DS-16-737 Miami Shores Village
10050 N.E.2nd Avenue NE ,
Miami Shores,FL 33138-0000
Phone: (305)795-2204
a
Expiration: 09/1812016
Project Address Parcel Number Applicant
230 NE 107 Street 1122310130670
Miami Shores, FL 33161- Block: Lot: BENJELLOUN HASSAN
Owner Information Address Phone Cell
BENJELLOUN HASSAN (305)207-0606
Contractor(s) Phone Cell Phone Valuation: $ 2,650.00
TRUE STAMP CONCRETE LLC (305)494-4465
Total Sq Feet: 400
Approved:In Review Available Inspections:
Comments:
Date Approved::In Review Inspection Type:
Final
Date Denied:
Type of Work:INSTALL NEW DRIVEWAY IN RANDOM PF Additional Info: FoundationReview Planning
Bond Retum: Classification:Residential Review Building
Scanning:3
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.80
DBPR Fee Invoice# DS-3-16-59090
$2.00 03/22/2016 Credit Card $117.80 $0.00
DCA Fee $2.00
Education Surcharge $0.60
Permit Fee $100.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $117.80
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 AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constructio and ning. ore,I authorize the above-named contractor to do the work stated.
March 22,2016
A Ignatur®: r / Applicant / Contractor / Agent Date
Buil apartment Copy
Mardfi 22,2016 1
y • Miami Shores Village
R 2 2016
Building -Department BY
1WS0 N.E.2nd Avenue,Miami Shores,Florida 33138 -=
Tel:(305)795-2204 Fac(305)756-8972
INUECTION LINE M ME NUMBER:(30)7624949
FBC 20 Q�5
BUILDING Master Permit No.
PERMIT APPLICATION Sub Permit No.
PBUIU)ING 0 ELECTRIC rl-ROOFING C REVISION 0 EXTENSION nRENEWAL
[]PLUMBING [JMECHANICAL aPUBUCWORKS [ CHANGE OF 0 CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADIWEss: 7-30 6t /®? 7-xe7`
City Miami Shores County: Miami Dade zio: /7LcY
the Bugling Historically Des4nated:Yes NO
Qctupa"ncyType•__�„� ibad Wnstrvctlon.Type: Flood Zone BFE:, FFE�
OWNER:Name(Fee Simple Titleholder)- A S'S A41 42 a ,�"��loaA.1 Phone#-tij f 4-
Address:
.-Address: 2 3 Y9 rte j�11D State:
Cita: �f.' t--? , � h1OState: ,�'`G zip: 1+3
Tenant/keseee Name: Phone#:
Email:
CONTRACTOR:Company Name: 7k ye 7. =1 c a se c,, ,0 rZ Phone#. "?2 L9 5
Address:- Z-d Y—&., 3.�..4 ?-
City: til,- r.4,onh_,'- state: 0!5�
Qualifier Name:� lG 6;7-71 :s Phone#:
State.Certification or Registration#: LIQ D 8 7 L/ Certificate of Competency#: "C'qX o D 7,l 2r, _
DMNRW Ard:ltect/EngUeer. Phone#:
Address: City: State: Zip:
Valae of work for ills PrrmTr ;5 0 yokeLm � gD O S
Type of Wyk: Q'FA lditi�t_ [� Alteration E �Neur [] RepairjRepiace Demolition
aesciptim 6twe*:rn.S, (/. �?4/ o�uve�vs�T �:u .a�c.,g�•r oma, P.a f'l`ees.r✓; -4k� r,a
6 x�' . 3�k Ct PCS�.✓ /7o 4Z4Aje
S;m*color of Color thru tile:
Submittal In$ Permit Fee$ CCF$ Co/CC$
Sawing Fee$ Radon Fee$` DBPR$ Notary$
Tedwolbgy Fee$- _-Tna Mucaatiotfee$ Double Fee$
Strucfturai Reviews$ Bond$
Bonding Company's Name(if alfplicabie)
q
Bonding Company's Address
city State
zip
Mortgage Lender's blame(if applicable)
Mortgage Lender's Address
t•
City State Zip
o
Application is hereby made to obtain.a permR,to do the work and Installations as Indiarted. I"y tit no work or Installation has
commenced prior to the Issuance of a permit and that aq wont 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 wlthtail
applicable laws regulating construction and zoning. r
aWARNING TO OWNER: YOUR,FAILURE TO;IECORD-A NOTICE OF COMMENCEMENT Mi4Y
RESULT IN YOUR PAYING TWICE.:FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU,WEND
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$25DQ the appdcdnt must
promise in good faith that a copy of the notice of commencement and.construction lien law brochure wN be delivered to-thepers6
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 ftYst inspection which occurs seven (77) days after the building permit Is-Issued. In-the absence of such posted'notie, the
Inspection will not be approved and a reinspection fee will be charged.
Signature
Signature
ER or AGENT CONTRACTOR
The foregoing in nt was acknowledged before me this The foregoing Instrument was acknowledged before me this
,120 _day of 20 1'4 . .by 20 day of_A2,ox c 4 .20 $� .by.
_1'43 .v /�P.L.joLl :i��I ersonaliy knori to G/lL %lose S'9- .who pelsonallyk o..
me or who has produced as_ me or who has produced as
Identification andwh a oath. identification and who did
NOTARY PUBLIC: APAN9A=9W
�' ON#FF9133b6 NOTARY PUBLIC.
, _ Vf (i00FPF9Z
18,201
EXPIRES:S
� eptember 9 EXPIRES:
BMW � 9a ttn�na8ma :Sr�ger 18,;219.>
1? .
�Pim tk�n,r�is
Sign: Sign: ,� p
Print: n \\,s Print: `"gXLS
Seal:. Seal:
APPROVED BY I 1 Plans Exwnh 4-. V
- -7cnning=
Structural Review Clerk
r '
True Stamped Concrete LLC.
Date:
State of: Y
County of: A'i1 XAXA _
Before me this day personally appeared Wiyk C�TN `CYve-bc, who,being duly sworn,
deposes and says:
That he or she will be the only person working on the project located at: D 3y kJ G I
Sworn to(or affirmed)and subscribe before me this 00 day of IAaYc 20_i�
by: k&AVk 0.r-\ T1 k-YA
Affiant Signature:
Personally Known:
Or Produced Identification:
Type of Identification Produced:
Q-
Print,Type or Stamp Name of Notary
OItt% MANMGOWAM
W
EXPIRES:Septen W 18,2x19
,' BortdadTlauNota�yP�lke
.�. Miami Shores Village
Building Department
AOR 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
Notice to owner- Workers' Compensation Insurance Exem tion
Florida Law regaires 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 fiam 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 eToys one or more partes or full-time
employees,including the owner,must obtain workers'compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the mon industry may elect to be
exempt it~
1. The offices owns at least 10 percent of the stock of the corporation,or in the case of
an LLC,a statement attesting to die minimum 10 percent ownership;
2. The officer is listed as an officer of die 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 Dent of
State,Division of Corporations.
No ware 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 requesUng a permit under this workers'compensation exemption and has acknowledge that he or she will not use
day labor,partes employees or subcontractors for your project The contractor has provided an affidavit stating that be 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 TI'S•
CONTENTS.
i
Signature:
State of
County ofMiami Dade
The foregoing was acknowledge before me this 2D day of/d
By. Ste✓ P.c/s L���iw/ whoina2lykaowg to me or has produced
as identification.
Nosy, if1 _ :rte
SEAL: " "' AFAMs cotttM
MYC0WAS"#FF9,1M
EXPIRES,SepWnber'18,2018
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CFH 2016RO173535
OR BK 30009 Pss 2579-2580 Mss)
RECORDED 03/23/2016 10:57:45
HARVEY RUVINY CLERK OF COURT
DOCUMENT COVER.PAGE
MIAMI-DARE r.0uhlTYg FLORIDA
For those documents not providing the required3 x 3 inch
space on the first page,this cover page must be attached.
It must describe the document in sufficient detail to
prohibit its transference to another document.
An additional recording fee for this page must be remitted.
(Space above this line reserved for recording office use)
Document Title: co V P n.0,fw C yy �MC-�@n fzk,
(Mortgage,Deed, Construction Lien,Etc.). ��
Executing Warty:
Legal Description:
(if Applicable)
As more fully described in above described document.
Return Document To E Prepared By:
(Relevant excerpts)
Rule 2.520(d)On all. documents prepared...:..which are to be recorded in the public records of any
county...a3-inchby 3-inch space atthe top right-hand comer onthefirst page and a1-inch by3-
inchspaceatthetopright handcomeroneachsubsequenipageshallbeleftblankandreservedfor
use by the clerk of court
F.S.695.26 Requirements for recording instruments affectingrealproperEy— covey
(1)No instrument by Which the title to real properly or any interest therein is conveyed,assigned, can cg
encumbered,or otherwise disposed of shall be recorded by the clerk of the circuit court unless:
(e)A 34nch by 3-inch space at the top right-hand corner on the first page and a 1-inch by 34nch
space at the top right-hand corner on each subsequent page are reserved for use by the clerk of the oot l
court...
N Klf:T 9r,,..,Pew fld/1r, —4,4—............s.,...1
Miami Shores Village C`0
Building Department
IDp'
10050 N.E. rid Avenue -�R►
AAialtti Shores,Florida 33138Tsh +�
Fax»�756.8972 7?GJ
m0
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY 0
Whereas.( f «v.ti heriainaRer referred to as the owner of �
ON Mowing described property(wwxwl: 2
---
Legal ip#iorh .o,��,v Pa,a P K Lot _.i3tock r s sub wwon 1".4 s T,,,v J.,
Four,# 112-2 1,/ Dl 0�7D �'¢`t'/C
Requests pem bsion to hnstell(d mit ww /9 L ' 2
/tq ova/+, Lir S
Within the public right of way of(addieasl Pe 7`
IN CONSIDERATION of the approval of this permit by the Vttlaq%the owner agrees as tbnow L.-
1. To maintain and repair,when necessary,the above awffloned ibem(s)installed within the'dedicc;atted right of
�gtS
I H
way. fit becomes.111e0889ary for Mhamd Shores Village or Dade County to hake repairs or maintain said
Items within public right of way including restoration of street by reason of the Owners failure to do so, p
such expense shall be paid by the Owner or shall constitute a nen against the above described property c u
until paid.
2. The rnlvaer don hereby agree to Indemnify and hold MkW Shores Village or Dade County harmless from any
and all liability.which may rise by virtue of permitting the hstelletlon of thea items within the public right of way. c cis.
3. The owner does hereby agree to remove or relocate their facilities at their own expense,within 60 days W.o
notice by the While to do so.Failure to comply with this notice win result In the Village causing the s) o oU.
� a
lo be mnhoved and a(Ion being placed an the property and/or assaftedl against the Owner for all costs O m
w
Ir Ted In the removal and disposal of the"s). 0
4. The undersigned further agrees t at these conciftns shalt be deertred.s coferarit rugning witlh titre land . o -a .e a W
and shallierhah In AM forge and effect and be binding on the undersigned,then heirs and swigis,until & -,
� C
c� �
such tithe as this obligations las Leen canceled by.an affidavit tiled In the Public Records of Dade County,. U v C4
Flees by the Vitlege Merager of Miami Shores cc
VIIISP(or his fully authors )• w w
i
' n � os ►.. pc y
SIGNED,SEALED.EXECUTED AND ACKNOWLEDGE at this 201(
• I Z(Owno's Sign
SIGNED.
D.AND DEWERED In the preser>ce ot:
ao#0a Notary State of Florida
Sindia Alvarez
oQ My Commission FF 156750
of�o� Expires 0 9/0 312 01 8