DS-13-1349 �`
�' �' -�- Mia
S mi Shores Village
Building JUN 12 2 13
J , u lding Department _
\u 10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel: 305 795.2204 Fax:( ) .(305)756.8972
(� INSPECTION'S PHONE NUMBER:(305)762.4949
b FBC 20 LC:)
BUILDING Permit No.1151 -3 - 1349
PERMIT APPLICATION Master Permit No.
Permit Type: BUILDING ROOFING
JOB ADDRESS: U D o Al G 1 72 PLIE
City: Miami Shores County: . Miami Dade Zip: 3
Folio/Parcelk
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Sim ) S�l i~lG�- �t �,� Phone# S,q to—q`�
Simple Titleholder :
P
Address: 1 Z-o D K Q I fit°
City: N 1u _S V1 ol/-p-S State: '
Zip.
Tenant/Lessee Name: Phonek
Email: CA-A-rZ-C>r
CONTRACTOR:Company Name: PEDYKA ll W Phone#: +
Address:
City: State: zip:_ d
Qualifier Name: Phone#:
State Certification or Registration#: Certificate of Competency#:
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer: onek
l
i
Value of Work for this Permit:$ f 0 0 150 Square/Linear Foota of Work:
Type of Work: ❑Addition OAlteration ONew ORep /Replace ODemolition
Description of Work: vvjS 6\A
d V1ytj' a!4 . Ice' w-e ayk1 1'x .�o I a LP- tVA
Color thru tile:
***************************************Fees*** *******************s********************
Submittal Fee$ Permit Fee$ ) CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
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 ELECTRICAL WORK,PLUMBING, SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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 1
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 b pr ved and a reinspection fee will be charged.
Signature Signature
Owner or Agent Contractor 1
The foregoing instrument was acknowledged before me this i 11L The foregoing instrument was acknowledged before me this
day of�( �,20-,by C112071 N-4--C'�t-�l day of ,20_,by ,
who is personally known to me or who has produced 4?il0 who is personally known to me or who has produced I
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC• ���\`""' I 1"''//�,, NOTARY PUBLIC:
• p1� ....31d�s'%,
Sign: '\\\� 5 s��� Sign:
Print' = a W = Print:
My Commission Expires: �% 9��Z19 �'�.•
-)4 My Commission Expires:
APPROVED BY ✓"�� Plans Examiner Z 2 t'/ Zoning 1
I
I
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
3
SNOI1Vl1103S'C11JV S1`lY 1'NSI-):T INV 31VIS
Wb3n33 TIV PJ IAA 3014,f IdI'J:)7 OI 103r Ef1S
(� 143 �
7 a19 !
(}� Jd317�JNINOZ
0 VC l C �11
Go 111A SG OU,S lurk:
Buz �� --- _ sl
GL BAL 14770 SW 43rd WAY, SCALE 1"=20' JOB NO: 13n1-025
MIAMI,b M E N S I ONS INC. (3 MNIFFL 31185. FIELD OATS 01-22-2013
PHONE: (305)5724225 TYPE OF PROJECT:
Land Surveying Services FAX: (305)5124914 BOUNDARY SURVEY
9
FOR:CHRISTINA MARISA CRESPI LEGAL DESCRIPTION,
Lot 25,less the West 15 feet and the West 35 feet of Lot 26,Block 2,WATERSEDGE,
PROP.ADD:1200 N.E.91 st TERRA.E MIAMI SHORES,FIL 941' according to the map or plot thereof,as recorded in Plat Book 9;Page 141,of the {
Public Records of MiamFDade Coun ,F_Wdo.
N E, 91st TERRACE
50.00'Total R/W -
- 20'As halt
" o -
Asphalt
15'Parkway w
S�
FND.I.P.1/2- /'M7J FND.I.P.1/2
—LO IDL 70.00' \ NO ID 365.00'
I e� I
I 90 ',j W.M. � I B.C.
11.140' I
I I �
I o/
AsphaltlDriveway
0 o I I
od
o O
o I tl
15.49 I
13 I Q
I
10 40.45' 108S
I L j
N
----
L ,
ONE STORY CBS `o r I
m RESIDEMCE#1200 N o I t
tiny It "C m I
V J O r I O
� � s c F < I E.M.` r
E
I 42.50' I
PLad 31.69
7Ji�?�J�il Pum
7'b-VV /_J 13.
7 T/ v
I
I
D Q) oncr t o
B9.
FND.I.P.1/2° 70.00' -ND.I P 1/2' J
NO ID) W.P.P. IND IO)
15',Asphalt
N.E. 91'st STREETCHRISTINA MARRISA CRESPI.IED .
SURVEYOR's NOTES: PRIMARY RESIDENTIAL MORTGAGE,INC.,ITS
1.)THE SURVEY OF THE PROPERTY SHOWN HEREON IS IN ACCORDANCE WITH THE SUCCESSORS AND/OR ASSIGNS.
DESCRIPTION FURNISHED BY CLIENT. GUARANTY TRUST E:TITLE,INC. _
2)UNLESS A COMPARISON IS SHOWN,ALL GEARING,ANGLES AND DISTANCES SHOWN FIDELITY NATIONAL TITLE INSURANCE COMPANY.
3 ARE THE SAME AS POWNIAT VALUES. ABBREVIATIONS:
1 RECORHE DED
SHUMBERAHERE ON WERE NOT NONTCTEDFOAND THE EASEMENTS OR OTHER SWR-SMeweq CBS--CoipeM Bb4 SI—W=C,.in LMk Fero,
RECORDED ENCDMBERANCES NOT SHOWN ON THE PLAT AND THE SPARE,IF ANY MAY PL•RopM Une.OUE'OreYnppee UMyEuemeM,IF bon Pye,
NOT BE SHOWN ON THE SKETCH. PK}Ai ConCManer Petl,P,A FopMCamu,DM•ONeE NOM,
4.)UNDERGRAUNO PORTIONS OF FOOTINGS,FUNDATIONS OR OTHER IMPROVEMENT WiF=W.E"',PE9 Re�Maae,Cl=CIvu,6A bon Rra,UE•Vliy
WERE NOT LOCATED. Faummrp,CONC=Coit SMb,PAY+F6ftN Wry,DE=drop EewnanA
5.)FENCES TIESARE TO THE CENTER LINE OF THE SAME. GL=CeMm Lia,a OMmtler,TYP-Typbl,W Menvea,R•RewrMtl,
6.1 WALL TIES TO THE FACE OF THE SAME. ENCS Emoetlmew,LOMP=CampMx,0.9Rp Wphe1,ILA Nvtl d DMC,
TIELEVATNOESS ENSHOWN
EARE
BA ED ON NATIONAL GEODETIC VERTICAL DATUM ��FFE.r Rm,E-SOn,DS•O!W'PN Powe P.W.
'I
) wetm MNar,MPP=WooJPow,r PMe,
8.)THERE NO ABOVE GROUND ENCROACHMENTS OTHER THAN THOSE SHOWN. E.Kma dIM W.I.M.F=k1eMl Feea,P.F=PMetic Fro,DME.=Divbope
McWemroEeemNM,CM.E.= .M"—
M. 6eemeN,LMF.gaks
9)TH/S SURVEYIS FOR MORTGAGEPURPOSES ONLY,NOT TO BE USED FOR Neroro EaumM,ME.=AYinennae bumetl,e.C.=Bbrk Corr�r, )
CONSTRUCTION PURPOSES.
1111 N1.*
(FLOOD ZONE INFORMATION) �`.—BlamoreukWrAww..e>=ne,w.kLWe.er.e.rrm
ZONE:-&E--COMM:120652 PANEL12U86C0306 SUFFIX L DATE 9-1 1-2009BASE:8.00'
NOTE DETERMINATION OF FLOOD ZONE LINES WERE BASED ON SCALING OF FEMA MAP LISTED ABOVE A4mMNeil'a.cm..nev wcrF`.mm,�'svaiw
NOTE:ALLBEARING HEREON ARE BASED TO THE PLAT BEARING OF
} ON THE CENTER LINE OF PROPERTY LINE.
EASEMENT VIOLATIONS: ❑YES ®NO DAVID L.FLITCH
APPARENT VISIBLE ENCROACHMENTS: ❑YES ®NO REGISTERED LAND SURVEYOR i 4843
STATE OF FLORIDA LB 0006874
COMENTSS
NOTE NOTVPLID WdE3S
SIGNEOMA SEALED SHEET 1 DF 1
t
Miami Shores Village c � ]F--D
Building Department APR 0
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY--: — --
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 1
FBC 20+9
BUILDING Master Permit No. DS I — C,(A
PER T APPLICATION Sub Permit No.
7ILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL
F-]PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: /2—v D �✓E 9
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
I Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): jfW,-/S iAht C11- pi Phone#: a� 2Z) '�30 r
Address: �-
City: i /►I- State: Zip: �� 3
Tenant/Lessee Name: Phone#:
Email: �L //-t ✓'" � -s��-+L-
CONTRACTOR:Company Name:--�jcp �f �rivi ��li�•eY Phone#: �.
i
Address:
City: State: Zip:
Qualifier Name: Phone#: s
State Certification or Registration#: Certificate of Competency#: >
s .A ,i'•1 e,• k a
DESIGNER:Architect/Engineer: Phone#:'
Address: City: State: Zip:
Value of Work for this Permit:$ �.�, Q O U Square/Linear Footage of Work: V�
Type of Work: ❑ Addition ❑ Alterationr
❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: :to V-e L,)\aC`Q -ex of A P"erre i-�
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$' Notary$
Technology Fee$ Training/Education Fee$ Double Fee$,
Structural Reviews$ Bond$
I
# TOTAL FEE NOW DUE$
(Revised02/24/2014)
Bonding Compariy's�N`ame(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City I. ' 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
I
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
rr''__0,,,,`` day of/�,. /1 ri 20 \� by day of 20 by
- 1'rist-,Y'a . M.If�eSDI ,who is personally known to who is personally known to
me or who has produced 3)l(!Wy as me or who has produced as
identificati n an who did e a ath. identification and who did take an oath.
NOT RY UBLIC: NOTARY PUBLIC:
Sign: Sign: s
Print: 6 Print:
Seal: ;gray., NADY PRIEM Seal:
MY C MISSION#FF 214031
%..
P EXPIRES:March 25,2019
Bonded Thru Notary Public Underwriters
******* ********************************************************************
18,
APPROVED BY � Plans Examiner Zoning
I
I
?` Structural Review Clerk
(Revised02/24/2014)
•7 ti.h d
SN0IJ-V_1fI03H CINV S=_1` P/ 'NSI j:1(NV-AlViS
-1VH3n33 1-IV NJ IM 3314 1 ldIN')O O 1103('8f1S
(�� y J.dda ONINOZ
da yl8 0311\oHddd � ..
96ell!A Sa)oyS Iu/e IN —
GLBAL 14770 SW 43rd WAY, SCALE: 1"=20' JOB NO: 1301-025
MIAMI,FL 33185. FIELD DATE: 01-22-2013
DM E N S 10-N S INC■ PHONE: (305)5124225 TYPE OF PROJECT:
Land Surveying Services Fes: (305)512-1914 BOUNDARY SURVEY
FOR' CHRISTINA MARISA CRESPI LEGAL DESCRIPTION.-
Lot
ESCRIPTION:Lot 25,less the West 15 feet and the West 35 feet of Lot 26,Block 2,WATERSEDGE,
PROP,ADD: 1200 N.E.91st TERRACE.MIAMI SHORES.FL 33138 according to the map or plat thereof,as recorded in Plat Book 9;Page 141,of the
Public Records of Miami-Dade County,Florida.
N.E. 91st TERRACE
50.00'Total RNV
20'Asphalt
o - o
� Asphalt
15'Parkway C"! _ a NV 15
30.00' y
365.0FND.I.P.1/2" 7\�t ND.LP.112
T—LNO DL 70.00' NO ID 0'
I 99 W.M. ,�o� I B.C.
I � 11 10�
Qf 'AsphaltlDriveway CN I
C5 q
Cal I O
CD I �
I c-- j 15.40' I
1 0
1 0. ` tri 13_0' -4 I Q
I
1 L \'� `<_ dvetmgV- —— 6.30' I m
{0
40.45'- I 0.85'
I I M L
I N
- — ONE STORY CBS
Fj
m RES/DE1�10E#1200 r- oN A/C - I
Nnr 1N T 1 aJ`� N a7 ��. E.M.` cm � 1
®► ,d - 1 42.50'
r ci I �a
(/ 1 ani U o co
y7 r7 p f�✓��� ICr o I o
Co
Pool Q 1 31.60'
l I Pum II �ZQ I CD
•0 13.
7 a o POOLILL: to
o I
vqp
-v I � C I 30.00' = I
o
I 10) once t o m
I
I . .
L
I 89. I
---- 4'C.L.F. I �a bo" I
FND.I.P.112" FND.I.P.112"
(NO ID) 70.00' o W.P.P. (NO ID)
15'Asphalt
N.E. 91st STREET CHRISTINA MARISAPIED CRE PI.
SURVEYOR'S NOTES: PRIMARY RESIDENTIAL MORTGAGE,INC.,ITS
1.)THE SURVEY OF THE PROPERTY SHOWN HEREON IS IN ACCORDANCE WITH THE SUCCESSORS AND/OR ASSIGNS.
DESCRIPTION FURNISHED BY CLIENT. GUARANTY TRUST Hr TITLE,INC.
2.)UNLESS ACOMPARISON IS SHOWN,ALL BEARING,ANGLES AND DISTANCES SHOWN FIDELITY NATIONAL TITLE INSURANCE COMPANY.
ARE THE SAME AS PLAT VALUES. ABBREVIATIONS:
3.)THE LANDS SHOWN HEREON WERE NOT ABSTRACTED FOR EASEMENTS OR OTHER SWK=Sidewalk,CBS=Concrete Block Structure,CLF=Chain Link Fence,
RECORDED ENCUMBERANCES NOT SHOWN ON THE PLAT AND THE SAME,IF ANY MAY PL=Property Line,DUE=Drainage Utility Easement,IP--Iron Pipe,
NOT BE SHOWN ON THE SKETCH. A/C=Air Conditioner Pad,PIC=Property Comer,DM=Drilled Hole,
4.)UNDERGRAUND PORTIONS OF FOOTINGS,FUNDATIONS OR OTHER IMPROVEMENT WIF=Wood Fence,RES=Residence,CL=Clear,IR=Iron Rebar,UE=Utiky
WERE NOT LOCATED. Easement,CONIC--Conc.Slab,RNV=Right of Way,DE=Drainage Easement,
5.)FENCES TIES ARE TO THE CENTER LINE OF THE SAME. CIL=Center Line,0=Diameter,TYP=Typical,M=Measured,R=Recorded,
6.)WALL TIES TO THE FACE OF THE SAME. ENCR=Encroachment,COMP=Computer,ASPH=Asphalt,NID=Nail&Disc.,
7.)ELEVATION WHEN SHOWN ARE BASED ON NATIONAL GEODETIC VERTICAL DATUM S=Set,FFE=Finish Floor Elevation,O/S=Offset,PIP=Power Pole,
(1929)UNLESS OTHERWISE NOTED. OHP-Overhead Powerline,WM=Water Meter,WPP=Wood Power Pole,
8.)THERE NO ABOVE GROUND ENCROACHMENTS OTHER THAN THOSE SHOWN. E.M.=Electric Meter,M.F=Metal Fence,P.F.=Plastic Fence,D.M.E=Drainage
Maintenence Easent,C.M.E=Canal Maintenance Easement,L.M.E=Lake
9.)THIS SURVEY IS FOR MORTGAGE PURPOSES ONLY,NOT TO BE USED FOR Maintenance Easemement,M.E=MainteO nance Easement,B.0=Block Corner,
CONSTRUCTION PURPOSES. P = oCurvature. Fo I o dentilication.
(FLOOD ZONE INFORMATION) I HEREBY CERTIFY:
Thatthe attached'BOUNDARY SURVEY'of the lands shown hereon Is true and correct'.the
PANEL: SUFFIX: .L DATE-9-11-2009 BASE: �atamylm.wkdgeand1,00 are«mn a.rvcredanddraarnunder mysupervmlonand
ZONE:AE ''COMM: 120652 12086003068.00 direction.This survey compUaser the applkable tMntmum Technical Standards adopted by the
NOTE:DETERMJNATION OF FLOOD ZONE LINES WERE BASED ON SCALING OF FEMA MAP LISTED ABOVE. Administateewm pursprofuant to Chasional pter 472.027,and Fri ppe Stats as coMalnetl In Chapter SJ-17,Florida
Adonis tate BCode, Pte odds Statutes.
NOTE:ALL BEARING HEREON ARE BASED TO THE PLAT BEARING OF
ON THE CENTER LINE OF PROPERTY LINE.
EASEMENT VIOLATIONS: ❑YES ®NO REGISTEREDLAND L.LAND UTCIYFOR#4843
APPARENT VISIBLE ENCROACHMENTS: ❑YES ®NO STATE OF FLORIDA LB#0006874
COMENTS: NOTE:NOTVALIDUNLESS SHEET 1 �OF_j_
SIGNED AND SEALED
i ,
Inspection Worksheet
.Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax:(305)756-8972
Inspection Number: INSP-195421 Permit Number: DS-6-13-1349
Scheduled Inspection Date: July 18,2013 Permit Type: Driveways/Sidewalks/Slabs
Inspector: Rodriguez, Jorge -
Inspection Type: Foundation
Owner: CRESPI, CRISTINA Work Classification: Addition/Alteration
Job Address: 1200 NE 91 Terrace
Miami Shores, FL 33138- Phone Number
Parcel Number 1132050010490
Project: <NONE>
Contractor: HOME OWNER
Building Department Comments
INSTALLATION OF PAVERS ON EXISTING DRIVEWAY Infractio Passed Comments
AND WALKWAY AND PATIO INSPECTOR COMMENTS False.
Inspector Comments
PassedCREATED AS REINSPECTION FOR INSP-193628. DRIVE WAY MUST BE
` 5' FROM PROPERTY LINE 7/15/13
Failed
Correction
Needed
I Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.,
July 18,2013 For inspections please call: (305)762-4949 Page 16 of 20
1
,SNoR Miami shores Village
logo Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OWNER BUILDER]DISCLOSURE STATEMENT
NAME: &All .I DATE:
ADDRESS:
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
i contractor with certain restrictions even though I do not have a license.
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 lice se, hers on
permits and contracts.
Initial
1
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 builtAr substantially
improved it for sale or lease,which violates the exemption.
Initial
5. 1 understand that,as the owner-builder,I must provide direct,onsite supervision of the construction.
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 or
municipal ordinance.
Initial
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. �e/
Initial k/`�
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 with all 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#Nml
Initial
11. 1 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:
Initial
12. 1 agree to notify Miami Shores Village immediately of any additions,deletions,or changes to any of the informati'V 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 day of 20
By C*-t fi?--�57r A-4 6-104LJI who was personally known to me or who has
v-era
Produced there License or
OWNER
�s
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 ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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
inspectionspection fee will be charged.
Signature= Signature d
Owner or Agent Contractor
_ The foregoing instrument was acknowledged before me this r••l The foregoing instrument was acknowledged before me this
day of 20-L3,by 2157/ nom-- l day of 20_,by
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: v�``" r'"''l% NOTARY PUBLIC:
Sign: _=\\\�\ ••4 = Sign:
Print: = a�`� = Print:
My Commission Expires: % 9�OZ19 �'>i.'a , My Commission Expires:
Salk
a
I eA liS���������
APPROVED BY �!J"�� Plans Examiner 77; Zoning
r
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
i
° 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: 111 rll-S'h afl, Cf SD/. . DATE:
ADDRESS: 17-0 L Nr 32 5 I rev A t a S k r—C 3 3 f 3�
Dohereby petition the Village of Miami Shores to act as my own contactor pursuanfto the•laws of the State of Florida,RS 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 yourown 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;.tfie law will presume that you built for sale or lease;"which is-a' violation-6f 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 fhatemployee,`all as prescribedtiy 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.
2. 1 understand that building permits are not required to be signed by'a property owner unless he or she is responsible for the
constructiori and is riot 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,of 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 liven numbers on
permits Arid contracts.
Initial
4. I 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 tie for my use or occupancy.It may
not be built or substanfially 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 bUri
ntially
improved it for sale or lease,which violates the exemption.
Initial
5. 1 understand that,as the owner-builder,I must provide direct,onsite supervision of the construction.
Initial_
6. 1 undefstand 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. G
Initial &
7. 1 understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner-tiuilder permit thats
erroneously implies that the property owner is providing his or her own labor and materials.I,as an owner-builder maybe 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' Old £
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 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 govem oiMe4uilders as well as employers.I also understand thafthe
Construction niustcompiy with all applicable laws,ordinances,'building codes,""and zoning regulations. ///�I(�'�'
V
Initial.
k
10. 1 understand that I may obtain more informationregarding 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 l may contact the
Florida Construction Industry Licensing Board at 850.487.1395 or htto://www.mvBoddelicense.com/dborlaro/cilbfindex.html
Initial
11. 1 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:
Initial'
12. 1 agree to notify Miami Shores tillage immediately of any additions,deletions,'or changes to any of the informatio at 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 employeeofan 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 contractors 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'icceptable to the local permitting agency is required when
the permit is issued.
Was acknowledged before me this / 'day of
By �� �'`�- �/ who was personally known to me'or who has
Produced there License or - r as id�htifi tir A/./,,�
OWNER
i,��� ��an I I S•SSV\`���