REV-15-8 iami Shores Village —, , --
RECT
uilding Department JAN o6 2016 1
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 '
o Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949 1 —(H
FBC 2014
ING Master Permit
ERMIT APPLICATION Sub Permit No \/1
❑BUILDING ❑ ELECTRIC ❑ ROOFING Ej REVISION ❑ EXTENSION ❑RENEWAL
a
❑PLUMBINGI❑MECHANICAL E]PUBLIC WORKS ❑CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 361 AIC- /01 ST
City: Miami Shores Countv: Miami Dade zip: .33') 3 8.
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): w,,�)&i Phone#: ZpS
Address: 3o ( K)I= 10
City: cqr"11 -Sf.,.oCQ State: ,F-L. Zip: 3'S I X
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name:_ 1dV0Z N/X OODNwC' Sy97_6 5 Phone#:_(345)74W2/x15"
Address: 222/ iV 699 sr Y1711
City:_ /I��p////�� State: /r_L Zip:
Qualifier Name: Cd% 012.0ZC'D Phone#: (LJ`� 7y5�2/ 5
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$_ Square/Linear Footage of Work:
Type of Work: ❑ Addition Alteration ❑ New ❑ /Re Re air lace
p p ❑ Demolition
(Description of,work: Z,vs�n•en+ tri_ �yc� wor Ir! rpos ton
.K I
yftM
Specify cQlor_..of roior_thrurtiie:1 M of
ell- 15
Submittal Fee$_ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ G� Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$ Y
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ 89 • 0
(Revised02/24/2014)
Bonding Company's Name(if applicable) 'J
13
Bonding Company's Address <1-
City State Zip
Mortgage Lender's Name(if applicable)
'e"
Mortgage Lender's Address
City State Zip
.-A
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
.1
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, Sibl\IS, 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$250"0, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien low 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 ai 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.
Signatue�--- Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 1 Cl,
6A)C1e-1-J 1 t
20 a by day of ' jL n) 20 /(,3 by
who is personally known to PZ/Z!S;0Q P�, J ho is personally mown to
me or who has produced -9aQC2- UQE05F—as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign—.
4ARTINEZ
Print: 4�1 Print: 1,� .7"W4 T 1115A, WVA
Seal: Seal: MY COMMISSION#FF228453
VEXPIRES May 07.2019
5pstl P0 Public state of Florida
Notary
FJWV&*40M-yS*fV1rA CAP
Sindia Alvarez
My commission FF 156750
i e5 09!0312018
APPROVED BY tans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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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 1 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 with all applicable laws,ordinances,building codes, and zoning regulation
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.mvfloridalicense.com/dbpr/pro/cilb/index.html
Initial
i
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 fina cia�lly responsible for th ropp?ssedd 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 information that I have provided on
this disclosure.
Initial f�
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.
I
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.
F
,Was acknowledged before me this day of U 20
Y�)S:t.Npr 1
�exGn �rG s�� ,p �=
Y__ �vho was personally known to me or who has
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Produced the a icense or ' o� -(0S � asOentification. o.%
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