RC-14-1181 (2) A/
Miami Shores Village CEI.VF,D
Building Department JUN os 2014
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305)795-2204 Fax: (305)756-8972 - -
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 2016
BUILDING Master Permit No.
f
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING MECHANICAL PUBLIC WORKS [:] CHANGE OF CANCELLATION SHOP
A'1 .` (�(� CONTRACTOR DRAWINGS
JOB ADDRESS: 12-� `�`'w ,�/X S,
City: Miami Shores County: Miami Dade Zip: 35ICS0
Folio/Parcel#: Is the Building Historically Designated:Yes NO ✓
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): �A Phone#: �T5 LA (0-757(03
2.71 ` SA— -A0
5
Address. ��G ��►'� NtJ
City: V�`��' State: zip: 3Z
Tenant/Lessee Name: 14 Phone#:
Email: �/
CONTRACTOR:Company Name- ! Phone#: `7 C/ 4244
Address:
City: State: Zip:
Qualifier Name: l/C Phone#:
State Certification or Registration#: Cv 003 74 V Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: dK)_ City: State: Zip:
Value of Work for this Permit:$ !Z Yon
Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ElNew ❑ Repair/Replace -1 Demolition
Description of Work: / �� - ,A-r 4l�
Lu P AAAJ VZE-a Q � Y'c6 e,
Specify color of color thru tile:
Submittal Fee$, Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
t .
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.....
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.
&424�-
Signature Sign re
OWNER or AGENT CONTRACT
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 120 by ;,2-V day of M 201K by
who is personally known to /A & who is personally known to
me or who has produced as me or who has produced as
identification and who d take an oath. identification and w o did tak an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
SSEAU ` J'RGE ROSS AU
SI n: -A4 O S. N#FF1190 Sign: s MMMISSION# 1045
Sign:
`N OF {'IBES May 4, 2018 :'?os EXPIRES May 4, 2018
Print: 407 Print:
m
Seal: Seal:
APPROVED BY /�/V Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
SNORES '
e,,, � Miami shores Village
Now Building Department
OR 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, oy u maybe
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.
01
nn ��Owner Contrac
Print Name: C. G Print
Signature: e:
State of Florida) State of Florida E 11, OSSEAU
County of Miami-Dade) County of Mia ffia ) '_ F
Sworn to and subscribed before me this �=� Sworn to and s y m 119045
day of :n(f, 20 1�. day of
o......... PI ES- aG 2018
"" etaryService.com
By .; Ll na Lasso By i✓- L& U
(SEAL)
r
>' a EXPIRES:AUG.05,2017 (SEAL)
•, �u* duWhApiMR0NNOT mwm
Type of Identification proced Type of Identification produced
Cu'v VA L _#_: DNX 1'-1y'1`A19
OMB No.2502-0265
A. Settlement Statement (HUD-1)
I, ®FNA 2 O x1u 3.0 conn UNus6.File Number 7.I=Number 8.Mona;im can th®ber
4. 0 VA S. O Cuov los. 6.O Seller fin 23-26d694FI. 1404001 ty3 2 476 gQ3
7. ❑Cub Sale
C.Note: This from is fumidtW to Siva you a smement of amw soutaineat costs.Amounts paid m and by the settlement agcota t shown.hems madxd
o.�•wore aid outside the d ass s here for htfotme load and are not inducted in the tolds.
D.Name&Address of Bonoacr &N1=AAAdeers ofSelia E Now&Address of l.coder
Jacob A.Grksba& Federal National MOTISMAaoelatiaa A/K/A Fasoie Egwky Martgape Bs alters,LLC
411 NE 27th 6L use 83110 NW 53rd Street
Fort Lauderdale,FL 33334 14221 Dallas Pkwy,Ste Iwo $olte 102
DaNA8.7%15254 Dont,FL 33166
G.Prtpedy Locit6i H.Settles entAgeni NaTA f.sow Daae
Tide 4i Aktract Apeacy of Ancrics,Inc. 3/12!2814
LOT 10 AND THE EAST 1/2 OF LOT 11,BLOCK 4630 Woodland Corporate Blvd Fund;
4,GOLD CRM,ACCORDING TO THE PLAT Ste 160
THEREOF,AS RECORDED LY PLAT BOOK Tampa,FL 33614
2IM6,MIAMI MADE COMM,FLORIDA.
AIMUZ Underntlttea B.First Americas
1703877247 Ptut of Settlement
123 Northwest IGM11 Street Title 4i Abstract Agency of Anaia,lot
-
400 SHIES,FL 331SO suit Woodland Corp Bird
Suite I68
Taps Fl.33614
100.Gross Amoost Doe tram lornrwer 408.Gmss'.Atstouot Dna to5elkr'
101. Couttodsalts Vim Hsuit " 401 CoolswAak% is 5240,000AO
102.Pcrwnnl PICTCM 402. Pawmal prtperty :.
103.S00cmatdommtobutt£mcr 520AX19
104 AW.'red Fuc to}?it lA bp.t tstirm $125.00
105.
405.': ..
Adirutoeanr tvr ikss paid b�s Iter is ndvaaet idtaatsidok lositema pnld h}`se>aei is idsaare
106 couw4PtopertyTaer 4U6;Countyptopsity:
1'a,xs
t07.OthrrPtolran Parts 407, Otha.lhbpeity Te et
lop odmpnpaty•faos 4011.t>tltahopetty7axa
109. IIUA Dna #09..110A Do,
110 Rem pionnou 454.RauPmmatieat
III Other 411,Uibtt
112 412
113- 413
114. #14.
iI5 415..
116 316
128.Grnu""at But Froom 8arro tr 5260 r9 420.Giois.tnovot Dae.to Seller' ';` $240,12S.00
200.Aa440h raid k Or in FthdFOSBon suer 500.Rcdvefmm in Aaww but to SeM
201 Depositaeammt 550400.00 "1.
laceia delxxit(ta tttgtttctioaa)
2.Q2.'Prawatamount ofamhw,) S23S,631.00 $02 SehkMooielgrpcstoteller(Iox140U1 S13035.00
203 E+dstia It hmils)taken subject to 103, laisttny losnls)taken subject to '
204. = 503 TayolCol"fuu
moatioge tvsn �.. . .
20S Creddlos hcmwo S423M 5w; Yapoffbfsetoiidaicit�eloan
306 tco4erCrafii SI.MAO 3116.,
2Q7. SU7:{t7,11115,4W 1lisbmuiadssPiocccrh}': :,.. :,
20S-PtrtioavCOWmet'sFWkyPaid by Seller SIMSAD 5I. 1`6i6k6` OwiiiSN1lcS Paid byStLc:'.::"'': $1,27500
204_Fotuiia oflawa'sPohey PAW br Seller•: 5190.00 509.:Patica'ofI etidm's P Paid bpStliu :: 1t90A0
4<eljastaes4 AKitims sell& Ad tamadn6i'for iteiaa rte aid tr6tr ...::.;
21Q`;Cmmty Pti,pertrTnes Ok011t4 W OS/12'14 51.295.64Govr¢y•P(►tPe!iY 01101/14 toosdV14 51,295.64
Tants.:.......: .:. .
211.Oiba ProctlyTo." 511 OOWPtopaty'Iatei
212 0thopro9esil'7aimes $12'.Oft
213. HOA Dun.. ...
533:11(jA Dmiei` '::..
214 Real Ptautiau $14.=Rrrt Ptvtativa
2.13 Atha
353 Othir _.
216 . 516-.:
217:'.
215 318:
219.
228 Total Peid Mor Bahr i et 1245 438.64 320:'rat it Rtdociio "eltaoaiit Dena Sttlir- :' Sl 95.64
300 CasbAtStkhmtalFroatiraBoiraawei: 600.GithAfSkAtmtatTN7foinswir-. .:;:.'.;.'::.:
30t,Caou A»mt due ftmv bwoui2(iiiie'120) 5260236.19 601;Gi&i,memiIIi'dw to s#IWr(hnc 420):: SZ40,t25 00
312.Cosi wiaiuiq aid `!(ui bouoanc{lust 320} 1248,435.64 602't oat nxhteuoag in am due'wIltrtiiae 520)`> 516,695.64
303.gosh Frain Botivu et ..: ...: S11,79745 603.fyib Ts Stpir. ::: 5223,42936
The Public Repwft Burden for this collation ofinfarmstion is o timacd at 35 twoutes pa reponse for collecting,reviewing,and reposing the data.This qmty
MAY not collect pelt infntmatia>,and you ate sat required to cowl to this ftmn,halite it displays a aancudy valid OMB conual autber.No coafldemislity is
assured;this disdosvre is mandatory.Ibis is designed to provide the partes to a RBSPA comrd U a sedoo with infotrmtiou duff the mWement process.
Previous editfoos are obsolete Page a of 5 11uD-1
700.Total Real EKMc Broker l:tet 513,280 b0 'paid From Pald Prom
Lhriuta of c*araisiwn pine 7001 at follows Aanowei4 s
761.S6,M0 M to tertaae latrraatlaaat F{aids W
]LeeltT
702.S7.mso to Ceneea ltaa Setete.for-
701
aa701 I;oatattssfeapaidatSct8emeot 5000 S132Q080
ful.( ' 1%W fioaiUFT Elf
t Y�wr etakt a chat tl fat the M=Lfic rm dome ]OOB Ooa(il1:.F3
403 tont 4LIAW arigmalim chrges p) Eerytly Mortgage Beakers
(fromEiFls�+l) 51,146.00
804.'AM"Ilec
to
805-CYeda la
from 11['f:l3)
806 Tuxmvica 10
(fiomGFkt3y
{lium mE u)
107 i:loalccrnAcatipt w Ata" a mood liewateh
' {trolnGfBf}) S14.00
}"
9Ol 1)44 mum chmsm front SlI711014 to 611Rt14 2.S39.tlidtp (ttmn tint;N 16 SM."
902 Manpp Imtatetac l'remtom tie 12
ntiaahs to Egtnt)•Mottgagt Bankers,LLC 83) $44"
903 Ihwtwmnaer"s UOA=Mft I vets to :(h m OFE811) 53 100
1001.hiatal prpotk lett cwir ciao*'eccnmt
(hoiti Gtf 049)
t0 51,129.73 Y
(L+.flotoaiirliiifa inttnaaue 3 mm8n�" S_433t ramtlh 1177.74
1003 mslaattt moanu 525RN paafaath SUO
1004.Cwmy!Mtvgl me 9 mrattturk 531083 moa8t : 53.707-47
1005.Odler lhopmy'iaot mmt>tit Fr SOHO pa meth 5Q 00
10%OthvPRomaymuffta 'SM pm mootb 50.1Q
1007 a 1O."Du► tooatFa it 50.00pamonth SO.00
1008 pmpmgb a mrnilukt SBO prom+ 5000
1009 Cubes' .. 0 maaft a .
1010 Oam 0 .munihs;a
Jot 1, Adluutamt 51.75530
R Y T�. .-.,,.�.� .dSs:...�:,::-�� -:�=�` 't,�.:"v?3s' ^>'. r:a;�..,.W��':..:t�r`,E�+:�>1Ls"�a"•�,.� �',"'..�-... t'%....a.'M-.....�''�'t�:..'S'" r'.�
1101'litkiertiicsdcrsitd
u�dlaemaiaRtwae to ;: 1Yt[cA:kMhtet. !lust ltoerteaa '.,:;::.: (froaiGEYtW) SI.41000
1102&Mua cat a elmmg ice' Yltlr It.1G11taet 5950-48
s!Cdiirt lar
1103,OwuW%lift iaantmee ut Titkd AWhrethReaev/firstAetrncaa (thiai<it72ts) S1,27S.00
1104 Lander%tickuounme to :.Tsps do;batrattA e1NFtKtA�erion`:`: S25.00
1105 1=d 1,bile poli*tutu S S23SAS3.08/5790.00.
I lob:O%nm i{tde lk'y ltrnri S : 1340.000.00/51,275.00 ..
1177:ApWxpottamoftitctoWWemmmeoprgminmto :.YiBc#;4bslract glAliSO
!First Amentan
1108-L'adataitd's paaon of the tWl tilk itna.iaecr
pmium .54"F1tatAturkaaTitle.. 50
1109_Qu*Rmc Prcroana woo) to
1110:Jte6ob um=t fa scetch foa3ige tc 4bwtttAtleaty. 1175 DO(4em'GFl t4) SAO
ofhmerira Joe
1111 htobikCksingla ZQ ttmmt)PCW) $OAO
1112 Aume),Foe td URPI FFl%JlX=i& 515000
Illi F-rRPC 0 X j CM RM EACH to Simpme (faaOFLRi) so"
1114.El.rose 9 , Tdk&Abwmt tJI30110
lftnt as
Tits&AbtRaet i15 00
1 t 15 Fl.Envnonarat pn>ssraitwl to.� ���
1116 Courier.fu wadtuki Battu biforia,Step :
roP� m SF33W(taa131CW� 50.00
c �� ��.. - .r"�": 'r*.. ..4�A,F FESS" ✓.:...:'£:s '"
MI..Cmvaaareatsr. chat
_.. .-.,_ {66m131747) 579.00
to attant Dade
I 1Soa1 S1S S0:54ott Sit S0.Rdwc 50.60
Clerk'af lht
art
1303. 71am,feitawev OcmOfEM 53,736.26
1204. Dod.Son;MoISW oAliaml Dada Cj"k+ wttar
oftYj tbmt
ro
1205 StNs toc+stamps i1 00:Mrwtgfgc : 1litttm Aadc Clark
Seed U of Conn
E 1tFLpR17i1 tCJ ti4 00 LAC(l
1206 to :Stnpantemw. awC'nin
DWIMHNP
1301.Koquited;ietliira yai can ihop tbt (8pn b'IEb) s3oaao
t3Q2..%um} Ia TrtxNSary LLC`:: :S300Ao(tiowtlfteoJ Koo
131U.i R&KL•Y['EL•.
1304 !Hiatal Dude Ceaal}Tac: rpc l8
.2t113hoptityTasa to.'CaQestor' saaass
Previous editions am obsolete Page 2 of S MEW
File No,13-26"94FL
1305_Pee COO=Lim Stub 6n1113-iW14 h. GwSkp Lira SaarclN
sr.
1306 Po9(Cn*2d IJM Safi V1113-5!12/14 W on step Lus StarrN
1307 Pie Cosbud FzkVpd No HOA to p Leu 5ureh, 55000
14S13
POC(B)-PaldOmidoufCI*$WCbyBwroner.POC($1-Paid WNidrofpocioSbyS41m PDC(L)-PaWOmbWeofCWFiAgbyLmder.
Previous editions are obsolete Page 3 of 5 HUD-1
t?1t.r=cc;i riteennt tRi(esei([tlbt tne!!tiidbKr,:
Our on Choy801 5419648 S4,196.00
Your tsadrt or ehst (pmnly)tbrlhe ipceific tato choses Sd2 F50.00 50.00
YtRtrotyoaad ori ' ann char `. 103 54,19bti0 54,1%.80
Tomefa Uveas 120.1 S2,736.45 73626
j� �i, -� .. �., �u,:: i. 4sodl iutt6_�1•atim"att :: IItfD-�a,,._��
Cwvtxamcuitroernli tdt 1301. ' S100.O0 _ $79.00
i1w�d c«ti0muipu 8117 : S14M $1400
--
:..
54,167.00 54.24600
S-21.00 or 4.5%
:Cliff "Ttie"t:EiuieCha s tiF�1lM>Ett±Fe�ie `I;Zfi
lauid depow for imnaserowaooaaa 13001 il. SI.M.73
dailytotvxat dMPM 901 S29A&djLy 5746.50 $97.20
Flomamvnc'a ntwrdacc 903 .: S2,696.04 11.FN1
Title mrsiw mW Icnckes talo inxamtce 1 to t` 51600A0 S1,4411.98
thvsan's title inataarsoc 1103 S1,275A Sl 75.00
11302 5350.00 S380A0
Loan Terms
You initial It=anouat is 527565300
Yam(amt term is 30yeas
Yrm initial intretst nttd is 4.625%
You initial rncwh(y amount owed lot prind*intMeesl.and any nwtow St,470.27 iaehtdcs
bwwrnocc is In Principal
®Interest
� tnrnramca
amynat utterat talc ries? Ila Na.❑Yas,it eau rise to a maximum of 0%The first ehaage will boon
and can cbmW spin every after.Every change date,your interest rate can
inn-use or decrease by 0%Over the life of the loan,your Wetest rate Is
to never be than 0%or hither than
INN if you Mika pgrmcnts m tun*a,cart yourloan balance Aw? 0 No.❑ Yes,it can rise to a maxim=of$0.00
L%-n if you mAM poytrcnts m tLLne.COIi yourmnnlldy _w''. 0 No.❑Yes,the first inetease can be on and the monthly amount owed
amount Mod for sad ism M riser can rise to S&IDO The maximum it can aver rise to is 50.00
DoeY ytatr lvrtabaNe a prgtaymcmi painhy? 0 No.❑Yes,your maximum prepayment penalty is$0.00
dear lorr m-a s ballast vmgm? M No.❑ Yes,you have a balloon Payment of SOAO dna in 0 years an
TOW mommy amount QWW including csaow accoinl payments ❑You do not bave a monthly escrow payment for items,such u ptoperty
taxes and homeowner's iosuraacc.You nmst pay these items datctly
Yourself:
M You love an additional monthly escrow payment of$593.41
that results In a tote]WtW monthly m mu owed of$2,063.62.This
includes principal,intetear,any mmtpgc inmence and any items cbeckrd
below.
0 Property taxes ®HomeownWs 5aswence
❑Flood insrtramc e ❑
D ❑
Note:If you have any questions about the ScIdeme nt Charges and Loan Tertass listed on this form,please contact your lender.
Previous editions are obsolete Page 4 of 5 Iltftl t
Fife No.I3-264694FL
,Shave McMy twiewed lite NUD i SattkmM Ststemmt MW to the b,1 of my ImowlK%t and belief;It is a nue and accuam statetant of aR sueipes Ind
bumemems made on y acmmi m by me in Chit maction. 1 fu&w certify first I have received a completed ooPY ofpegm 1,2 and 3 of thio HUD-I StWoncm
b Otfasbach Federal National Mortgega Association
By: S &Gachd,LLP as its Attorney-in-Fw
SE!'I MMENTAC ENTCERTIFICATION $
The IIUD-i ScUlmumt Statement Which I have p it a but and accurate
account of I bare eanssd the fiuuis to be disbursed is Stephanie Davis
.,at autfuarimd
sigttalory
act anee 7 fof Shapiro.Fishmmt&Gachl,LLP,as Anwaey n.Fact for FANNM MAE
dy !a l ah/e FEDERAL.NATIONAL MORTGAGE ASSOCIATION
t
Agent / I 4 n
l3Yaraktg:g s t crime to knowingly awkc Orbe statements to lite UWW
Sterna on this of any other sboilar form.Faadfies upon conviction can
Indudc afore cad Imptisomomt.For detaik roc:Title 18 U.S.Co&seetion
1001 and Section 1010.
Previous editions are obsolete Page 5 of 5 tivD t