PL-14-2162 ONS
Miami Shores Village
T D
Building Department ocT
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 : .
INSPECTION LINE PHONE NUMBER:(305)762-4949 L
FBC 20tO
BUILDING Master Permit No. 1r u—
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
%PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
} CONTRACTOR DRAWINGS
JOB ADDRESS: I Z r00 05 99- ST
City: Miami Shores County: Miami Dade Zia: 3'3
Folio/Parcel#: 11 . b2 Q S , Of 0 J O i Is the Building Historically Designated:Yes NO V
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: //��
OWNER:Name(Fee Simple Titleholder): Kri Srt-ec) M U,rf O.'-d Mae'la �ho e#: 30 3 " q-35- f(Wo 3
Address: 1260 NE q 4 S-T
City: M(MTMl cS�S State: Zip: 33136
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: S r I o ► f Pho #: 2 —CC 3j
Address:�>� C ` o r l tiii Ci A—C ( S
City: opa 1-od!L-aL StatZip:
Qualifier Name:
Phone#:
State Certification or Registration#: " Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ L5800V Square/Linear Footage of Work: 2-2s
Type of Work: ❑ Addition ❑ Alteration®® ❑ New Repair/Replace ❑ Demolition
Description of Work: G Ce h
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ _ y' CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ �. Notary$ W
Technology Fee Training/Education Fee$ 1 Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ �9' 60
(Revised02/24/2014) -7;9 Go
w
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. ,he absence of such posted notice, the
inspection will not be app ed and a r inspection fee will be charged.
Signature Signature_ G
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
Z day of oc+ ,20 r Lt- by day of 0 C�t 20 I4-1- by
M a,r(c: mad -I-e Z ,who is personally known to�/_ ��_So e-,/,�,z who is onally known t
me or who has produced fL A- (moiy L'Ce4%,x 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:
Sign: / Siga
Print: ®f fz �� r"��o-- Print:
sppy vua Notary Pub is
Seal: „ Seal: :� or Joanna M Feliciano
•4jkZ ' ., a M Commissjon FF 082753
:�; ••" TERESA J SOLOMON o° Expires0111212018
� MY COMMISSION#EE131935 'Forti�
� c!" EXPIRES November�8,J*1 0 5
*******�*�**��**�** �►j)"��-�i*s'�**�x*�x�x***�***�** * ** �x�*�>k�**x��w***w*�m**��x**�***x�>k*�xx��xw*x��w****t�**>«>x�***x��** _
FWdallo{aryServicexom
APPROVED BY / T Z�Y Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
MIAM4DiADE���
MIAMI-DADE COUNTY - STATE OF FLORIDA N/A October 02,2014
LOCAL BUSINESS TAX RENEWAL
4886330 2014 -2015 APPLICATION RECEIPT,5100094
STATE#SEP021074
DBAIBUSINESS NAME: BUS.COMMENCEMENT DATE:08/01/2002
STATEWIDE SEPTIC CONNECTION INC SEC TYPE OF BUSINESS
BUSINESS LOCATION: PLUMS SPECIALTY PLUMBING CONTRACTOR
OPERATING IN DADE COUNTY 1
MIAMI,FL 33999
OWNERICORP. APPLICATION DETAILS
STATEWIDE SEPTIC CONNECTION INC FEE AMOUNT
PHONE# 305-661-6633 Receipt Fee 30.00
UMSA Fee 30.00
P O BOX 3865 Beacon Council Fee 15.00
HOLLYWOOD,FL 33083 Bingo Permit Fee 0.00
Nightclub Permit Fee 0.00
Multi-Municipal Contractor Fee 0.00
Restricted Contractor Fee 0.00
Library Fee 0.00
Transfer Fee 0.00
NAICS CODE: 238220 Doing Business Without a License Penalty 0.00
Late Penalty 0.00
Collection Cost 0.00
NSF Fee 0.00
Prior Years Due 0.00 /
Amount Recently Paid - 75.00
TOTAL AMOUNT DUE: 0.00
.................................................................................................................................................................................................................................................................................................................
If no longer in business,please notify us in writing. To pay online go to www.miamidade.aovitaxcollector
Review and correct the information shown on this application. To pay by mail,make check payable to:
Miami-Dade County Tax Collector
A 25%penalty will be assessed to anyone found operating Business Tax
without a paid local business tax, in addition to any other 200 NW 2nd Avenue
penalty provided by law or ordinance(Sec 8A-176(2)). Miami FL 33128
To pay in person go to:
A Certificate of Use and/or City Business Tax 200 NW 2nd Avenue
Receipt may also be required. (305)270-4949,fax(305)372-6368
A service fee of not less than$25.00 up to a minimum of 5%
will be charged for all returned checks.
t RETAIN FOR YOUR RECORDS t
.................................................................................................................................................................................................................................................................................................................
MIAMI-DADE COUNTY- + DETACH HERE AND RETURN THIS PORTION WITH YOUR PAYMENT + N/A October 02,2014
STATE OF FLORIDA
RENEWAL
LOCAL BUSINESS TAX
2014 2015 APPLICATION I II IIIIII�III I� II III I� I I ISII�IIIII STATE#SEP 21074
0
BUSINESS LOCATION:
OPERATING IN DADE COUNTY
MIAMI,FL 33999 BUS.COMMENCEMENT DATE:08/01/2002
SEC TYPE OF BUSINESS
OWNER/CORR PLUMS SPECIALTY PLUMBING CONTRACTOR
STATEWIDE SEPTIC CONNECTION INC 1
APPLICATION IS HEREBY MADE FOR A LOCAL BUSINESS TAX RECEIPT OR PERMIT FOR THE BUSINESS PROFESSION
OR OCCUPATION DESCRIBED HEREON.I HAVE BEEN INFORMED OF ALL ZONING RESTRICTIONS IMPOSED ON THIS RECEIPT.
I SWEAR THAT THE INFORMATION IS TRUE AND CORRECT.
STATEWIDE SEPTIC CONNECTION INC
TERES J SOLOMON PRES
P O BOX 3865 SIGNATURE REQUIRED SEE INSTRUCTIONS ABOVE
HOLLYWOOD,FL 33083 Please pay only one amount.The amounts due after Sept 30th Include penalties
per FS 206.053.
lfReceived By Oct 31,2014 Nov 30,2014 Dec 31,2014 Jan 31,2015
Please Pay $0.00 $0.00 $0.00 $0.00
7000000000000000000000005100094201500000007500000000000006
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• ,,,, p,„M” Miami shores Village
Building Department
�0 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner - Workers' Compensation Insurance Exemption
SMONSW®R.
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 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.
wner Contractor,r
Print Name: i' % 00, N Print Name:
cn E
W o S
Signature: O w m z Signature:IV
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State of Florida) N z State of Florida) A
County of Miami-Dade) W 2 J County of Miami-Dade) x
Sworn to and subscribed before me this L OG o a Sworn to and subscribed before me this =
day of CC+ ,20(Lf W day of Dc f ,204f. 19 a
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By C- `�1 x -1 By — v
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(SEAL) Pr � ( )
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Type of Identification produced V° A— ®Y►-%J1 Type of Identificat'