PL-17-393 (2) a
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Miami Shores Village PmtTje Plflmb��»Rientlal
10050 N.E.2nd Avenue N
Miami Shores,FL 33138-0
000
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'APPROVED
Phone: (305)795-2204
'emelt to
Issue Date !1{1 t1" ' Expiration: 09/06/2017
Project Address Parcel Number Applicant
9301 N BAYSHORE Drive 1132050270560
GUY&SELIN KURLANDSKI
Miami Shores, FL Block: Lot:
Owner Information Address Phone Cell
GUY&SELIN KURLANDSKI 9301 N BAYSHORE Drive
MIAMI SHORES FL 33138-
15811 COLLINS Avenue
SUNNY ISLES FL 33160-
Contractor(s) Phone Cell Phone Valuation: $ 1,500.00
ROBAINA WELL DRILLING INC (786)683-7437 (786)683 7437
Total Sq Feet: 0
Type of Work:LAWN SPRINKLERS Available Inspections:
Type of Piping: Inspection Type:
Additional Info:LAWN SPRINKLERS Final
Bond Return: Underground Sprinkler
Classification:Residential Scanning:6 Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $1.20
DBPR Fee Invoice# PL-2-17-62952
$2.25 03/10/2017 Check#:8396 $ 125.70 $50.00
DCA Fee $2.25
Education Surcharge $0.40 03/06/2017 Check#:8383 $50.00 $0.00
Permit Fee $150.00
Scanning Fee $18.00
Technology Fee $1.60
Total: $175.70
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 EL TRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AF ID VIT: I certify Meforegoinginformation is accurate and that all work will be done in compliance with all applicable laws regulating
construction a d oning. Futhermove-named con ractorto do the work stated.
e)C I?d, � March 10, 2017
Autho f Usignature:Own7 Applicant / Contractor / Agent Date
Building Department Copy
March 10,2017 1
Miami Shores Village
P 1
Building Department
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 2014
BUILDING Master Permit No.P� J�
PERMIT APPLICATION Sub Permit No.
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
7&1 PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 01 0 LCUA& vp_ Dr
City: Miami Shores U County: Miami Dade Zia•
Folio/Parcel#: I I -3'�-o 5- 05(0® Is the Building Historically Designated:Yes NO �C
Occupancy Type: Load: Construction Type:: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): Cg V4 I&){I W'&&� L\ Phone#:
Address: 9 Wil-✓` \� LCA
CAA A V'C CQ a 'r
City: State: Zip: 3 ►3 S
Tenant/Lessee Name: Phone#:
Email:
P v r a•,
CONTRACTOR:Company Name: �' Phone#:A ,,
Address: �� J
City: a State: k_ci Z�i-p-:7
Qualifier Name: Phone#: /� � M 7
State Certification or Registration#: o fd Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 1500 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„$, ��- Permit Fee$ yr (�_ CCF$ 2.0 CO/CC$
Scanning Fee$ -Radon Fee$ 2 • Z5 DBPR$ 2 ' ZS Notary$
pp
Technology Fee$ • b0 Training/Education Fee$ 0 . 4-
0 Double Fee$ X
Structural Reviews$ M ly Bond$ \�
TOTAL FEE NOW DUE$ Y p z ._10
(Revised02/24/2014)
t a
Bonding Company's Name(if applicable)
Bonding Company Address
City 6 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
v
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 suNect to attachment. Also,a certified copy of the recorded notice of commencement mus*he posted ct the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature �rt � Signature � a
NER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
J 20 1�
day of UVWC4 20 1� by I4 day of 5 by
(foto Ct S�►,wilo is personally known to Jjpge �!� y�4 who is personally known to
me or who has produced as - me or who has produced LA:• 1 as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign: /^
Print: (:� ( Print: / ' (�/y�C!/`Co� L x4
-id
Seal: El
+".>s ,, MAWCIASiERRA Seal: »"«.., ) OIICHO:5717]
MY COMMISSION FF 224104 •, MYCIl8310N EXPIRES:April 23,2019 YPO Bonded Thru Rotary Public Undervrriters :t = EMREs"�y 26'
•' BmWO Tlau Nomry Pubic
APPROVED BY ° `l.� Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
A
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
Notice to Owner —Workers' Compensation Insurance Exemption
177 _
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 tbree 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,parttime employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS. 1
Signature:
Owner
State of Florida
County of Miami-Dade
The foregoing was ac wledge before me this LP day of 0 220
By GJU G S K; who' ersonally known o me or has produced
as identification.
Notary:
potu.% EL LOPEZ
S * * MY MIAI SS M 1FFOI W
EXPIRES:k aoh 212018
p�"'�amd'`O' BondtdllwBudplR 8�vtoea
n R08AINA WELL DRILLING INC
24425 SW 214 Place HOMESTEAD FL 33031
March 3,2017
Miami Shores Village
Building Department
To whom it may concern,
Before me this day personally appeared JOSE ANGEL ROBAINA who,being duly sworn,
deposes and says:
That he will be the only person working on the project located at 9301 N Bayshore Dr.,
Miami Shores,FL 33138
ier ,
STATE OF FLORIDA
COUNTY OF MIAMI DADE
Swornto (or affirmed) and subscribe before me this 3rd day of March 2017 by �E
• ��I`iAiNrr who is [subscribe
known to me or [ ] produced identification
&uriclr4 oa,Jt`4 4L.
ELVIRALOPEZ
* M1' ION# NIN
Notary
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