PL-16-1704 �y�► s�� Miami Shores Village
10050 N.E.2nd Avenue ` zW
n � E�C�rIi�Ateiio3 ;
•• Miami Shores,FL 3313&0000 R !� PRO,
177
Phone: (305)795-2204 - � ,,
Xii
3
Issue late Expiration: 12/21/2016
Project Address Parcel Number Applicant
249 GRAND CONCOURSE 1132060133610
RONALD AND CARLY SILVER P --
Miami Shores, FL Block: Lot:
Owner Information Address Phone Cell
RONALD AND CARLY SILVER 249 GRAND Concourse
-- --- MIAMI SHORES FL 33138-
249 GRAND Concourse
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 300.00
DECONEX INC (305)817-8777 Total Sq Feet: 00
Type of Work: Available Inspections:
Type of Piping: Inspection Type:
Additional Info: Top Out
Bond Return: Final
Classification:Residential Scanning:3 Review Plumbing
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.60 Invoice# PL-6-16-60256
DBPR Fee $2.00 06/24/2016 Credit Card $64.60 $50.00
DCA Fee $2.00
Education Surcharge $0.20 06/20/2016 Credit Card $50.00 $0.00
Permit Fee $100.00
Scanning Fee $9.00
Technology Fee $0.80
Total: $114.60
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 co ormity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permi assume r sponsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELEC ICAL,PL BING,MECHANI ,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFF AVIT: I rLify that all the r of g information is accurate and that all work will be done in compliance with all applicable laws regulating
construction d zo ' Futhermore,I e bove-named contractor to do the work stated.
June 24,2016
A horized Signature:Clivner / Applicant / Contractor / Agent Date
Building Department Copy
June 24,2016 1
Miami Shores Village
Building Department JUN 10 201s
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.P44---- 1,6
PERMIT APPLICATION Sub Permit No.-
1— 16
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
E94LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 2-4-9 G-Tl;�k �D C® ts� co U RS 2
City Miami Shores County Miami Dade Zip: 33 J�
Folio/Parcel#: 1 1- 3'1046 - 013- 3 6 I Q Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
Rc>JAL-E> P►2SCA l � i
OWNER:Name(Fee Simple Titleholder): ��L� ,51%--VCR PA�0w f yPhone#: r/I�7Z'1 • b7%3
Address: 4 L �f-"'► �Nr0J 1� h
City:M[TNyKI SIA�rL State: FL- Zip: 3 CS
Tenant/Lessee Name: Phone#:
Email: P `
CONTRACTOR:Company Name: b � -� Phone#: J
Address: //it M S�
City: lnr,� >I, I i _State: Zip:-P,;?
Qualifier Name: PA Ute Jed koi Phone#: fi
State Certification or Registration#: (e I"(J-W Z- 2 ) Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State:
Value of Work for this Permit:$ 30P ao Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition
Description of Work: RC -� K IFD4t-11� S r�K
-Specify color of color th►
Submittal Fee$ ,-a' I-) Permit Fee$ 0 G / _ CCF$ 0- GG CO/CC$
Scanning Fee$ 9 • Radon Fee$ °W DBPR$ Notary$_
Technology Fee$ 9 - Training/Education Fee$ ® ° Double Fee$
Bond$
Structural Reviews$ pp cc�
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 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 in coon which occurs seven (7J s after the building permit is issued. In t bsence of such posted notice, the
inspection 1 not b approv d7reins a ion f e will be charged.
Signature
Signature 10114
OWNER r AG T CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
_day of JU�L_ .20 p ,by day of 57UII IS ,20/- , by
who is personally known to ��PP :75k. ,who is personally known to
me or who has produced FL M\10K as rJr,e or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: A Sign:
Print: Print:
JORGS ROSEAU- JOR"Rosmw --
Seal: }• rewCOMMMMS"119 �s Seal: pMcommssmamme-.
EXPIRES May 4 9018 EXPIRES May 4 018
APPROVED BY I Nd� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
5k{ORE'
Miami shores Village
Bull milli"
Building Department
L �, `� 10050 N.E.2nd Avenue
LORIDA 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:
�er
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this 17 day of �,� ba g ,20
By__e F ( �@ F�,s, -1 who is personally known to me or has produced
L_ as identification.
Notary: tecsr
IWD ESAR rWos
SEAL: SE a+00t
Aut�Us,I?,=7
ed Pub9c Undem
DECONEX, INC.
233 Madeira Street
Coral Gables, FL 33142
786.443.9590
June 17, 2016
State of Florida
County of Miami Dade
Before me this day pared V PC tJ I � J n �n who,
being duly sworn, depose says :
That he or she will be the only person working on the project located 249 Grand Concourse, Miami Shores,
FL 33138.
Sworn to (or affirmed)and subscribed before me this 11 day of ryA6. 20 X11, by
Personally know
Or produced identification
Type of identification produced
rt'o 1-7poi?
BXP ons
rint,Type or Stamp Name of Notary