PL-15-2330 , a
PW tv 1-5-2330
ow
st!O." s Miami Shores Village
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10050 N.E.2nd Avenue NW
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Miami Shores,FL 33138-0000
Perr if� PP
`2ad� Phone: (305)795-2204
912W20W, Expiration: 03/26/2016
Project Address Parcel Number Appifcant
88 NW 111 Street 1121360030400
Miami Shores, FL 33138- Block: Lot: Trifecta Capital LLC
Owner Information Address Phone Cell
Trifecta Capital LLC 1504 BAY Road (954)465-3753
MIAMI BEACH FL 33139-
1504 BAY Road
MIAMI BEACH FL 33139-
Contractor(s) Phone Cell Phone Valuation: $ 4,500.00
UNIVERSAL PLUMBING CORP (305)887-3131 Total Sq Feet: p
Type of Work:NEW PLUMBING Available Inspections:
Type of Piping: Inspection Type:
Additional Info: Top Out
Bond Return: Final
Classification:Residential Scanning:3 Water Main
Review Plumbing
]]L]]E]EE]
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $3.00
DBPR Fee Invoice# PL-9-15-57073
$4.50 09/14/2015 Credit Card $50.00 $276.00
DCA Fee $4.50
Education Surcharge $1.00 09/28/2015 Check#:1051 $276.00 $0.00
Permit Fee $300.00
Scanning Fee $9.00
Technology Fee $4.00
Total: $326.00
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,MECHAN INDOWS,DOORS,R FING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that a e foregoing info ation i ate a d that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhermor ,I uthorize the above- amed c ntractor to o the work stated.
September 28, 2015
Authorized Signature:Owner nt / Contractor / Agent Date
Building Department Copy
September 28,2015 1
Miami Shores Village
Building Department SEP 4 2015
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 j
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 s
FBC 20(q
BUILDING Master Permit No. Qc a 1.5 - 55�
PERMIT APPLICATION Sub Permit No. PL- IS- 2331
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
/ CONTRACTOR DRAWINGS
JOB ADDRESS: 8 t5 /UGJ I f 1`'`` S TL
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: // . a 13 3 - 0�&n Is the Building Historically Designated:Yes NO aG
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): It-i �C 4-CA- CG:eb4a , L [,Phone#:
Address: 150 Y /1jaa4-f 2d ):;t / Z v y
City: '{" QAz' )944.et State: I-'L_ Zip: 33(3 ]
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Phone#: `T Y46, 435'
Address: IYI E k gr
City: Al,gZf A-,Y State: ' Zip: —430 f3
Qualifier Name: 1U/1 G E)_ 6,3 R6 j PhoneM `1 Ka74 �/q
State Certification or Registration#: CJCC_ T����! Certificate of Competency#: �6 Fef
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ CF$ `'� CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ �
(Revised02/24/2014)
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 estimdted 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 inspectio hich occurs sev n (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will n e app ved and a rei pection fee will be charged.
Signat re Signature /
OWNER or T ONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 120 1-5 , by day of �'-n Y w ait ,s ,20 3 i by
cel C411,n. who is personally known to ai11 i :.. a 1 t4 i Ili,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:
OLGAOLMEDA
CO S II FF 17
Sig Sign:
ru 8gdgewe"swim,
Print: �4 andA , t �� Print:
Seal: _ EUANA MEDAGLIA Seal:
Notary Public -State o1 Fknic
Commission N FF 19244
My Comm. Expires 15
**** * * * oc ** **comm** *** ******** **000 *** ** ***** ***co ********m************ co***oco**
APPROVED BY �'�5'�S Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
♦gt1s,C,NINE
Miami Shores Village
Building Department
filR ► 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 ins verage fr e contractor's company for day labor,part-time employees or subcontractors.
BY SIGNING BE YOU A LED THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Owner
State of Florida °
County of Miami-Dade
The Jforegoing was acknowledge before me this day of
By_�t.`t��- �1.t�'l�.n who is personally known to me or has produced
as identification.
ELL4M#AEOA"
Notary: �Y Pdit_gam ot Floes
C"Irds$ i,r 1F 192191
ry� IYy►COMM,E iun ts,2D18
SEAL:
Universal Plumbing Corporation
141 E 60th ST
Hialeah, FL 33013
7864862435
Cfc1428421
State of: Florida
County of: Miami Dade
Before me personally appeared Michael Garcia who being duly sworn,deposes and says:
That he will be the only person working on the property located at 88 NW 111th ST Miami Shores, FL
33168
Sworn to(and affirmed)and subscribed before me to this 8th of September, 2015
By Michael Garcia
Personally Known by Eliana Medaglia, Licensed notary.
EUANA MEDAGLIA
• Notary PWft-SWI of Florida
�. COMISSlon•FF 132191
'•a, ,i�� '� MY Corton.Expires Jun 1S,2018 !21 CSG 6-1✓�-
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