PL-15-364 (2) Permit NQI PL-2-1 3W4
Miami Shores Village Permit Type:Plu, ng-Res ontial
10050 N.E.2nd Avenue NE Perill 't
Wo*Clessif►fa t/on.,Pool rivate
Miami Shores,FL 33138-0000 d
y iD►o' Phone: (305)795-2204 Pel'mi�Status: VEd
[st Dazs:4M=15 Expiration: 10/06/2015
Project Address Parcel Number Applicant
1059 NE 98 Street 1132050180230
Miami Shores, FL 33138-2505 Block: Lot: MARIA SARMIENTO JTRS
Owner Information Address Phone Cell
MARIA SARMIENTO JTRS 1059 NE 98 Street (786)333-2300
MIAMI SHORES FL 33138-
1059 NE 98 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 1,500.00
DREAM DESIGN POOLS INC (954)916-5337 (786)402-2253
Total Sq Feet: 00
Type of Work:POOL PIPING FOR NEW POOL Available Inspections:
Type of Piping: Inspection Type:
Additional Info:
Main Drain
Bond Return: Final
Classification:Residential Scanning:3 Rough
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.20
Invoice# PL-2-15-54535
DBPR Fee $3.38 04/09/2015 Check#:5090 $ 193.96 $50.00
DCA Fee $3.38
Education Surcharge $0.40 02/19/2015 Credit Card $50.00 $0.00
Permit Fee $225.00
Scanning Fee $9.00
Technology Fee $1.60
Total: $243.96
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
„
OWNERS AFFIDAVI . I- ify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction ao ng. Fut ermore,I authorize the above-named contractor to do the work stated.
/I April 09, 2015
Auti d Signature:Owner / Applicant / Contractor / Agent ate
Buildin Department Copy
April 09, 20115 1
Miami Shores Village
Building Department ; -t319 �
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795-2204 Fax: (305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 I�
BUILDING Master Permit No-UP �6
PERMIT APPLICATION sub Permit No.]?L )5 -
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
,/g �p G CONTRACTOR DRAWINGS
/V /l
JOB ADDRESS: �// 2 5;r
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): /4'fA131,g W/'1/2WrgT Phone#:
Address: /P. � &E ff ,-r
City: 4�qagl;r State: f::4— Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Pz oozw p g:izzG/y F�� ,//C Phone#: Aly
Address: F ?z GOVIF GlI�GL$
City: State: FL Zip:
Qualifier Name: A PiFA t*VO Phone#:
State Certification or Registration#: LPG 4057p�?/ 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:
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ ;f,77,S• �`'' CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ Q
TOTAL FEE NOW DUE$
(Revised02/24/2014)
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.
Si natureQ�� Signature
g g
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
_day ofy„G1A 1 20 \5 by f D day of A0,OI3b"Y 20 �7� by
ho i=persona to I� �L �,YI/. ho' ersonall n to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
i
Sign: Sign:
Print: Print: :ti :*z ' L �
=� •r tq DAR X
Seal: r MY COMMIS"ILTE 08�C�oo Sea I: � ES April 25,2016
EXPIRES:M5,2015 �,,,Banded Ttru Notary Undena"
*********************************************************************** ************************************
APPROVED BY `P,c -4 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
r
-• S, ,mss
C1
Miami shores Village
Building Department
ORID 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 and has acknowledge 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 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 Contractor
17J7..
Si nature: ,V tr Signature: CIL
State of Florida State of Florida
County of Miami-Dade County of Miami-Dade p
The foregoing was acknowledge before me this The foregoing was acknowledge before me this 0
day of 1GrO1111A ' day of l��j//� ,20Ob
��.
BY AI TO B 4eAe,4 PF.L.4,itA
who ' ersonally kno toit a or has produced o is petsoriallty known e or has produced
as i a tification.
�U DOMINGUEZ
Not N I EL ONfINGUFZ
SES!41F.
PIRES April 25.2016 2818
L4o 10, ,. • , ES Ap;¢ 25,2016
N
r
(786)402 2253 Dreamdesignpools@gmail.com
Date: 2-18-2015
State of Florida
County of Miami-Dade
Before me this day personally appeared Rafael Pellerano who, being duly sworn,deposes and says:
That all the work to be performed at 1059 NE 98 Street, Miami shores will be done by myself.
Sworn to(or affirmed)and subscribed before me this l9 day of . 20j,.f
le
Personally known ✓
so y
Or produced Identification
Type of identification produced
. . p
I L MINGUF»� ',
#EE19261
M ,2016
63
Print, a or stamp of notary