAIL
4x4 Post Spacing
Fences <= 5" high posts spaced at Yon center maximum
Fences <= 4` high posts spaced at 6"on center maximum
Fence must not exceed Tin height
4x4 pressure treated
posts embedded Tinto
concrete footing 10"
diameter x 2`deep
ALL wood must be pressure treated L
All fasteners must be corrosion resistant
No less than two fasteners in any connection
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Ix pickets fastened
with two corrosion
resistant fasteners per
connection
2x4 horizontal
pressure treated
wood members
with two corrosion
resistant fasteners
per connection