DEMO-15-2556Miami Shores Village
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 .544v
FBC 204
BUILDING Master Permit No..DET40 (5- 2556;
PERMIT APPLICATION
BY:
OCT 0 8 2015
Sub Permit No.
❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL
PLUMBING n MECHANICAL (PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
�oBADDREss: 671 NE 105 Street
City: Miami Shores
County:
Miami Dade
Zip:
Folio/Parcel#: 11-2231-012-0100
• Is the Building Historically Designated: Yes
Occupancy Type: Residential Load:
NO X
Construction MaSOnryFlood Zone: X BFE: n/a FFE:
OWNER: Name (Fee Simple Titleholder): Robert M More rib''� Phone#: 786-348-3903
Address: 14629 SW 104 Street #498
city: Miami State Zip: 33186
Tenant/Lessee Name: n/a
Email: n/a
CONTRACTOR: Company Name:
Address:
14629 SW 104 Street #498
Phone#: n/a
Phone#: 305-785-5024
City: Miami State:
Qualifier Name: Robert M Moreno
orida
Zip: 33186
Phone#: 786-348-3903
State Certification or Registration #: CGC1520941 / i Certificate of Competency #:
DESIGNER: Architect/Engineer: 1 Phone#:
Address: �.�d City: State: Zip:
Q "6 000 s C
Value of Work for this Permit: $ / a� �,' Square/Linear Footage of Work: r
Type of Work: ❑ Addition
Description of Work:
DPM"/' ieA
Alteration
❑ New ,, epair/Replace Ti Demolition
o‘ f; c -ii
1412" a -alar -A211
re 4. m ! r i o C ,e -.S /L�. f< /f �7 iv I //7 �o h
Specify color of color thru tile:
Submittal Fee $ 5& Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $ `] G
TOTAL FEE NOW DUE $ l ' o 0
(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 c:. ified copy of the recorded notice of commencement must be pos d at the job site
for the first inspection which occurs seven (7) days ,fter the building permit is issued. In the absence of such pos d notice, the
inspectio l not be ap•roved and a reinspection fee ill be charged.
The foregoing instru
�
day of
ic,V ri CC .1111 V'2. W(_L , who is personally known to
ent was acknowledged before me this
, 20 1 S . by
'CON
Signature
R
The foregoing instrument was acknowledged before me this
t4
day of
m
►` , 20 IS , by
i m��Q � who ispersonally known to
me or who has produced as me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:-
ti
I
Sign:
Print:
Seal:
/ r i&.:1 rL VLG‘
` F&,. Marisol Quintana
r`.Commission#FF 172378
:5:
AExpires: OCT 28, 2018
ft„'. 1ST F
********************************* *************************************************************************
t
identification and who did take an oath.
NOTARY PiUBLIC:
Sign:
Print:
Seal:
�qY?v Mar sol Quintana
• '.Commission#FF17Z378
• 4 Expires: OCT 28, 2018
Cg ' BONDED THRU
BONDED THRU ''�. ,,,,,, , 1ST FLORIDA NOTARR LLC
FLORIDA NOTAR LLC
APPROVED BY
c�Plans Examiner Zoning
(Revised02/24/2014)
Structural Review Clerk
•
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� / /
# OWNER BUILDER DISCLOSURE STATEMENT
NAME: :/ a ha
ADDRESS: /O S T" '
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
DATE: 0/11,/r
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 e an unlicensed person as a contractor. It is your responsibility to make
sure the people employed by you have licenses required by sta law nd by county or municipal licensing ordinances. Any person working on
your building who is not licensed must work under your supervisi n a 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 ery,q ee\all as prescribed by law. Your construction must comply with all
applicable laws, ordinances, buildings codes and zoning regulati
Please read and initial each paragraph.
1. I understand that state law requires construction to be done b a licensed contractor and have applied for an owner -builder permit under an
exemption from the law. The exemption specifies that I wner of the property listed act as my own . ntractor with certain
restrictions even though I do not have a license.
Initial
2. I understand that building permits are not required to e signed by a property owner unless he .r she is responsible for the construction and
is not hiring a licensed contractor to assume responsibilit
Initial
3. I understand that, as an owner builder, I am the resp • si. of record on a permit. I understand that I may protect myself from potential
financial risk by hiring a licensed contractor and haul ;the per t 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 a his or license numbers on pe i' -.d contracts.
v
Initial
4. I understand that I may build or improve a one family or two-family residence or a farm outbuildi g. 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 sal • or e, which violates the exemption.
Initial
5. I understand that, as the owner -builder, I must provide direct, onsite supervision of the cons u '.,..
Initial
'‘V
6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise pe ons working . n my building or residence. It
is my responsibility to ensure that the persons whom I employ have the license required by I... . by county or municipal ordinance.
Initial
7. I 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. 1, 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 -build . nd am aware of the limits of my insurance
coverage for injuries to workers on my property.
Initis ....
8. I understand that I may not delegate the responsibility for supervising work to be a licensed con actor 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 forthe ee. I understand that my failure to follow
these may subject to serious financial risk.
Initial
9. I agree that, as the party legally and financially responsible for this proposed Construction ac ' it
requirement that govern owner -builders as well as employers. I also understand that the
Construction must comply with all applicable laws, ordinances, building codes, and zoning regu
I will abi
e by all applicable laws and
Initial
10. I understand that I may obtain more information regarding my obligations as an employer from th • Internal evenue Service, the United States
Small Business Administration, and the Florida Department of Revenues. I also understand that m ontact 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 under ands that I am the party
legally and financially responsible for the proposed construction activity at the following address:
los-
Initial
12. 1 agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any
this disclosure.
Initial
the info
mation that 1 have provided on
V.V r
Licensed contractors are regulated by laws designed to protect the public. If you contract with a pers n wh. • oes not have a license, the
Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may .e 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 C),S) day of 0 C`J-' , 20 1 5
BY
Produced there License or
MO--(\lf3 who was personally known to me or who has
as identification.
Notary Public State of Florida
Sindia Alvarez
My Commission FF 156750
Expires 09/03/2018