PW-17-2395Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit
Permit NO. Pte' -10-17-2395
Permit Type: Public Works
Work Classification: Public Works
Permit Status: APPROVED
Issue Date: 10/13/2017
Expiration: 01/11/2018
Parcel Number
Applicant
Owner Information
Address
Phone
Cell
Darren Ockert
445 NE 94th Street
Miami Shores FL 33138
917 573-9022
Contractor(s)
HOME OWNER
Phone
CeII Phone
Valuation:
Total Sq Feet:
$ 4,000.00
0
Scanning: 3
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Notary Fee
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$0.00
$0.00
$0.00
$0.20
$5.00
$100.00
$9.00
$0.80
$115.00
Pay Date Pay Type
Invoice # PW -10-17-65275
10/13/2017 Credit Card
10/06/2017 Credit Card
Amt Paid Amt Due
$ 65.00 $ 50.00
$ 50.00 $ 0.00
Available Inspections:
Inspection Type:
Excavation
Review Public Works
Final Public Works
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 zoy jng Futhermore, I authorize the above-named contractor to do the work stated.
Authorized Signature: Owner / App i�ican
Building Department Copy
/ Contractor / Agent
October 13, 2017
Date
October 13, 2017 1
111111 11111 IIIl111111 11111 11111 11''ll l 1111
:6= N 2O1 r R[_E57671 7
OR BK 30716 Fs 3294 (1Pss)
RFCOR jLL iii 1.,r . i i
HARVEY RUQ+!Ns CLERK OF COURT
M i AMI--DAL)E COUNTYv FLIJk11W
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) IDA 2,(2:0\1 OGILE . i hereinafter referred to as the
owner of the following described property (address): 4-4-5 MC 94- "S -t -2E I miAm% SHOe S
Legal Description Lot 2Od2.) Block 52 Subdivision in SHeees
Folio# It- 32-06-0IL- -os 20 sec---rtGN .2
Requests permission to install (describe work): t RR1G a -s a r\t �� � -1 NG , LAN35cA P iNG,
DalUEtNlerY
Within the public right of way of (address) 4-4-5 NE (14-T" S -1 -2E -ET r „A rill
sHoiZeS rL f '33t3�
IN CONSII ERATION of the approval of this permit by the Village, the owner agrees as follows:
1. To maintain and repair, when necessary, the above-mentioned item(s) installed within the
dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County
to make repairs or maintain said items within public right of way including restoration of
street by reason of the Owner's failure to do so, such expense shall be paid by the Owner
or shall constitute a lien against the above described property until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade
County harmless from any and all liability, which may rise by virtue of permitting the
installation of these items within the public right of way.
3. The Owner does hereby agree to remove or relocate their facilities at their own expense,
within 60 days notice by the Village to do so. Failure to comply with this notice will result
in the Village causing the item(s) to be removed and a lien being placed on the property
and/or assessed against the Owner for all costs incurred in the removal and disposal of
the item(s).
4. The undersigned further agrees that these conditions shall be deemed a covenant
running with the land and shall remain in full force and effect and be binding on the
undersigned, their heirs and assigns, until such time as this obligations has been
canceled by an affidavit filed in the Public Records of Dade County, Florida by the
Village Manager of Miami Shores Village (or his fully authorized representative).
Signature
Owner or Agent
.The foregoing instrument was acknowledged before me this 13
DIME OG Kr d who is personally known to me or who has
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expire
SUE pF FLoFtm
Coe, f\1 a t' , DADf
dof O �fif(L , 20 F , by
produced
ay fiOfr` L
ALEXANDER FRIEDMAN
NOTARY PUBLIC
STATE OF FLORIDA
Comm# FF084158
Expires 2/8/2018
REBY CERTIFY that this ,s a true copy of the
nal hied in this ofhc /.ddy of
Cr/j D A D 20 /.74—
WITNESS my hand and Off ,al Seal.
HARVEY RUVI CER wood and County Courts
AY ozf- D.C.
0/11'\:3'
Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 33138
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village
Name of Applicant (if utility see below): A
o CGc_�2T
or Miami -Dade Property
Permit#:
7V\1
Owner off the following described property:
Legal Description: Lot Block
Subdivision
Folio #;
Address: 4-4S f E Amt St -to -2E
3313S)
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #:
Requests permiss� orp to install (describe work, attach separate page if necessary) in the adjoining right of
way: /lepet:r^artPWat, cti%4 iretoaf-:ovN sySt-414artCi (andsccife cies ;Alex ar.c,
P(antir,1/43 wale .
Type of Work: [" Paving ❑ Utility
f Landscape ❑
Antenna
0 Sidewalk 0
Electric""t Irrigation
❑ Other:
DESIGNER: Architect/Engineer:
Address:
City:
State:
Telephone: Email:
Registration #:
Value of Work for this Permit: $ 470:70
�a6tsw,L I P
''• 1.- i "'JP -'.A
Square/Lineal Footage ofWork.
*****Fees*****
Permit Fee $ 100.00
Notary $ 5 •O Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $ '
Bond $ -- (if required) Total Fee Now Due $
Bonding Company's Name (if applicable):
Bonding Company's Address:
City: State: ZIP:
Application is hereby made to obtain a public works permit to do the work in the right of way 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, regulation construction in
this jurisdiction. I understand that separate permits must be secured for
APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be
done in compliance with applicable laws regulating construction and specifically construction in the
right-of-way.
"WARNING TO APPLICANT: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN
YOUR PAYING TWICE FOR IMPROVEMENTS TO THE RIGHT-OF-WAY. 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 die issuance of a public works permit with an estimated value
exceeding $2,500, 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 the
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 public works permit is issued. In the
absence of such posted notice, the inspection will not be approved and a reinspection will be charged.
Signature Signature
pplicant or Authorized Agent Company/Utility Agent
The foregoin instrumept was ack owledged before The foregoing instrument was acknowledged before
me this day of ( 20 (-by me this day of , 20 by
YYer _ who who
is personally known to rpe or who h produced
.fit 11C-12411 is personally known to me or who has produced
as
identification.
`*' :*1°'EXPIRES: November 2, 2020
; c o?, Bonded Thru Notary Public Underwriters
APPROVED BY:
2017-04-15
as
identification.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
*****************************************
16't Z11`� , Public Works Director, or Designee
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: CLQ N) DATE: /0/6 /i
ADDRESS: 4-4-5 e 81- mkewA1 sHo EL ) 313g
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. I 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.
Initial 6
2. I 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. I 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 co acts.
Initial
4. I understand that I may build or improve a one family or twos -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, which violates the exemption.
Initial
5. I understand that, as the owner -builder, I must provide direct, onsite supervision of the construction.
Initial
6. I 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 or municipal ordinance.
Initial
<�r
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. 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. 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 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. I 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 with all applicable laws, ordinances, building codes, and zoning regulatio
Initial
10. I 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:
44s E 94-114ST2ZE ( NIIAwttSI-to (1 Pt. 33t3Q
Initial
12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the information 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 &".1
day of nc i o (& C61-, 20 l4 •
who was personally known to me or who has
Produced there License or�-- as identification.
O4sr Pu Notary Public State of Florida
NOTARY ? P;: SindiaAlvarez
, My Commission FF 156750
>' '?af0op Expires09/0312018