CC-14-1892Miami Shores Village AUG 2� 01�
Building Department .v
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel; (305) 795-2204 Fax: (305) 755-8972
INSPECnON LINE PRONE NUMBER: (305) 762-4949
FBC 20 10
BUILDING Mem Pwmft No. o-4 —1 g' -
PERM IT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING M MECHANICAL ❑PUBLIC WORKS ❑ CHANGE' OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: qaa 7 J&SeQA` Ad
City Miami Shores County: Miami Dade Zip: IIA
Is the Building Historically Designated: Yes NO
Occupancy Type: Loads Construction Type: Flood Zane: SFE: FFE:
OWNER: Name (Fee Simple Titleholder):5d_e 5" Zld y 4-4C Phbne#: ff,;* "
City: N Miami State: Joe Zip:
Tenant/Lessee Name: & A«S rum kd- PhoneM-&--y'.
Email:
0 ®S'- 3l8-
CONTRACTOR: Company Name: ax-en.,.Lons r hon In G Phone* �� q" y
Address: 98 29 NW /0-C
City: P1,4ND MI
State:
p%}' Zip:
Qualifier Name: GhwAl M41-1flFlz
Phone#:
State Certification or Registration
M 4,44,12r/ VOY0
Certificate of Competency #:.
DESIGNER: Architect/Engineer.
Phone#:
Address:
City: State'
_ Zip:,_
Value of Work for this P e mit: $
!gD� DOD
r
Square/Linear ge of Work: lip
8
...
Type of Work: ❑ Addition
D4 Alteration
❑ New ❑ Repair/Replace
❑ Demolition
�lA 0d0)/%P//7�•CvL�T 1I lfil'�l•_;Vi���
Specify color of color threw We
Submittal Fee $ Pero* Fee $ �� C - CO/CG $ ,a r.
Scanning Fee $ Radon Fee $ DBPR $ Notary
Technology Fee $ • Training/Education Fee $ - Double Fee $
Structural Revlemrs $ Bond $
TOTAL FEE NOW DUE $ 44 _ 1 I Q
(R -1-02/a4/2014)
nmn
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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC.....
OWNWS 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 $250a, the. appftant Proust
promise in good faith that a copy of the notice of commencement and construction lien law brochure wift be delivered to the person
whose property is subject to attachment. Also, a ce+tifred copy of the recorded notice of commencement must be pasted 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 areinspection fee will be charged
or AGENT
The foregoing instr6nent was acknowledged before me this
XI' day of I'U . 20 /5� . by
46CA& IZ4 who is personally known to
me or who has produced as
Identification and who did take an oath.
NOTARY PUBLIC:
KATYA GONZAI EZ
Commission # FF 032722
APPROVED BY
Signature 40
CONTRACTOR
The foregoing instrument was acknowledgedbefore me this
V-1- day of Ai Lts4- 20 �l" by
-Ch4n M— 411W , who is personally known to
me or who has produced
Identification and who did take an oath.
NOTARY PUBLIC:
Sign:_
Print:
Seal:
Plans Examiner
__� �` 1 / Structural Review
(24rA14)
=VMS" # 102$128
Q(FM' Sq>t. 7, 2415
wwwAARONNouncom
as
Zoning
Clerk
BICRON
EONSfRUCTION
9829 nw 1 st ct
Plantation FL 33324
Phone 954-471-1247
Ken@Mtcronconstruction.com
8/26/14
Building Official
Miami Shores Village Building Department 11050 N.E.2nd Avenue, Miami Shores, Florida 33138
Re: Building permit application 9 04 } 13! S CAYhG I -wo Uhl
RECEI' ED
AWO 2 010%
VU"
Please allow this letter to serve as a formal request to allow work to commence for the above referenced location prior to the
issuance of the permit.
Micron Construction Inc asserts that all work will be performed and representef on the plans submitted with the application and in
accordance with the Florida Building Code. IT is understood that the Florida Building Code may require changes to the proposed
scope of work and applicant herby agrees to indemnify and hold harmless, the city of Wellington, it's employees and agents
(including the building official) from any legal action or damages resuting from the approval to commence work, and that any work is
entirely at the risk of the Permit applicant. At no point will the work progress past the point of the first required inspection for each
discipline. Demolition work involved - removal of partitions.
We undrstand the risks and responsibilities associated with this request and appreciate your consideration in this matter.
Please indicate your decision below and return a copy for our files
Sincerely Yours,
CGC1516040
nDebre Sr�r
x � co if �M28
EX�S Sept. 7, 2015
Page 1 of 1
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-8314000
VALID OCTOBER 1, 2014 THROUGH SEPTEMBER 30, 2815
DBA- Receipt#;Gas-> C0l�TG3Ft
Business Name: MICRON CONSTRUtTrION INC Business Type:
Owner Name- amN MALLga
Business Location: 7092 WOODMON'T AVE
(TAMC
Business Phone:
Rcoma sects
Number of Machines:
Business Opened:as/35/20x0
StaWCOUntytCe rt]R+eg:CGC 151,6040
Exemption Code:
Employees Machihea
z
Vendinsa'Type:
.
Tax An -cunt
Transfer Fee
NSF Fee
Penalty
Prior Years.
C0116C OOn Cost
Total Paid
27.00
0.
b-00
2:. ?
D: li
6,0b
29.70
THIS RECEIPT MAST BE POSTEDCONSPICUOUSLY IN YOUR PLACE OF BUSINESS
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION FORM
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS
SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. COPY OF QUALIFIER'S STATE LIC CARD
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. =COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT)
D. _� COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTfON)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER
B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT
C. COPY OF LIABILITY INSURACE ,(CERTIFICATE HOLDER MW BE MUS SHORES VILLAGE MXG DEPT)
D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION)
YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
...........................................................................................
COMPLETE CONTRACTOR'S INFORMATION
BUSINESS NAME: n -c ra C On6 �r'-C- It G
BUSINESS ADDRESS: 9 9 i A CITY /����i 17
STATE Fl- ZIP CODE
BUSINESS PHONE: 9514 &-t 2-,4 FAX NUMBER
CELL PHONE ( QUALIFIER'S NAME: GXe.,
QUALIFIER'S LIC NUMBER: G6 -GIS / G d L4 0
E-MAIL ADDRESS (IF APPLICABLE):
Cmated on 3i' 9M BY EM / RV MAN NAY
c
f
41940 STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
®�
NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
MALLER, CHEN
MICRON CONSTRUCTION INC
9829 NW 1 ST CT
PLANTATION FL 33324
Congratulations! With this license you become one of the nearly
one million Floridians licensed by the Department of Business and
Professional Regulation. Our professionals and businesses range
from architects to yacht brokers, from boxers to bartmque restaurants,
and they keep Florida's economy strong.
Every day we wank to Improve the way we do business in order to
serve you better. For information about our services, please log onto
wwwjnynoridalicense.com. There you can find more information
about our divisions and the regulations that impact you, subscribe
to dem ient newsletters and learn more about the Department's
initiatives.
Our mission at the Departinent Is: License Eifidently, Regulate Fairly.
We constantly strive to serve you better so that you can serve your
customers. Thank you for doing business in Florida,
and congratulations on your new license!
DETACH HERE
RICK SCOTT, GOVERNOR
(850) 487-1395
STATE OF FLORIDA
DEPAR ti QF BUSINESS AND
PROFESSI REGULATION
CGC1516040 08/05/2014
CERTIFIED 0- J O
MALLER, CHEN'- � ? ..
MICRON CO
IS CERTIFIED under the provisions of Ch.4a9 FS.
ren dde : AUCs 81, 2016 L140 ism
KEN LAWSON, SECRETARY
.STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
CGC1616040 K""tee
The GENERAL CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2016
MALLER, CHEN
MICRON CONSTRUC
�,.
,.
DISPLAY AS
REQUIRED BY LAW
4
CERTIFICATE OF LIABILITY INSURANCE" "'"`
THIS'CERTIFICATE IS ISSUED AS A FATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREIM, AUTHORED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER
AIAPORTANT: N tleHolder IS an ADDITIONAL INSURED. fireWAIVED subod to
the tend arnl conr�ara of the Pte) must be endorsed. tl<SUBROGATION IS
tabid t Pel RMY require en andarsement Aslabnowd on li to does mall comer rwo to the
cerIWcds holdsrh1 ftu a1 smk
Rainbow Inslnance, Inc,
1344 N. State Road 7
MWUGb. FL 33063
Phone (954) 977-W47
INSURED
Micron Construction Inc
492 Sweet Bay Ave
Plantation, FL 33324
Fax (954) 977,5225
C>:CrrCrr_erx lin
L
977.5225
,.......�..ra..w.aocst.
THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LI37 ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE. FOR THE POLY PERIOD
INDICATED: NOWNI STANIMIG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUI lENT tAffftl RESPECT TO WHICH THIS
CERTIFICATE L%y BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEFNS.
EXCLUSIONS AND CONDmONS OF SUCH Pte& LATS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAtMS.
--
TYPE OFI BURANCE PaucYNUmeER Lam
A
GENERAL LKBIL"Y
® COWdERCIALGENERALLIARIM
❑ ❑ CtAnS-I+eaQE 0 OCCUR
1000 PD DED
N
N
l(�AO03540-00
flt/1612014
O4l16JZ015
EACH $ 4,0Qa,Q00
a 1�,Of)0.
MED EXP Any arra $ 5,000
PERSONAL & AOV WARY S 1,000,000
❑
G84RALAGGREGAIE s 2,0001000
GO& AGGREGATE LMT APPLIESPER:
® POLIOY ❑ m ❑ LOC
PRODUCTS-COMPIOPAGG S 2,OMIDOD
$
AUTOMOBILE U MMM
❑ ANYAUTO
COMB04ED SWGLE LWF s
(EaswWw )
BODILY PWURY(P rpwsm) $
ALL OWMAUTOS
❑ scxmta EQ AUTOS
BODILY NJURY owad4nt s
❑ NMAUTOS
❑ NON -OWNED AUTOS
PRO(P- DAMAGE $
s
s
❑
❑ UYBRELLALUu; ❑ OCCUR
❑ mmm LL" ❑ ADE
N/A
EACH OCCURRENCE s
AGGREGATE $
❑ OEDUffM3LE
wORKERS COMPENSATION
ANDEMPLOYERS'LUUNUiYANYPROPRETORIp YIN
(Mandatuy In NH)
yyam�,,
$
$
M=6 OTH-
ELL- EACH ACCa7ENT $
EZ DISEASE - EA ENQ>LOYE $
EJL D(ASE - POLICY La1gT s
QESCRIPiiON OF OPERATIONS Belmt+
-----------
1CRIPWN OFOPERATK}NS! LOCATION$ i VBaLEe (AUnch ACORO IM. AdcWbm t Rsm o= Sdm&d% iramm fa mquirom
GENERAL CONTRACTOR COMMERCIAL/AESIDIENTIAL REMODELING
CERTIFICATE HOLOFR
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
10M NW 2ND AVE
MIAMI SHORES, FL 33438
ACORD 25 (2009" QF
a�IVY VCL1..F\ I lull
SHOULD ANY OF THE ABOVE DESCRWED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVIMOW
1 -)a a:
01988-200FACORD CORPORATIOIL All kghts rosefted.
The ACORD name and logo am regtsbMW marks Of ACORD
t\i"i,�J4J.t b Y t�+Wfiit..
JWFA'TWATM
MM F'B+IAlaMALOFF M
100°Ar
*' CEIMFLCATE OF aECTI(NN TO iE EKEWT FROM FLORA WOI '.CO lWWSATIOM LAW**
CONSTRIUCTIO INDUSTRY EXEN TiLON
TIft cert that theirWh&ht d llama bdow Inas eleded tb be exempt tmm RmWa wDrt<eris Compensoam taw,
EFFECTIVE DATE 4/1312013 EXPI A710M DATE: 4/1312015
PERSON: MAI LER CI EN
FIERY: X37
BOSOM NAME AND ADDREW
MICRON CONSTRUCTION INC,
492 SWEET BAY AVE
PLANTAnON1 FL 33324
SCOMS:OFBUSINESS ORTRAIlE-
CONNTRAACTOR�
OPI-F2-Dwc-=C RYFFMATEOFF imToBa= rRP-mmox-1z
QUESTKM (W*13-160
r ago: 1- Lei 1.
b tgsJla=8.fld&.camlcrremrmewer/renortyit-Wer.aenor?ii.gta=krtv„a;,,c�nlnq u6TP1RIA R/1711ntd
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 any 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
Print Name:
Signature:
State of Florida )
County of Miami -Dade)
Swornto s bscribed before me this
day of2 20�.
By Jalu
(SEAL) ��"i n bra Wer
. iY ,Y
RYd�
Contractor
Print Name: G-\y,r1 lid Al l E c
Signature:^
State of Florida )
County of Miami -Dade )
Sworn to and subscribed before me this
day of
By;.
(SFAL)�.�-
Type of a cp
EMM- W 7. 215
111. �°� www.AmoNNotARr-coag