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FW-19-280Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Permit ivy.: FW-02-19-280 Permit Type: Fence/Wall Work Classification: Ornamental/Metal Permit Status: Approved Issue Date02/08/2019 Expiration: 08/06/2019 Parcel Number 10505 NE 3RD CT, Miami Shores, FL 33138 1122310130280 Contacts CYNTHIA COLON Owner 10505 NE 3 CT, MIAMI SHORES, 33138 Home: 3059788230 HOME OWNER Contractor HOME OWNER Description: ALUMINUM GATES (2) MANUAL Valuation: $ 500.00 Inspection Requests: Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Notary Fee $5.00 Planning and Zoning Review Fee $35.00 Scanning Fee $9.00 Technology Fee $2.50 Wire and Wood Fence Fee $50.00 Total: $156.30 Building Department Copy Payments Date Paid Amt Paid Total Fees $156.30 Credit Card 02/08/2019 $156.30 Amount Due: $0.00 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 regulatingS ru and zoning. Futhermore, I authorize the above named contractor to do the work stated. Signature: Owner / Applicant / Contractor / Agent February 08, 2019 Page 2 of 2 Miami Shores Village Building Department F EB 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 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING I FBC 20 j �Q Master Permit No. V w N { Q l - Gcc) Sub Permit No ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: tJ Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Address: \ ©s 0S 3Q6 City: qv�(M ,�l1�ScP S State: lc- one#: 3>5S- 0 S r 8'2 3,0 Tenant/Lessee Name: 1N�1-1 _ Phone#: Email:��' �C-D\D`p CW '� M611 l /� oyti CONTRACTOR: Company Name: Rom Phone#: Address: City: State: Qualifier Name: Phone#: State Certification or Registration #: Certificate of Competency #: DESIGNER: Architect/Engineer: p: Address: City: State: Zip: i Value of Work for this Permit: $ S® Square/Linear Footage of Work: 1 { i 2 PA t Type of Work: ❑ Addition ❑ Alteration New \ ❑ Repair/Replace ❑ Demolition Description of Work: 5 Y'j \ Specify color of color thru tile: Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $, Structural Reviews $ Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) • t F Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 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 he approved andov reinspection fee will be chm-ged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrumenMuCkYUk cknowledged beforerr me this day of20 I by 01 b 0" whcoI rsonally known to me r who has produced rIV�YI � A S `P as who did-talfaan oath. C: The foregoing instrument was acknowledged before me this day of 20, by who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: as Sign: w Sign: Print: N 6AC f i Print: Seal: Seal: y;WyPRIETO COMMISSION 0 FF 214031 A EXPIRES: March 2 , 2019 nde�w hers ********** *il�iifh184** � APPROVED BY �17tePlans Examiner llr-Zoning Structural Review Clerk (Revised02/24/2014) Miami Shores Village Building Department SURVEY AFFIDAVIT STATE OF (FLORIDA) COUNTY OF (DADE) 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 The undersigned Affiant, 0, VA 7V 1 - does hereby attest that (Property owner) C The attached survey, performed by Q()� \N, eI s- `� ' � nA 11 (Name f st:rvy is company) For address: �s o_t►V 3� l.r Performed on ` �11-06 (date of survey) is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a•survey less than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The'Affiant further understands that the existence of any such structures may affect final inspections as applicable to this or other permits. Fu her, A, et Property Owner Signature Property Owner Print Name SWORN TO AND SUBSCRIBED before me this D� d of �Tvor%A �01 °1 Affiant is personally known to me, produced i V� r lioj Revised on 5/22/2009/ Revised on 6/12/09 Q..�'� � cl� 0 v\00 .;;;: dv'•, YANADY PRIETO 4 MY COMMISSION # FF 214031 i,,v ,A, ;•a EXPIRES: March 25, 2019 'RF'` Bonded Thru Notary Public Undenurlterb �F � __ - .� . � `.. m - ^ 7th STREET, SUITE 202 )RIDA 33126 T;(305)264.2660 264.0229 o \� J Cn Q Q W g W u- QCc <o < F U Z rC y o u_ C a u a ( ? Cl] l) 1 _ Nova ortitnri SURVEY NO. tsu LAND SURVEYORS SHEET NO. � OF BOUNDARY SURVEY Scale 1" of 0 5582 N.W. TTH STREET; SUITE 202 \ Nova_ Surveyors, I Inc. 0-0003902-2 MIAMI, FL 33128SURVEY NO TELEPHONE: (305) 264.2660 FAX: (305) 26"229 . SHEET NO 1 OF 21f DRAWN BY: A.A. LAND SURVEYORS {{ -SURVEY OF LOT-18, BL'OCK 11,-OF FIRST ADDITION TO PASADENA PARK, ACCORDING TO THE PLAT THEREOF -AS RECORDED IN PLAT BOOK 6, PAGE 82, OF THE PUBLIC RECORDS OF MIAMI-DADE COUNTY, FLORIDA. PROPERTY ADDRESS: 10505 NE 3 CT, MIAMI SHORES, FL 33138 FOR: CYNTHIA T. COLON LOCATION SKETCH Scale 1" = NT.S. / SUBJECT PROPERTY w Sai 0'119 C T, _ I ABBREVIATION AND MEANING LEGEND TYPICAL A = ARC FNIP. = FEDERAL NATIONAL INSURANCE RAID. = RADIUS OF RADIAL —OH- OVERHEAD UTILITY LINES A/C = AIR CONDITIONER PAD PROGRAM RGE. = RANGE A.E. = ANCHOR EASEMENT IN.&EG. = INGRESS AND EGRESS R.P. = RADIUS POINT C.B.S. = WALL (CBW) A/R = ALUMINIUM ROOF EASEMENT R.O.E. = ROOF OVERHANG C.L.F. = CHAIN LINK FENCE A/S = ALUMINIUM SHED L.F.E. = LOWEST FLOOR ELEVATION EASEMENT ASPH. = ASPHALT L.M.E. = LAKE MAINTENANCE EASEMENT RAN = RIGHT-OF-WAY -0--0- I.F. = IRON FENCE B.C. = BLOCK CORNER L.P. = LIGHT POLE SEC. = SECTION B.C.R. = BROWARD COUNTY RECORDS M. = MEASURED DISTANCE S.I.P. = SET IRON PIPE L.B. #6044 - W.F. =WOOD FENCE B.M. = BENCH MARK M/H = MANHOLE SWK. = SIDEWALK B.O.B. = BASIS OF BEARINGS N.A.P. = NOT A PART OF T = TANGENT + 0.00 =EXISTING ELEVATIONS C = CALCULATED NGVD = NATIONAL GEODETIC VERTICAL TWP = TOWNSHIP C.B. = CATCH BASIN DATUM U.E. = UTILITY EASEMENT C.B.W. = CONCRETE BLOCK WALL N.T.S. = NOT TO SCALE U.P. = UTILITY POLE SURVEYOR'S NOTES CH ■ CHORD O.H.L. ■ OVERHEAD UTILITY LINES W.M. = WATER METER 1) IF SHOWN, BEARINGS ARE REFERRED TO AN ASSU" ED CH.B. = CHORD BEARING O.R.B. = OFFICIAL RECORD BOOK W.R. = WOOD ROOF MERIDIAN, BY SAID PLAT IN THE DESCRIPTION OF THE CL ■ CLEAR sees O/S = OFFSET W.S. = WOOD SHED PROPERTY. IF NOT, THEN BEARINGS ARE REFERRED16 = CHAIN LINK FENCE OVH. = OVERHANG = ANGLE .E!. COUNTY, TOWNSHIP MAPS. WLF. IE CANAL MA11h?LNRNCE • •P.B. ■ PLAT BOOK 2) THIS IS A SPECIFIC PURPOSE SURVEY. • •P.C. = POINT OF CURVE L = CENTRAL ANGLE • EASEMENT$ 3) THE CLOSURE IN THE BOUNDARY SURVEY IS ABOVE+ • • • • CONC. - CONCRETE • • P.C.C. = POINT OF COMPOUND CURVE $ = CENTER LINE 1:7500 FT. • *CI' f CONCRETL•PORCN 000600 PL. = PLANTER 4) IF SHOWN, ELEVATIONS ARE REFERRED TO • C.S. -CONCRETE -%LAB • • � • • C.L.S. = PROFESSIONAL LAND � = MONUMENT LINE MIAMI-DADE COUNTY. • •1)D. w VRAINAGE EASEMENT SURVEYOR •D.M.E. ■DRAIAG W*4rENANCE • • • 4'.O.B.. ■ POINT OF BEGINNING BM# ELEV. FEET OF N.G.V.D. OF'19§9. • • • • f.ASEME�j•R• • • • • rwO.C.. = POINT OF COMMENCEMENT • • • •DRIVE = DRIVEWAY P.P. = POWER POLE E 4CR.%ENCROACHMEW• • • • • •FiP.S.. = POOL PUMP SLAB • r}r,%..r fLECTRI�TItANSFORMER PAD • P.R.C. - POINT OF REVERSE CURVE R.F.E. ■ FINISHED FLOOR ELEVATIOPf • • •PRM = PERMANENT REFERENCE P.H. = FIRE HYDRANT • • • • • • MONUMENT • jj.R.FfOUND IRQN PIPE. • • PT. - POINT OF TANGENCY PVMT. = PAVEMENT SURVEYOR'S CERTIFICATION ; F.I.R. - FOUND IQ ►jQ I HEREBY CERTIFY: THAT THIS "BOUNDARY SURVEY" OF • F.N. =FOUND NAIL • • •PWY - PARKWAY THE PROPERTY DESCRIBED HEREON, AS RECENTLY :P.A.G.%::OUND N/4L•& DISK • • , R. = RECORD DISTANCE SURVEYED AND DRAWN UNDER MY SUPERVISION, • • COMPLIES WITH THE MINIMUM TECHNICAL STANDARDS LEGAL NOTES TO ACOOME NY SKETC OF SURVEY ("SURVEY"I: �. AS SET FORTH BY THE FLORIDA BOARD OF jj PROFESSIONAL LAND SURVEYORS IN CHAPTER THERE MAY BE EASEMENTS RECORDED IN THE PUBLIC RECORDS NOT SHOWN ON THIS SURVEY. FLORIDA ADMINISTRATIVE CODE PURSUANT TO 72.d2472.d2 7, THE PURPOSE OF THIS SURVEY IS FOR USE IN OBTAINING TITLE INSURANCE AND FINANCING, AND SHOULD NOT BE USED FOR CONSTRUCTION PURPOSES. FLORIDA STATUTES. EXAMINATIONS OF THE ABSTRACT OF TITLE WALL HAVE TO BE MADE TO DETERMINE RECORDED INSTRUMENTS, IF ANY, AFFECTING THE PROPERTY. THIS SURVEY IS SUBJECT TO DEDICATIONS, LIMITATIONS, RESTRICTIONS, RESERVATIONS OR EASEMENTS OF RECORD, AND LEGAL DESCRIPTIONS PROVIDED BY CLIENT OR ATTESTING TITLE COMPANY. BOUNDARY SURVEY MEANS A DRAWING AND / OR A GRAPHIC REPRESENTATION OF THE SURVEY WORK PERFORMED IN fI� //��•� THE FIELD, COULD BE DRAWN AT A SHOWN SCALE AND / OR NOT TO SCALE. BY: - •��V'`i EASEMENTS AS SHOWN ARE PER PLAT BOOK, UNLESS OTHERWISE SHOWN. T;C (11A E L THE TERM "ENCROACHMENT' MEANS VISIBLE AND ABOVE GROUND ENCROACHMENTS. ARCHITECTS SHALL VERIFY ZONING REGULATIONS, RESTRICTIONS AND SETBACKS, AND THEY WILL BE RESPONSIBLE FOR SUBMITTING PLOT PLANS WITH THE CORRECT INFORMATION FOR THEIR APPROVAL FOR AUTHORIZATION TO AUTHORITIES IN NEW CONSTRUCTIONS, UNLESS OTHERWISE NOTED. THIS FIRM HAS NOT ATTEMPTED TO LOCATE PROFESSIONAL LAND SURVEYOR NO. 2534 FOOTING AND/OR FOUNDATIONS. STATE OF FLORIDA (VALID COPIES OF THIS SURVEY WILL BEAR THE EMBOSSED SEAL OF THE ATTESTING LAND ' FENCE OWNERSHIP NOT DETERMINED. THIS PLAN OF SURVEY HAS BEEN PREPARED FOR THE EXCLUSIVE USE OF THE ENTITIES NAMED. SURVEYOR). HEREON, THE CERTIFICATE DOES NOT EXTEND TO ANY UNNAMED PARTY. • THE SURVEYOR MAKES NO GUARANTEES AS TO THE ACCURACY OF THE INFORMATION BELOW. THE LOCAL F.E.M.A. AGENT SHOULD BE CONTACTED FOR VERIFICATION. THE FNIP FLOOD MAPS HAVE DESIGNATED THE HEREIN DESCRIBED REVISED ON: LAND TO BE SITUATED IN ZONE: X COMMUNITY/PANEUSUFFIX: 120652 0093 J DATE OF FIRM: 07/17/1995 BASE FLOOD ELEVATION:. REVISED ON: CERTIFIED TO: CYNTHIA T. COLON N GUILLERMO PEREZ, ESQ GE /B ATTORNEYS TITLE INSURANCE FUND, INC. ��` AR �F...'�atiFlcgr y I �l AMERICA'S WHOLESALE LENDER, ITS SUCCESSORS AND /OR ASSIGNS, AS THEIR a O NO. ''• * Hr E INTEREST MAY APPEAR o : : 4 Gr� {0, , a y I 0, �, �'., STATE OF ? 0�9 , v 9!y' 'OLORIOP'.'o� 9J `��ND S,u SURVEYOR'S SEAL S t i z Z* Uoitf r-A&vc IRM Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHAIN LINK FENCE DESIGN DETAIL (ACCORDING TO THE F.B.C. SECTION R4408.11) TABLE R4408.11 CHAIN LINK FENCE MINIMUM REQUEREMENTS Fence Terminal Post Line Post Dimensions Terminal Post Line Post Concrete Height (ft) Dimensions (in inches) Concrete Foundation Size (in inches) (o.d. X wall thickness) Foundation Size (diameter X depth) (o.d. X wall thickness) (diameter X depth) (in inches) (in inches) UP t 2 3/8 x 0.042 1 5/8 x 0.047 —&x-2 ver4to6 1 /8x0.055 10x24 1 8x24 For SI: 1 inc = 25.4 mm. NOTES: 1. This table is applicable only to fences with unrestricted airflow. 2. Fabric: 12 Yz gauge minimum, Black or Green. 3. Tension bands: Use one less than the height of the fence in feet evenly spaced. 4. Fabric Ties: Must minimum the same gauge of the fabric. 5. Fabric Tie Spacing on the Top Rail: Five ties between posts evenly spaced. 6. Fabric Tie Spacing on Line Posts: One less than height of the fence in feet, evenly spaced. 7. Either top rail or top tension wire shall be used. 8. Braces must be used at Terminal Posts if top tension wire is used instead of Top Rail. 9. Post Spacing: 10 foot (3m) on center maximum. 10. Post shall be embedded to within 6 inches (152 mm) from bottom of the foundation. 11. In order to follow the contour of the land, the bottom of the fence may clear the contour of the ground by up to 5 inch (127 mm) without increasing table values to the next higher limit. NOTICE TO PROPERTIES WITH POOLS: •••• If the fence is to meet the criteria as a pool barrier, the fence shall not be climbable and all rail$ mUt be placeVIRding the inside of the property. Pedestrian gates shall have self -closing and latching devices installed*A thrlminimD%oFV" above ground. For further details see Section R4401.7.1 of FBC. • • •; • • • `• •••••• • CONCURRED Created on 5/22/2009 MLDV;06/22/2015 •••• • • •••• ••• • •• • • •• • • • z� 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: L'A k COl () DATE: ADDRESS:Ldo G17 3Q-d O'�- M��V�1 S���S 4f(.531.30 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. 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. 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 C 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 license numbers on permits and contracts. Initial 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 built or 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 b -county or municipal ordinance. InitialT 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. 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 -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. 0 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 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.mvfloridalicense.com/dbpr/pro/cilb/`index.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: Sas cN 3r� 2 M IOlml JVj ittq S� I J 8 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_Z 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 CArVei!M.20 By OWAS(h6r) " li`eh who was personally known to me or who has rry�R�I CgVkS-C�V�S—� as identification. OWNER N y ,,tip+` h YANADY PRIETO MY COMMISSION # FF 214031 EXPIRES: March 25, 2019 ,:•. '•.;;RF;�°:' Bonded Thru Notary Public Underwriters