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REV-16-1326 Miami Shores Village Buil dln MAY 172018 10050 N. ve h e 'd 5 9 3 ) 56 px: LI O 6 FBC 20y-t BUILDING Master Permit Ivo. Q( —3 — k31 PERMIT APPLICATION Sub Permit No. .��—� 1 (�� — F-1 BUILDING ❑ ELECTRIC ❑ ROOFING GZREVISION ❑ EXTENSION [:]RENEWAL ®PLUMBING ❑ MECHANICAL ❑PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP e�f CONTRACTOR DRAWINGS JOB ADDRESS: . f 2a! r" t q! City: _Miami Shores County: Miami Dade Zip: Folio/Parcel#: �'-3 S ®� 01-1 0 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titlgholder): gobeal-1 Ihone#E,�✓�s� Address: Z tj C 1 5-lvt City: M/A-&A4j �l State: Zip: 33 1 3 8 Tenant/Lessee Name: _Phone#: Email ------------ CONTRACTOR:Company Name: e�" `©i`J� � ��L! e9°j`• Phone#: ���) -766 ca-T / Address: ����S 5� � 1 City: /"�,/k'°' A State: 944jm- zip:-q3/03- Qualifier ip:q3/ 03- Qualifier Name: hoe%ti j Phone#:(7,e )-7 06 8'� 14-f State Certification or Registration J!#/J (,p�� �� � �� Certificate of Competency#: DESIGNER:Architct/Engineer: / ',44io �eiAy Phone#:C-�Sl �� / 74 9 ' Address `/t/ �� ����-� City: ® 1� State Zip:--'>31-30 Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition Alter ation ❑ NewElRepair/Replace ElDemolition Description of Work: '.lM� �v to JFK v� �/ l s Specify color of color tthru tile: Submittal Fee$ Permit Fee$��'C�A CCF$ CO/CC$ Scanning Fee$ Ok-"� Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ , 00 (Revisedo2/24/2014) 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 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-cammencemelnt-must-se p-"te"t-the�o"te for the first inspection which occurs seven (7) days after the building permit is issued. In the absence o ch posted notice, the inspection will not be approved and a reinspection fee will charged. Signatu Signature it OWNER or AGENT CONTRACT The foregoing instrument was acknowledged before me this Theforegoinginstrument was acknowledged before me this day of B 20 �� by day of 8� 20_[(Q .by who is personally known to *'� & & 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: `'dN1vP��� JUAIVALBERTOBRUGO °�yP PrintNowy Public ''. ° Print: ``� °.,''s AN BERTO BRUGO Seal: .y My Comm.Expires Jul 15,2017 Seal: :� Q my Comm.Expires Jul 1S,2017 '••.,gy t�t�•:�` Commission#FF 1 BS , art ;°' Canmlasioo i�FF 195 %,�,� •. 4ttn�� ############################################################################################################ APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) I � PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE IMPORTANT STATE OF FLORIDA I Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation DEPARTMENT OF FINANCIAL SERVICES who elects exemption tram this chapter by!long a certificate of i DIVISION OF WORKERS'COMPENSATION I F election under this section may not recover benetts or i CONSTRUCTION INDUSTRY EXEMPTION compensation under this chapter O I CERTMATE OF ELECTION TO BE EXEN"F M FLORIDA L Pursuant to chapter 440.05(12),F.S.,Certitcates of election to I WORKEWCOMPENSAIMIAW D be exempt..apply only within the scope of the busheess or trade f EFFCMEDATe srlawle EKPMtwn DAM alienate listed on the notice of election to be exempt. hatem- LEVUS ANDREA H Pursuant to Chapter 440.05(13).F.S.,Notices of election to be Feel. 2OW4410 E exempt and certificates of election to be exempt stag be BUSINESS NAME AND ADDRESS: R subject to rev.ca.W,m anytime after the Mm of the nG*,,- ACA CONSTRUCTION INC E or the Issuance of the oorUticate,the person named on the ACA PLUMBING notice or certificate no longer meets the requhements of this Section for issuance of a certificate,Th.departrnent shall revoke 10925 SOUTHWEST 56TH TERRACEanyurepersonname MIAMI FL 33166 oerttcatet meet the reWmnenls of this Sect€on. SCOPES OF BUSINESS OR TRA I I LICENSED GENERAL LICENSED PLUMBING LICENSED ROOFING CONTRACTOR CONTRACTOR __ ._. CONTRACTOR _ DFS-F2-DVC 252 CERTIFICATE OF ELEMON TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 one Miami Shores Village Building Department �R11 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: I. 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 insfrance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BEL O OU ACKNOWLEDGE THAT-YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS., Signa er State of Florida County of Miami-Dade The oing was acknowledge before me this day of By who is me or has produced as identification. Notary: SEAL: o`"" �B�'•. JUAN A TG �HUGC -+. •os Notary PWC• ta;e at Florida U. nrrrm b FF 195 ACA Constructions, Inc. CGC 1511172 CFC 1427635 Address:10725 SW 55 Terrance. Miami,FL 33165 Phone:305-788-8914 Date: State of Country of A— Before me this day personally appeared 41P4K /&4"66 who, being duly swom deposes and says: That he or she will be the only person working on the project located at: sT" , f 41A MI S-felze, --rt 33 3 L Swom to(or affirmed)and subscribed before me this 1day of d , 20j,�&, by Personally know OR Produced Identification',O Type of Identification Prouced i aggv"Oe°�,, JU N ALBERTO BRUGO ? °I Notary Public-State of Florida My Comm.Expires Jul 15,2017 °• c. Commission#FF 195