FW-15-2555r
BUILDING
PERMIT APPLICATION
/,11LDING ❑ ELECTRIC
F-7 PLUMBING ❑ MECHANICAL
�oBADDREss: 671 NE 105 Street
Miami 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
n ROOFING
❑PUBLIC WORKS
RRCVTVVTT)
OCT os zoic
FBC 2014.
Master Permit No. T- �4l' - 1S-
- 25 SS
Sub Permit No.
❑ REVISJ , EXTENSION ❑ RENEWAL
n CHANGE OF •CELLATION n SHOP
CONTRACTOR 1'J DRAWINGS
5
City: Miami Shores
County:
Miami Dade
Zip:
Folio/Parcel#: 11-2231-012-0100
Occupancy Type: Residential Load:
Is the Building Historically Designated: Yes NO X
Construction Type: Masonry Flood Zone: X BFE: n/a FFE:
OWNER: Name (Fee Simple Titleholder): Robert M Moreno
Address: 14629 SW 104 StreQt #498
Phone#: 786-348-3903
City: Miami (i State: Florida Zip: 33186
Tenant/Lessee Name: Na. Phone#: n/a
Email: n/a
CONTRACTOR: Company Names. r� J. Phone#: 305-785-5024
Address: 14629 SW 104 Street
city: Miami
Qualifier Name: Robert M Moreno
State: Florida Zip: 33186
State Certification or Registration #: CGC1520941
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $
Phone#:
Certificate of Competency #:
786-348-3903
Phone#:
�/ City: State: Zip:
7/ 700 Square/Linear Footage of Work: / OV //
Type of Work: ❑ Addition ❑ Alteration
Description of Work: %m, rota.
7:
-r--r few ''""# y�,€ Repair/Replace n Demolition
L/! /4,7
7� r � � /-e o �
Specify color of color thru tile:
Submittal Fee $
Scanning Fee $
Permit Fee $ CCF $ CO/CC $
Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ ) 't . �0
(Revised02/24/2014)
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Zip
Mortgage Lender's Name (if applicable) .4//A
Mortgage Lender's Address /
City State Zip
Application is hereby made to obtain a permit to
commenced prior to the issuance of a permi
construction in this jurisdiction. 1 understn1410:
FURNACES, BOILERS, HEATERS, TANKS, AIitito,
ER' AFFIDAVIT: I certify that al
bx1
rk and installations as indicated. I certify that no work or installation has
at all work will be performed to meet the standards of all laws regulating
separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
ONERS, ETC
OWNER'S regoing 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. Als', a
for the first inspection which occurs seven (7) d
inspection i no . - apoveand a reinspectio
Signature
"ed copy of the recorded notice of commencement must be pas e• • the job site
r the building permit is issued. In the absence of such posted . tice, the
e charged.
ys a .
ee will
OWNER or AGENT
The foregoing instrument was acknowledged before me this
�I 14 day of SCSI �[_ (Y1,t21 , 20 IS , by
I( bi (�_ C(�'Q-_ _VLO, who is personally known to
._roe or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
1 611 'WA/
Sign:
Print:
Seal:
Signature
CO TRACTOR
The foregoing instrument was acknowledged before me this
1Lk day of SQ r -VA ' , 20 , by
In c,r'10,ho is personally known to
me or who has produced as
mar aYiS6I LVL6L-4,1
'Marisol Quintana
417 , .Cenmicsion# FF172378
.
'TtI ' Expires: OCT 28, 2018
'9?r �BONDED THRUT Y,
r F 1ST FLORIDA NOLLC
*****************************
APPROVED BY
(Revised02/24/2014)
identification and who did take an oath.
NOTARY P),JBLIC:
Sign: 1' ft�U �U.Ml 7 i‘
MO 15; I (i.%>`: l tzz-i
Print:
Seal:
:4- :64;-. Marisol Quintana
.Commission # FF172378
'. 7,` Expires: OCT 28,2018
.
, BONDED EDHRU
1STFLOR� A�y(T�
********************************** *****************
Plans Examiner
Zoning
Structural Review Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME: OCI/ 4/fi7o/.. 4C • DATE: l0 lS"
ADDRESS: li ? / /tiE /O r s/
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 pre)iby law. Your construction must comply with all
applicable laws, ordinances, buildings codes and zoning regulations.
Please read and initial each paragraph.
1. I understand that state law requires construction to be done by a licensed contractor a
exemption from the law. The exemption specifies that I, as the owner of the property liste
restrictions even though I do not have a license.
lied for an owner -builder permit under an
as my own tractor with certain
Initial
2. I understand that building permits are not required to be signed by a property owner unless
is not hiring a licensed contractor to assume responsibility.
Initial
she is respons
le for the construction and
3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understnd that I may .rotect 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,Fiorida and to list his or license numbers on permit d contract
4. I understand that I may build or improve a one family or two-family residence or a farm outbuildi g. I ma also .uild or improve a commercial
building if the costs do not exceed $75,000. The building ov fesidence must be for my use or occupancy. It may not be built or substantially
improved for sale or lease. If a building or residence th4I 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 orI:�whic violates the exemption.
Initial
5. I understand that, as the owner -builder, I must provide direct, onsite supervision of the constructi
1
1
Initial
6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise :..ns working on my building or residence. It
is my responsibility to ensure that the persons whom I employ have the license required by law an. cou ty 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 -b ' .er and am aware of the limits of my insurance
coverage for injuries to workers on my property.
Initial
8. I 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 . nd social security contributions under the
Federal Insurance Contributions Act (FICA) and must provide workers compensation for the empl, --. 1 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 activity,
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 regul
will abide by a I
Initial
applicable laws and
10. I understand that I may obtain more information regarding my obligations as an employer from the nternal Revenue Service, the United States
Small Business Administration, and the Florida Department of Revenues. I also understand that
Licensing Board at 850.487.1395 or http://www.myfloridalicense.com/dbpr/pro/cilb/index.html
Initial
contact the Florida Construction Industry
11. I am aware of, and consent to; an owner-buptfr building permit applied for in my name and under ands that I am the party
legally and financially responsible for the propose construction activity at the following address:
!o �/ A4 / Dr"
as
12. I agree to notify Miami Sho
this disclosure.
Initial
ge immediately of any additions, deletions, or changes to any of
Initial
ation that I have provided on
Licensed contractors are regulated by laws designed to protect the public. If you contract with a perso 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.
t444d signed�n
Before a building permit can be issued, this disclosure statement must be co by the property owner and returned to the local
permitting agency responsible for issuing the permit. A copy of the propert n driver license, the notarized signature of the property
owner, or other type of verification acceptable to the local permitting ager uired when the permit is issued.
Was acknowledged before me this OU day of
,20 I�
ByKOTE, 0 who was personally known to me or who has
Produced there License or FL- t_ tas identification.
Oa P(4
moi+
•
•
NOTARY
Notary Public State of Florida
Sindia Alvarez
My Commission FF 156750
Expires 0010312018