RC-16-2873 Permit a C- 0- 6 -873
vy�+4ttEs y,� Miami Shores Village Petmit 7ype::Ftel,ld Inial Construction
10050 N.E.2nd Avenue NE
_ „...� Q1109sW tooft Alteration
Miami Shores,FL 3313&0000
tit etu "QVED
Phone: (305)795-2204
Aivt`
Expiration: 05/03/2017
Issue lti a .111412016
Project Address Parcel Number Applicant
1350 NE 101 Street 1132050230020 _ DIRK&ELIZABETH PETERSON
Miami Shores, FL Block: Lot: i
Owner Information Address Phone Celt
DIRK&ELIZABETH PETERSON 1350 NE 101 ST
MIAMI SHORES FL 33138-2611
Contractor(s) Phone Cell Phone Valuation: $ 1,200.00
HOME OWNER
Total Sq Feet: 14
Approved:In Review Available Inspections:
Comments:
Inspection Type:
Date Approved::In Review
Final PE Certification
Date Denied: Window Door Attachment
Type of Construction: INSTALL/DELIVER ABOVE GROUN Occupancy:Single Family Framing
Stories: Exterior: Insulation
Front Setback: Rear Setback: Drywall Screw
Left Setback: Right Setback: Window and Door Buck
Bedrooms: Bathrooms: Fill Cells Columns
Certificate Status: Review Building
Plans Submitted:Yes Review Electrical
Certificate Date: Additional Info:
Review Planning
Bond Return: Classification:Residential Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Structural
CCF $1.20 Review Mechanical
Invoice# RC-10-16-61746
DBPR Fee $2.00 10/21/2016 Credit Card $50.00 $71.20
DCA Fee $2.00
Education Surcharge $0.40 11/04/2016 Credit Card $71.20 $0.00
Notary Fee $5.00
Permit Fee $100.00
Scanning Fee $9.00
Technology Fee $1.60
Total: $121.20
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
constructio nd zoni Futhermore,I authorize the above-named contractor to do the work stated.
November 04, 2016
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
November 04,2016 1
p 2�1i� RECEIVED
-c Miami Shores Village
Building Department OCT 21 2016.
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 T4
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20(Lf5
BUILDING Master Permit No. ao— 28,13
PE IT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
Ip CONTRACTOR DRAWINGS
JOB ADDRESS: ` i s o !�I C I® ���L�e t (�
City: Miami Shores County: Miami Dade Zip: 3 .3 1 3b
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: jConstruction Type:'n Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): JI r� �Q '-tom �5Phone#: 3OS� 3 J 3
Address: 1 -3s® d ( O �
City: I „l ,5Ly l j SkDv e-5 State: Zip:
Tenant/Lessee Name: Phone#:
Email: (�
CONTRACTOR:Company Name: E/Y— Phone#:
Address:
City: State Zip:
Qualifier Name: Phone#:
State Certification or Registration M Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ �® %ins-vtlk-Rqu re/Linear Footage of Work:
Type of Work: ❑ Addition
❑ Alteration 1:1 New ❑ Repair/Replace Demolition
Description of Work: hsl�(` deWydly- ay eW V-)i'
caq&'
Specify color of color thru tile:
Submittal Fee$ 'C� Permit Fee$ 11 Vd CCF$ 1 - 2C2 CO/CC$
Scanning Fee$ —1 'CZ Radon Fee$_oc- �� DBPP1R. $ - Notary$ �•}�
Technology Fee$ C�0 Training/Education Fee$ 7 Double Fee$ Z
Structural Reviews$ Bond$ 30
TOTAL FEE NOW DUE$ U• zo
(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 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 Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
,�_day of 0C247- '20 (4:� ,by day of .20 by
—W rsonally known to who is personally known to
me or who has produced A -tQ Vf—.L1 OEPL a5 me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY P LIC: NOTARY PUBLIC:
Sign• Sign:
Pri Print:
Seal: �ogPnv a�®yam Notary Public State of Fbrida S I:
Sindia Alvarez
e� My Commission FF 15050
�r®Fr,F,o� Exp' s09/0312018
APPROVED BY Plans Examiner G u Zoning
Structural Review Clerk
(Revised02/24/2014)
,5 0 ` Miami Shores Village
Nag@� Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME: ems' i ATE: to LZ 1 1�
ADDRESS: [ J bo VV, (V ( Sf 1 '3 3 1
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida,F.S 489.103(7).And I have
read and understood the following disclosure statement,which entitles me to work as my own contractor;I further understand that I as the owner
must appear in person to complete all applications.
State Law requires construction to be done by a licensed contractor.You have applied for a permit under an exception to the law.The exemption
allows you,as the owner of your property,to act as your own contractor even though you do not have a license.You must supervise the
construction yourself.You may build or improve a one-family or two-family residence.You may also build or improve a commercial building at a
cost of$25,000.00 or less(The new form states 75,000).The building must be for your own use and occupancy.It may not be built for sale or
lease.If you sell or lease a building you have built yourself within one year after the construction is complete,the law will presume that you built
for sale or lease,which is a violation of this exemption.You may not hire an unlicensed person as a contractor.It is your responsibility to make
sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances.Any person working on
your building who is not licensed must work under your supervision and must be employed by you,which means that you must deduct F.I.C.A and
with-holdings tax and provide workers'compensation for that employee,all as prescribed by law.Your construction must comply with all
applicable laws,ordinances,buildings codes and zoning regulations.
Please read and initial each paragraph.
1. 1 understand that state law requires construction to be done by a licensed contractor and have applied for an owner-builder permit under an
exemption from the law.The exemption specifies that I,as the owner of the property listed,may act as my own contractor with certain
restrictions even though I do not have a license.
IQ �/?
Initial
2. 1 understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and
is not hiring a licensed contractor to assume responsibility.
Initial_
3. 1 understand that,as an owner builder,I am the responsible party of record on a permit.I understand that I may protect myself from potential
financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name.I also understand that the
contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts.
Initial
4. 1 understand that I may build or improve a one family or two-family residence or a farm outbuilding.I may also build or improve a commercial
building if the costs do not exceed$75,000.The building or residence must be for my use or occupancy. It may not be built or substantially
improved for sale or lease.If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the
construction is complete,the law will presume that I built or substantially improved it for sale or lease,whit folates the exemption.
Initial F 61
S. I understand that,as the owner-builder,I must provide direct,onsite supervision of the construction,e i
Initial
6. 1 understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence.It
is my responsibility to ensure that the persons whom I employ have the license required by law and by county, municipal ordinance.
f-,Initial
r
f
7. 1 understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner-builder permit that erroneously
implies that the property owner is providing his or her own labor and materials.I,as an owner-builder,may be held liable and subjected to
serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property.My homeowner's
insurance may not provide coverage for those injuries. I am willfully acting as an owner-builder and am aware of the limits of my insurance
coverage for injuries to workers on my property.
Initial
8. 1 understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the
work being done.Any person working on my building who is not licensed must work under my direct supervision and must be employed by
me,which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the
Federal Insurance Contributions Act(FICA)and must provide workers compensation for the employee.I understand that my failure to follow
these may subject to serious financial risk.
Initial
9. 1 agree that,as the party legally and financially responsible for this proposed Construction activity,I will abide by all applicable laws and
requirement that govern owner-builders as well as employers.I also understand that the
Construction must comply withal[applicable laws,ordinances,building codes, and zoning regulations.
Initial
10. 1 understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service,the United States
Small Business Administration,and the Florida Department of Revenues.I also understand that i may contact the Florida Construction Industry
Licensing Board at 850.487.1395 or http://www.myfloridalicense.com/dbpr/pro/cilb/index.html
Initial
11. I am aware of,and consent to;an owner-builder building permit applied for in my name and understands that I am the party
legally and financially responsible for the proposed construction activity at the following address:
Oe toy `�.
Initial �S
"�d
12. 1 agree to notify Miami Shores Village immediately of any additions,deletions,or changes to any of the infor ation that I have provided on
this disclosure.
Initial
Licensed contractors are regulated by laws designed to protect the public.If you contract with a person who does not have a license,the
Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial
loss that you sustain as a result of contractor may be in civil court.It is also important for you to understand that,if an unlicensed contractor or
employee of an individual or firm is injured while working on your property,you may be held liable for damages.if you obtain an owner-builder
permit and wish to hire a licensed contractor,you will be responsible for verifying whether the contractor is properly licensed and the status of
the contractor's workers compensation coverage.
Before a building permit can be issued,this disclosure statement must be completed and signed by the property owner and returned to the local
permitting agency responsible for issuing the permit.A copy of the property owner's driver license,the notarized signature of the property
owner,or other type of verification acceptable to the local permitting agency is required when the permit is issued.
Was acknowledged before me this 2.1 day of � -, 20 ( JG
By -T' ►WC.E: +4 VrC4h-.L ho was personally known to me or who has
Produced there License or 0_1eQ as identification.
rospter NO, Notary Public State of FloridaSindia Alvarez
My S �
k .1aFF�Q��R ExpCe 09/03/2018OMMisSion FF 1567 p
OWNER 'NOTARY
t'
Sundance Spas
STATEMENT OF PRODUCT COMPLIANCE
Model year. 2016,domestic(North America 60 Hz)
Factory-Built Electric Hot Tub Products:
0 Series: MaxxusTm,AspenTm, Optima meolm aprilm, MajestaTM,AltamarTm,MadnTm
780 Se '
Series: HamiltonT�,Chelsee ,CertaT", , Doverw, Montclalrw
680 Series: HawthomeTm, HartfordTm, Buriingtonw, Denalilm,Tacomalm, Payton1m, Edisonlm
Select Series: ConstanceTm.Victodalm,
'The models listed above meet the fonowring standards:
• UL 1563(5"h Edition)—Electric Spas, Equipment Assemblies and Associated Equipment
• Can/CSA-C22.2 No. 218.1-M89—Spas, Hot Tubs and Associated Equipment
• FCC part 15 Subpart B Section 15.107&15.109
• Virginia Graeme Baker Act—Sections 1401 -1404
• ASME Al 12.19.8-2007-Suction Fittings for Use in Swimming Pools,Wading Pools, Spas,and Hot Tubs
• ANSI Z124.7-97-Prefabricated Plastic Spa Shells/Uniform Swimming Pool, Spa and Hot Tub Code
• ASTM F 1346-91 -Standard Performance Specification for Safety Coversiand Labeling Requirements for
Al Covers forSw Imming Poo1s,Spas and Hot-Tabs --
• California Energy Commission 2007 Appliance Efficiency Regulations,Califomia Code of Regulations,
Title 20,Sections 1601-1608
• Products cavy the following marks: ETL,USPC
Laboratory Testing Performed at Sundance Spas,Inc.and by:
Intertek Testing Services(ETL) IAPMO R&T CKC Laboratories Inc
25791 Commercentre Dr. 5001 East Philadelphia St. 5046 Sierra Pines Dr
Lake Forest,CA 92630 Ontario,CA 91761 Mariposa,CA 95338
Person Maintaining Records of Compliance:
Tony Sadati
Sundance Spas, Inc.
14525 Monte Vista Avenue
Chino,CA 91709
800-883-7727
www.sundancespas.com
Updated 2-2-2016
o
Licensed&Insured
State.CPC Dam NATIONAL '
INA9TIm fill 111 V1 Vis-Eq
Fw*Owned 8
Opelaled Skm 1871
GUARANTEED VALUE,PRICE&SERVICE...SINCE 1971
11720 Biscayne Boulevard • Miami, Florida 33181 •Telepioe:(305)893-4036• Fax (305)895-4557
SAO" SU f
Customer New Dirk and Lisa Peterson Date: 8-1-16 Salesperson fc
Address: 1350 NE 101 St Phone#(M
City,State,Zip: Miami Shores FL 33138 (0) Lisa 305-333-9955
-_-lisav -ahoo.com (C)
Spa Model: meo Spa Color. Capt Color Coastal
TotalPrice of Spa...............................................
ntfa instant rebate
OPTION&
Ozone Water Purification ................. ........................
Heavy Duty Cover...............................................
ChemieKd...................................................
Delivery&Suet-up within 50 mile radius..............................
Synthetic Cabinet Upgrade Charge.................................
in home orientation ......................
Bluetooth stereo Op ion is$800. ......................
Total Spa With AD Opt
ResponsibiBles:
•Gazebo's DO NOT Inchtde assemby•7hat two is adequate Sales Tax
access to desired location of rowspa.if extra ,cranes,
or special equonent Is needed it Is an additional cost&Is 771E Total
RESPONSOWY OF THE CUSTOMER
•Electrical&hook-up is the CUSTOMER'S RESPOf1.S1811M..
The electrical regtdrenents are 220 00%de�a
Volt. 60 AMP, 3
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Wh%dedlo Irma with ground rod&GM Balance Due(cash or c
•Customer is for all permit cost$6 plus pkm fees,If we deck due upon De vmi
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are are requested to get the permits.
Rx mst be recanted prior to dativerp of spa,or tax will be dlarged. It y Is In Stoo
days the compete b
Approved all / once Two) I
Buyer Date /� E
Buyer
Date
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WE APPRECIATE YOUR BUSINESS
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