PL-18-3555Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
III
issue Dates 41/30/2018
Location Address Parcel Number
295 GRAND CONC, Miami Shores, FL 33138 1132060133600
Contacts
Permit NO.: PL-11-18-3555
Permit Type: Plumbing - Residential
Work Classification: Alteration
Permit status: Approved
Expiration: 05/28/2019
NEIL HART Owner
295 GRAND CONCOURSE, MIAMI SHORES, FL 331382852
Other:3059624547
MODEL PLUMBING CONTRACTOR CORP Contractor
ULISES MORATON
Business: 7863561986
Description: MASTER BATHROOM REMODELING . NEW TOILET - Valuation: $ 4,900.00 Inspection Requests:
76� 494
SINK AND SHOWER WITH SHOWER VALVE
Total Sq Feet: 0.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$3.00
DBPR Fee
$2.57
DCA Fee
$2.00
Education Surcharge
$1.00
Permit Fee
$121.50
Scanning Fee
$24.00
Technology Fee
$4.29
Total:
$208.36
Payments Date Paid
Amt Paid
Total Fees
$208.36
Credit Card 11/30/2018
$158.36
Credit Card 11/29/2018
$50.00
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 gonstruction a6zoning. more, I authorize the above named contractor to do the work stated.
Owner / Applicant / Contractor / Agent Date
November 30, 2018 Page 2 of 2
BUILDING
PERMIT APPLICATION
Miami Shores Village
Building Department NOV 29 018
10050 N.E.2nd Avenue, Miami Shores, Florida 33138__J
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20�1
Master Permit No. �� 1_�30
Sub Permit No. PM
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
�PLUMBIN ❑ MECHANICAL ❑PUBLIC WORKS CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
�331
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): L,f`� ,� nn �!_C4— Phone#:3o Rq6-ea�o /
Address: Za C lJ mc-)4
City: mkt State: Zip:`
Tenant/Lessee
(Name:
� Phone#:
Email: Et,Ij� A(%rh•
CONTRACTOR: Company Name: :HIVl Phone#: —114 ' 35(. .
Address: ( "l ('D sw 3 G 0-ye, ,fir
City: iM ty)-W "'' qq , , n State: �1 IN Zip: 33 15 S^
Qualifier Name: V 11 S4-Sy`� o r4-M ty Phone#: "b - 1%6
State Certification or Registration #: 1 2.°I'��`L Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 44.5 0 Lei Square/Linear Footage of Work:
Type of Work: ❑ Addition
Description of Work: M
❑ Alteration ❑ New
Specify color of color th tile:
S
Submittal Fee $ 0 u 1 Permit Fee $
Scanning Fee $
Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
® Repair/Replace
r
1, Lr . "LIA-1
❑ IDe� olition
+bt l.� S
CCF $ CO/CC $
DBPR $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ 36
LCI
(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
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 and a reinspection fee will be charged.
V
J_
Signature Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
b day of �T. 20 t Dre, by day of 120 � , by
who is personally known to Ses MID YGl WoVisNpersonallly�knnownn to
me or who has produced as me or who has produced 1�1as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sig.
Print: d Y Print:
2q ° `-==�d
044602
Seal: o�`"r' %, IDELL SHORTY Seal: =�: "=
?,P�`� ; State of Florida -Notary Public :,P2, 2020
-,,FOFF�o,•nderwriters
Commission # GG 143708
P c' My Commission Expires
September 17, 2021
Now
APPROVED BY ) Plans Examiner Zoning
Structural Review
(Revised02/24/2014)
Clerk
Model Plumbing Contractor
Date: November 1, 2018
State of FLORIDA
County of Dade -Miami
Before me this day personally appeared ULISES MORATON who, being
duly sworn, deposes and say:
That he will be the only person working the project located at:
295 Grand Concourse, Miami Shores, FL 33138
Ulises Moraton
Sworn to (or affirmed) and subscribe before me this 1 day of November.
2018, by U ks-c s IV loruA�o n
Personally know
OR Produced Identification
Type of ide ' cation Produced 1r;y kv,
No �Y
Y Fbai,,. tF f4031
March 25 4
dGr,JuGNJfIIrfS
Notice to Owner — Workers' Com
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
nsation 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 Z°Ir" day of �J o Vim b 20 18.
By W1 I PSI t i C j1 '�'GY l who is personally known to me or has produced
i't"r l ( as identification - -
oy YANAUY PRIE70
Notary. fA" Mti' C018h 15S'O J # FF 21'031
::
``� EXPIRES: March 25, 2019
SEAL: `� O { ;` 6ecded ll;,u KJrS _ ..c Uroerxn:_:; o-
�4I3°"'r"-�