PL-14-2692Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-224967 Permit Number: PL -12-14-2692
Scheduled Inspection Date: December 16, 2014
Inspector: Diaz, Osvaldo
Owner: BOURNE, ROBERT
Job Address: 490 NE 101 Street
Project:
Contractor:
Miami Shores, FL 33138-2449
<NONE>
Permit Type: Plumbing - Resential
Inspection Type: Undergreend S ier
Work Classification: _SPdn_ S_Ystem
AA MASTERS MECHANICAL AIR MOVING AND ENGINEERIN
sunaing uepanment comments
REPAIR LAWN SPRINKLER.
Phone Numbd,
Parcel Number
INSPECTOR COMMENTS False
Inspector Comments
Passed E�!
Failed
Correction ❑
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
Phone: (305)559-7004
December 15, 2014 For Inspections please call: (305)762-4949 Page 29 of 51
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BUILDING
PERMIT APPLICATION
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
No.?
201Qj
Master Permit No. �" q
Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
tQ PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
�p CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade zip:1
Folio/Parcel#: 11 2)Z OO 1 "( (54 Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type:
OWNER: Name (Fee Simple Titleholder):
Address: 4 (q0 Qv---�— VC) k";�
City: Nk tAaf t State:
Tenant/Lessee Name:
Email: �— t•�@ c
CONTRACTOR: Company Name:
Address: �QS�
City: �t
qualifier Name: Ov S &
State Certification or Registration #:C�
Flood Zone: BFE: FFE:
ZT i X27
33�
Zip:
Phone#11%
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $_ %�®�� ®lam Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of WorC % 1, W
Specify color of coli thru tile: ----
Submittal Fee $_ Permit Fee $ /So" CCF
Scanning Fee $
Technology Fee $
Structural Reviews $
(Revised02/24/2014)
Radon Fee $
Training/Education Fee $
DBPR $
CO/CC $
Notary $
Double Fee $
Bond $ 1
TOTAL FEE NOW DUE $ ! ®`-6
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 broc re will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of co en nt st be posted at the job site
for the first inspection which occurs seven (7) days after the building permit i is ued. In t e ab nce o uch posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signatu
VICV
OWNER or AGENT
The foregoing instrume t was acknowledged before me this The foregoinginstrum nt was acknowledged before me this
C day of . 20 " . by 1b day of 20�� . by
0 who is personally known to who is personally known to
me or who has produced
identification and wh i
NOTARY PUBLI
Sign:
Print: «
Seal:
..107) 399.0153 /
take an oath.
September 9, 2018
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal:
2018
as
APPROVED BY ®--?- =®d'a YPlans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation 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:
1. 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;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
3. 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 may be
personally liable for the worker compensation injuries of M person 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 c [�Contractor
Print Name
\� 1 Y� _ N Print Name:A
Signature:
Signature:
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County of Miami -Dade)
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Sworn to and subscribed before mei �s
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Sworn to and subscribed before me this
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