PL-19-74Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Issue Date: 06/27/2019
Parcel Number
540 GRAND CONC, Miami Shores, FL 33138 1132060171411
Contacts
Permit NO.: PL-01-19-74
Permit Type: Plumbing - Residential
Work Classification: Alteration
Permit Status: Approved
Expiration: 09/30/2019
DARIK & MARLENIS SMART Owner
540 GRAND CONCOURSE, MIAMI SHORES, FL 33138
Other:3057518127
MODEL PLUMBING CONTRACTOR CORP Contractor
ULISES MORATON
Business: 7863561986
ns ecti
Description: REPLACE SINK IN KITCHEN Valuation: $ 80.00 Ion Requests:
762 4949
Total Sq Feet: 200.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$0.60
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.20
Permit Fee
$50.00
Scanning Fee
$3.00
Technology Fee
$2.50
Total:
$110.30
Payments
Date Paid Amt Paid
Total Fees
$110.30
Credit Card
06/27/2019 $110.30
Amount Due:
$0.00
Building Department Copy
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, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS 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. Futhermore, I authorize the above named contractor to do the work stated.
/ Applicant / Contractor / Agent
Date
June 27, 2019 Page 2 of 2
MOOEL PLUMBING CONTRACTOR i
Ph 786-356-1986
CFC 1429352
Date: 6/27/19
State of Florida
County of Miami Dade County
Before me this day personally appeared UI is" who,
being duly sworn, deposes and says:
That he or she will be the only person working on the project locate at:
540 Grand Concourse Miami Shores, FL 33138
4a-
Contractor Signature
Sworn to (or affirmed) and subscribed before me this day of �� ��+� 201 1
By V U Sic.- 5 yyV� �-1 '*Y-"
Personally know
OR Produced Identification `
Type o lfiq on Produced A
\ a ..MYco
Print, type or Stamp Name of Notary
Miami Shores Village v, �.,
Building Department -, i l 0�9
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 4
Tel: (305) 795-2204 Fax: (305) 756-8972 Z
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20 �cjq-73
BUILDING Master Permit No. - G
f(
PERMIT APPLICATION Sub Permit No. ? L 1 � 4
BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
5OLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR
JOB ADDRESS: '5- 0 CKv-fj,—A carjccm rtsc—
DRAWINGS
City: Miami Shores County: Miami Dade Zip: 13131ti
Folio/Parcel#: Is the Building Historically Designated: Yes NO X
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): V, c\ r-t— Phone#: 3�5=-a`t� y34X
Address: -5-46 G-ra Ce,.icourrc-
City: C FNe-r es State: FL— Zip: 331 3p
Tenant/Lessee Name: Q Email: ar ►'v-exr^cl-kUZ
hone#: —
11
CONTRACTOR: C� G I ompany Name: C�A V rL k Cc-,� rc-+-cPh `one#:
Address: `�nt I � � � S�J � 1:2�1 IS+ 1
City: ' ' `t`'^'� State: c Zip: ��
Qualifier Name:
State Certification or Registration #:
Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: p� City: State: Zip:
Value of Work for this Permit: $ C/ ass: Oy ' W Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑\ Alteration ❑ New ,J Repair/Replace ❑ Demolition
Description of Work: Q(2 `CG'�
1 V
Specify color of color thru the:'
Submittal Fee $ v-- Permit Fee $ CCF $ CO/CC $}
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
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 after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved a a reinspection fee will be charged.
Signatu Signature
OWNER T CONTRAC OR
The foregoing instru
before me this
day of fc p4a rl: 20 _/9 by
who is personally known to
me or who has produced `—_ _ as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: `
Print: �YpCI✓unJN•
Seal:
�"
GRACE RUBY SARANGO
•
Notary Public - State of Florida
Commission r GG 257494
• orc�•.:
My Comm. Expires Sep 11, 2022
The foregoing instrument was acknowledged before me this
day of 10140420 by
who is p_ersonally.,known_to.
me or who has produced 1`1I SeS 0101'G-�OI't as
identification and who did take bn oath.
NOTARY PUBLIC:
Sign:
Print: 6l Sar
Seal:
4►a''•
GRACE RUBY SARANGO
Notary ?uo is State o` F orida
Commission : GG 257494
or r�
My Comm. Expires Se,- 11, 2022
Bonged through ratiora. Notary Assn.
APPROVED BY I AS-'�} Plans Examiner
Structural Review
Zoning
Clerk
(Revised02/24/2014)
Notice to Owner — Workers' Corn
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
nsation Insurance Exemation
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. r>1 i
Signature:
Owner
State of Florida
County of Miami -Dade q
The foregoing was acknowledge before me this , 1 day of , 20 ( .
JV��1 who is Banally icnnwn to me or has produced
\ 0 1171 n)jfication.
Notary: . a . . 99�%.
SEAL:
c>.Cp9, cn=
.Gi tP.i Q. =i �2 a