PL-15-2405 a . Miami Shores Village
Building Department SEP 2015
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20
BUILDING Master Permit No.
PERMIT APPLICATION sub Permit No--PL(�
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
K?LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
�f CONTRACTOR DRAWINGS
JOB ADDRESS: l �� �� / �C
City: Miami Shores County: VL Miami Dade Zip: 1309 _
Folio/Parcel#: /`—3206 '0t44 A Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): A11KC D 0 71-W Phone#:
Address: ✓ �� �� ✓ G' �-
City: state: L Zip: 331301
Tenant/Lessee Name: Irl Phone#:
Email:
+ CONTRACTOR:Company Name: G Z)A� Phone#:
Address: /ice
City: Ce Stater Zip: l CLZ
Qualifier Name: 6 Phone#:
State Certification or Registration#: (� L Certificate of Competency#:
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: COAV\jGC GaX
.Specify color of color tthru tile:
Submittal Fee$ ® 'w✓ Permit Fee$ !7 /®� ' CCF$ 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)
Y
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 bft'er the'b�ildin�,,permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature �~
OWNER or AGENT CONT CTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
NQ day of 20 (a by 10 day ofT' T�1(+`7�, ,20 J by
fa!-mubo who is personally know w_ n two 11J1 �C�°aul w o is persona known to
me or who has produced �L i-�00-0bt46y- IL11-4s me or who has produced as
identification and who did take an oath. identification and who did take an oath.
F
NOTARY PUBLIC: ,NF M A CARDONA NOTARY PU JULIAN A C:FF
A
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Print. /42 Print:
Seal: Seal:
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APPROVED BY -2815 Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
ELPIPIO MOT2EJON, lNC
_933 NW 134 PL
M64MI, FL 33192
PHONE
Date: septiembre 16,2015
State of Florida
County of Miami
Before me this day personally appeared Elpidio Morejon who, being duly sworn deposes and says:
That he or she will be the only person working on the project located at 8745 SW 4 Ave Miami Shores,
FL 33138
Sworn to(or affirmed)and subscribed before me this 16 day of September.2015 by Elpidio Morejon.
Personally Know
OR produced identification
Type of Identification Produce
a of Notary
5NORlogoFs
Miami V Village
Building Department
�LpRIpA 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 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.
Signature:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this I(o day of 'GeP ,204
By A a�a --y1lwho is personally known to me or has produced
a�
-OW— 6'l-4('i -0 as identification.
Notary: -�` io
SEAL: �