PL-14-1183 i Miami Shores Village
Building Department JAN 22 210115
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax: (305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
............
I FBC 20 C
)IJVUb-IV% Master Permit No. �0 �'-1 s—
PERMIT APPLICATION Sub Permit No. 'V3
'V3
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
�LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
' ► CONTRACTOR DRAWINGS
JOB ADDRESS: �� /V W r
City: Miami Shores
County: Miami Dade Zip:
Folio/Parcel#: 11310102,203Z (--) Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): 6 / 3 8n(R Phone#:
Address: / 2_J tu Lj /00
City: H-1 01H 1� State: ! Zip:
Tenant/Lessee Name: Phone#:
Email: &7(//
CONTRACTOR:Company Name:
Phone#:
Address: �� S ! S ( ) SOS AE-UA
�A �1
City: ,—/ A dY l State: /F/ d1 Zip:
Qualifier Name: 2/
S 6uceleA Phone#: 9's�� y� 'C�,JIG►y
State Certification or Registration#: (. / 7 ,� � Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace // /❑ Demolition
Description of Work: �C-� V 1� 1/V � 1�!'1/ PL �` / O
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ 22 5' 7 CCF CO[CC$
Scanning Fee$ ( Radon Fee$ DBPR$----) [� Notary$
Technology fee$ (nS�Training/Education Fee$ ) Double Fee$
Structural Reviews$� Bond$0
TOTAL FEE NOW DUE$
(Revised02/24/2014)
V �
* r
Bond g 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.....
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 reinspection fee will be charged.
1
Signature J��id "✓ Signatu �CGt4 �(
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foreg nginstru ent was acknowledged before me this
day of �U{l�_L�r.1 20 \S by a day of -120/'! by
h who is personally known to ''� who is Wally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did to an oath.
NOTARY PUBLIC: NOTARY P45LK-
i It r, t-ecr., U
/ r
Sign: Sign:
Print: IJ�(J" 'j(Y tr Print:
Seal: �-- _ Seal:
EXPIAES
&rwl-d l mu'die'..
APPROVED BY �'Z��s Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
OR
193
1932
some y ,,,.,� Miami shores Village
Building Department
ORtDp' 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
J 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 and acknowledges that he or she will not use day
labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be
the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of
workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors..
Therefore,you may be Personally liable for the worker compensation iniuries 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 HAVELADS NO • AND UNDERSTAND ITS
CONTENTS. Owner tractoPrint Name: �� Q ��SV' + Print Name `f
Signature: Signature:
State of Florida) State pTT?Mr
County of Miami-Dade Counitot
ii11i-Dates}x'
Sworn to sU_ crpedl efore m this-1'7 S sprdbcd bsfor� ,tJ s
day of day -'x; j.20L
Ak
(SEAL) S � Zo.f
Type of Identi a ro uce _ Iden ' "roduced
::- MY COMMISSION#EE 833224
'• o, EXPIRES:September 6 2016
"�Rf,"S`''' Bonded Thru Notary Pubk Underwrlers
AA MASTER MECHANICAL AND PLUMBING
CAC 057226-CFC1426169
15501 SW 105 TERRACE
MIAMI,FL 33175
January 21, 2015
State of Florida
County of Miami Shores Village
Before me this day personally appeared Felix De Jesus Guerra who, being duly sworn, deposes and
Says, He will be the only one working from AA Masters Company,on property address 125 NW 100 St.
Miami Shores, FI. 33150
Property own by Mr.Jacob Griesbach.
Sworn to(o a rmed) subscribed before me this 21 day of January, 2015, by
CPe:rso:nal:ly:kn:o;����-I&S�O��b- U
OR Produced Identification
Type of Identification Produced
BARBIE 80STWICK
r CommissIm#FF 13J2018
Expires September 1Thm TMY F*WdWMW
l I�
Print,type or Stamp Name of Notary
•
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.
EFFECTIVE DATE: 3/8/2013 EXPIRATION DATE: 3/8/2015
PERSON: GUERRA FELIX DE JESUS
FEIN: 752987328
BUSINESS NAME AND ADDRESS:
AA MASTERS MECHANICAL A
15591 SW 105TH TERRAS SPI
MIAMI FL 33196
SCOPES OF BUSINESS OR TRADE:
WELDING OR CUTTING PLUMBING NOC AND HEATING,VENTILATION,
NOC AND DRI DRIVERS AIR-COND
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.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609