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Miami Shores Village � 8i?! B DIV#nN1�,i #
1 40
10050 N.E.2nd Avenue NErm
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ass o on
Miami Shores,FL 33138-0000
,.� � ? err Status'APRCI'1/E� 3:
Phone: (305)795-2204 �, _d
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Issue Date 712 /2011 Expiration: 01124/2017
Project Address Parcel Number Applicant
9953 NE 4 Avenue Road 1132060171250
CARYN LUBETSKY
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
CARYN LUBETSKY 9953 NE 4 Avenue Road (305)756-6373
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 2,430.00
ONE STOP PAVING (786)299 1354 To
tel Sq Feet: 968
Approved:In Review I Available Inspections:
Comments: Inspection Type:
Date Approved::In Review Final
Date Denied: Foundation
Type of Work:ASPHALT RESURFACE AT 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-7-16-60779
CCF $1.80 07/28/2016 Check#: 1488 $647.80 $0.00
DBPR Fee $2.00
DCA Fee $2.00 Bond#:3168
Education Surcharge $0.60
Notary Fee $5.00
Permit Fee $125.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $647.80
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in c mpliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to thproper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or empl yes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POO work.
OWNERS AFFIDAVIT: I certify that all the foregoing information ' accu to and that all work will be done int compliance with all applicable laws regulating
construction and zoning. Futhermore,I authorize the above-nam co ctor to do the work stated.
July 28, 2016
Authorized Signature:Owner / Applica Contractor / Agent Date
Building Department Copy
July 28,2016 1
Miami Shores Village
Building Department
i
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 4BY
2 2816
Tel:(305)795-2204 Fax:(305)756-8972 `—
INSPECTION LINE PHONE NUMBER:(305)762-4949 201( S
BUILDING Master Permit 1�110.Ds�( (o`
PERMIT APPLICATION Sub Permit �0.
El'BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANgELLATION [:] SHOP
CONTRACTOR III DRAWINGS
JOB ADDRESS: Qoi5 3 o t?
City: Miami Shores County: Miami Dade Zip: 33 « 0D
Folio/Parcel#: << 320(v O 1i 1Z 9-0 Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: _BFE: FFE:
OWNER:Name(Fee Simple Titleholder): C"0 Phone#:
Address: c6r1 16- 3 0@ A J e
�,
City: vv-1 i <INOr'e s State: — Zip: 3'5\300
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: 00e Phone#: -7 P'6 Zq'ti k3 S`{
Address: � tV LT5
City: 11� State: Zip: 33� z
Qualifier Name: Co I.v 1 '$icn, Phone#: -79� 2qR L 35--4
State Certification or Registration M cj�C (S 13-11ci Certificate of Competency#: 23 f'SD
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 24 *3c2 . a-o Square/UnearFoot �yta�age of Work: [ lF b
Type of Work: ElAddition ElAlteration ElNew (rF� ep
A"Hair/Repjace ❑ Demolition
Description of Work: 512k .
k o. 1 Iiohr.or lid-[A -�
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ C CCF$ CO/CC$
Scanning Fee$ r � Radon Fee$ '2 " DBPR$ Notary$
Technology Fee$ `-C Training/Education Fee$ 0 .60 Double Fee$ _ 0
Structural Reviews$ Bond$ W
TOTAL FEE NOW DUE$
(Revised02/24/2014) i (^ �-
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 rel pection fee will be charged.
ignature Signature
I
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of ✓ 20 c b .by Z� day of M L, 2016 by
CDQ� who is personally known to cutin lkc,&-sTD ,who is personally known 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:
Sign: ( Sign:
Print: aFP r� r �TM Print:
,� o o6�4
13r,i°en0v1riers � Sea[: 19^634
kkk*hkkkkk4k#*kkkkkkkk*k*kk�kkkkk+kk8teN4*k+k&*k+k#kk&**&k*k+kkkik*Nk*kkk#*k*kk*kkkkkkk*kikk*k**kM*k Ie*lekk*kkkk+kkk
�� Zonin
APPROVED BY Plans Examiner g
Structural Review Clerk
(Revised02/24/2014)
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Paving Inc .
TO: 0lA'a✓n k cS Vlore s ';K)-i I I^ ti PROJECT: bn
NAME: NAME:
ADDRESS: ADDRESS: 10 C s
PHONE:
FAX: DATE
DESCRIPTION
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State f Florida
SirdiaAlvarez
Pit)LA
My Commission FF 156750
Expires 09/03/2018
1463 NE 173 ST N.MIAMI BCH.FL 33162 PHONE:786 2991354 FAX: 305 947 3233
SORES r,
s� Miami shores Village
altos Building Department
artment
10050 N.E.2nd Avenue
�L0RrpA 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.
Signa e:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this Z fo day of 20
By ( -01- yJ La who is personally known to me or has p�oduced
as identification.
Notary: .ieaunvepuno q dti
6WO C u a�a 5 -_' + [,J",
tessh i FF 15.;634
SEAL: z
2c1s
OPd'a OS�Ftv"ult3 F° ena ter,
°may
` Miami 8hores Village
NINON Building Department
10050 N.E.2nd Avenue
w4ft s Miami Shores, Florida 33138
ORiDA Tel: (305) 795.2204
Fax: (305) 756.8972
SURVEY AFFIDAVIT
STATE OF(FLORIDA)
COUNTY OF(DADE)
The undersigned Affiant,CatzY0 LV t3F 5T!! l: ,does hereby attest that
(Property owner)
The attached survey, performed by i-x4y_ & • Gam`oc_ZLL-
(Name of surveyor's company)
For address: �`� -.5 N U Q 9�'d-
Performed on 6 fZ10t (date of survey)is an accurate representation of the exiting conditions and
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property
without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to
remove or obtain permits for any structures which now may exist on the property which are not permitted or which
may violate zoning or building code regulations. The Affiant further understands that the existence of any such
structures m affec final inspections as applicable to this or other permits.
Fu say et naught.
"so LU 13 F-T S V-1
Property wner Signatur Pr�Iperty Owner Print Name
SWORN TO AND SUBSCRIBED before me this 7'(P"—day of w(6
Affiant is personally known to me, produced as identification.
BARB00S0', UO
.• '.,=_ P? 'I�'=!GDi#FF 155634
j ly:';F cS:=ebn ary 3,2019
'O Tiro J.rr,Prin!cUnderwiters
*Ctary
Revised on 5/22/2009/Revised on 6/12/09
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s� �► Miami Shores Village
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." ..,..� Building Department R BK130168 F's 2562 (lPgs)
,e 10050 N.E.2nd Avenue RECORDED 07/27;`201,
r Lt& Miami Shores, Florida 33138 HARVEYf;�UVIN4 CLERK OF COURTloRiDp' 41I4i lI Z- eE { OUN�'r,= FL '
5 rATE OFFLORIDA,COUM A
Tel: (305) 795.2204 PND COUHIY
HEREBY CERTIFY that this is a true copy of the CLERK (`
Fax: (305) 756.8972 original tiled this office on day of �J\ °p
1111 2 72016 , AD 20
WITNESS my hand and Offic Seal. 'r
w aoo wti mat 4
COVENANT OF CONSTRUCTION WITHIN RIGHT OIFAMMYU N,c K, of ircuitand CountyCourts
Whereas, (owner) GAQ,Yf � LuP3�'rsy-,-f Rv D.c. fCo_ur�'�
hereinafter referred to as the owner of the following describe #201144
property (address): aq 53 ' 01-- 1 k4e, '2d
Legal Description: Lots- Block Qh Subdivision �armi S ib �s • I PB L3-l4
Folio # l l '32,0(o o l`1 ZED
Requests permission to install (describe work): /�s G,�-l-} (Xs J e ( ;V-&A,-�
Within the public right of way of (address) iet 53 N4- rte- ((t,
IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows:
1. To maintain and repair, when necessary, the above-mentioned Iitem(s) installed within the
dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County to
make repairs or maintain said items within public right of way including restoration of street by
reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall
constitute a lien against the above described property until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County
harmless from any and all liability, which may rise by virtue of permitting the installation of
these items within the public right of way.
3. The Owner does hereby agree to remove or relocate their facilities at their own expense,
within 60 days notice by the Village to do so. Failure to comply with this notice will result in the
Village causing the item(s) to be removed and a lien being placed on the property and/or
assessed against the Owner for all costs incurred in the removal and disposal of the item(s).
4. The undersigned further agrees that these conditions shall be deemed a covenant running
with the land and shall remain in full force and effect and be binding on the undersigned, their
heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in
the PublicRecordq of D e County, Florida by the Village Manager of Miami Shores Village
(or his full r' ed r resentative).
YI-I'Signature
: I
Owner or Ag nt C Q`t N L 0 5E�Ts
State of Florida
County of Miami Dade
The foregoing instrument was acknowledged before me this ZZ day hof -TU , 20 , by
Uej o LV gr__rs)(,-► who is personally known to me or who ha$ produced
as id ratification.
NOTARY PUB
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