RC-14-2550 (6). i
Miami Shores Villagea �
Building Department NOVI R014
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 _
r Tel: 305 795-2204 Fax: 305 756-8972 -
INSPECTION LINE PHONE NUMBER:(30S)762-4949
FBBC204c)
(�
BUILDING Master Permit No. f CA4- eA,5450
PERMIT APPLICATION Sub Permit No. VL_I 4 --f;i55
F-1 BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 10(®k VXYT' �
City: Miami Shores ^� County: Miami Dade ZIy: Jy713,?
Folio/Parcel#: Is the Building Historically Designated:Yes NO Q
Occupancy Type: Load: /Construction Type: Flood Zone: BFFE:('� FFiE: 1
OWNER:Name(Fee Simple Titleholder): "Ilk ��t Phone#: l&6 - �t `S4t
Address: t b illy
City:° \ State: Zi 33
Tenant/Lessee Name: Phone#:
EmaH:
CONTRACTOR:Company Name: Ll L Phone#:?eS—c? - 017
Address: —2 �'C�
City: Stat Zip:
Qualifier Name: Phone#:
State Certification or Registration Mcec 1 2 b Certificate of Competency M
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zi
Value of Work for this Permit:$ uare/Linear Footage of Work: t
Type of Work: � Addition ❑ Alteration w ❑ Repair/Replace ❑ Demolition
Description of Work: PLj S
7
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$ 2q l
(Revised02/24/2014)
.fie
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip MM4
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 d ivered to the person
whose property is subject Wd ottochment. Also,a certified copy of the recorded notice of commencement mu posted at the j9b site
for the first inspection which occurs seven (7) days after the building permit is issued. In th absen such posted notice, the
inspection wT.-
ved and a reinspection fee will be charged.
Signature Signature
WNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
c _day of N\04 deer ,20 I"/ .by day of 6-'C -'20 ly ,by
t-t�iCQ CSZLxxLR- 1 ,who is personally known to vSam t ;a2- _____,who is personally known to
me or who has produced 1�L. c3Yl " �t� 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: Sign:
Print: Print: 6
Seal: Seal:
REBECA M.PASTRANA `"REBECA M.PASTRANA
MY COMMISSION B EES72624 e�, MY COMMISSION 9 BU72624
` EXPIRES:Fftummy07,2017 vea E70'1RES:F&nWy07,2017
*************
APPROVED BY f'2/0' Plans Examiner Zoning
7
Structural Review Clerk
(Revised02/24/2014)
loss Miami shores Village
• Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305)756.8972
Notice to Owner - Workers' Compensation Insurance Exemption
1
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.
r 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 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 Contra r
Print Name: j 0 Print Name: D
Signature: Signature-
State of Florida) State of Florida)
County of Miami-Dade) County of Miami-Dade)
Sworn toaud subscribe d before me this worn to and subscribed before me this
day of 1 20 °wwREBECA M. y of 1 da &�r 20 1A 1
' +��°REBECA M.PASTRANA '
W COMISSION a EEIC7M ItEBECA
y
By C
C v Uhl Ei�IR15:F&rmy 07,2017 ' M.P
ION 9
RES:F&MY 07,201
(SEAL (SE
Ty
W of Identification produced LpT of Identification oduced