DS-15-1683 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-240362 Permit Number: DS-7-15-1683
Scheduled Inspection Date: August 19, 2015 Permit Type: Driveways/Sidewalks/Slabs
Inspector: Rodriguez,Jorge
Inspection Type: Final
Owner: EUGENE, ETIENE & OLGA Work Classification: Addition/Alteration
Job Address: 203 NW 111 Terrace
Miami Shores, FL 33168-3324 Phone Number
Parcel Number 1121360010330
Project: <NONE>
Contractor: STAR ISLAND CONCRETE DESIGN CORP Phone: 305-253-5151
Building Department Comments
STAMP CONCRETE DRIVEWAY Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed CREATED AS REINSPECTION FOR INSP-238448. not ready for
inspection.
Failed
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
August 19, 2015 For Inspections please call: (305)762-4949 Page 23 of 39
91"
Miami Shores Village Portff 7'YPe Die ay 6IdO I cSIM
10050 N.E.2nd Avenue NW I*
cla's If Vo A I Ite40lt
Miami Shores, FL 33138-0000 Y 4
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E ` Phone: (305)795-2204 ifa'a#us {
%sue Date.7/171�t315 Expiration: 01/13/2016
Project Address Parcel Number Applicant
203 NW 111 Terrace 1121360010330
ETIENE&OLGA EUGENE
Miami Shores, FL 33168-3324 Block: Lot:
Owner Information Address Phone Cell
LETILENE& LGA EUGENE 203 NW 111 Terrace
MIAMI SHORES FL 33168-3324
203 NW 111 Terrace
MIAMI SHORES FL 33168-3324
Contractor(s) Phone Cell Phone Valuation: $ 2,450.00
STAR ISLAND CONCRETE DESIGN C( 305-253-5151 Total Sq Feet: 780
Approved: In Review Available Inspections:
Comments: Inspection Type:
Date Approved::In Review
Final
Date Denied: Foundation
Type of Work:STAMP CONCRETE DRIVEWAY Additional Info: Review Planning
Bond Return : Classification: Residential Review Building
Scanning:3
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Contractors Bond $500.00 Invoice# DS-7-15-56240
CCF $1.80 07/07/2015 Credit Card $50.00 $ 592.80
DBPR Fee $2.00
DCA Fee $2.00 07/17/2015 Check#: 1320 $592.80 $0.00
Education Surcharge $0.60 Bond#:2796
Permit Fee $125.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $642.80
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 certify that all rhorize
egoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zo hermor , I the above-named contractor to do the work stated.
July 17, 2015
Authorize ature:owner / Applicant / Contractor / Agent Date
Building Department Copy
July 17, 2015 1
i
Miami Shores Village PF
Building Department Ju� 0720,5
g p tment
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 $1':
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20// J-4h
BUILDING Master Permit No.&S 3
Q
PE IT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: �� -
City: M'oA , Miami Shores County: bCLQ Miami Dade Zip: 1� —
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): Phone#:
Address:
-- U
City: State: Q Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: ( - C' , � J phone#: 3 ` 1 3 7 Z
Address:
City:_ State: —Zip:-3
Qualifier Name: Phone#:7 � 3 ;�7/2-
State Certification or Registra ion#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: —City: State: Zi
Value of Work for this Permit:$ � Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑/New ❑] Repair/Replace ❑ Demolition
Description of Work: 5—/—Az"L d
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$SC--(-I-:)
TOTAL FEE NOW DUE$
(Revised02/24/2014) �� 2 �1�J
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 issu ! the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signatur ) Signature `—�
NER or AG ON T TOR
The foregoing instrument was acknowledged before me this The foregoingstrument was ac nowledged before me this
2 day of20 ,by 2 3 day of ZQ s by
1016 14, who t�personally kno n to
who is personally kn wn to
me r who has roduced as me or w o has prod a as
• ' UL
identification a t�k�'�r�tRi.A CORPAS identification L CORPAS
OMMISSION#EE827816
=••' a *COMMISSION#EE827816
NOTARY PUB
•
IBES August/8.2018 NOTARY P IRES Auger 16.2016
F1orklaN '� ( 33 Floddallotery8enksoom
Sign: Sign:
Print: Print:
Seal: Seal:
APPROVED BY Plans Examiner r r ` S/ Zoning
Structural Review Clerk
(Revised02/24/2014)
I
JE STAR ISLAND CONCRETE MO
DESIGN.) CORP. A��
Date: 7 4 — Q o 15
State of �,p2/�,�
County of ,¢ C
Before me this day personally appeared ` ��� who,being duly sworn, deposes and
says:
ace P'r6�
° 7Ze
That he or she will be the only person working on he project located`.ar:.�
am-iyy��
Sworn to(or affirmed) and subsc bed 1 e00T mecths (5 day of 20/ir,by
•
ersonall
OR Produced Identification
Type of Identification Produced
P �i e o A of Notary
,g`rs COMMISS►oN#DD925427
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FXPIRES: SEP.15.2013
3 ytyyw AwNNDTARYm-n
Oc�HRES
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logo U1111" Miami shores Village
Noe Building Department
�l0RiDp' 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.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Owner
State of Florida
County of Miami-Dade f
The forego'ng was acknowledge before me this. day of ,20 I d
BY I CIL c who is personally known to me or has produced
as identification.
Notary: qq pp q
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PROPERTY OF: Etiene, i.uy( e, 2U3 14 .10. lil.t.i1 Terrace, illarnlltores ,
Not valid unless embossed it BOUNL)iiRY SURVEY LANNES and G A R C I A, INC.
With Surveyor's Seal. 1,hereby certify that the survey repre-
sented hereon meets the minimum ENGINEERS - LAND SURVEYORS - LAND PLANNERS
technical standards set forth by the
Board of Lapd Surveyors pursuant to Office address: 4080 S.W.84th Avenue,Miami, Florida 33155
Section 47,2.'027,Fla.StayAes.There are
noenc/yichments,o rlaps,er han as Mailing address: P.O. Box 561131, Miami, Florida 33156
appe��ng on theAtat, other than as
shown hereto
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Fla. Reg. Land'Surveyor No. �`�1. DATE SCALE DRAWN BY DRWG. NO