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FW-11-662Miami Shores Village 10050 N.E. 2nd Avenue NW "`• Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Parcel Number Applicant 11110 NW 6 Avenue 3021360210500 JEAN & BERTHA LAURORE Miami Shores, FL 33168-3312 Block: Lot: Owner Information Address Phone Cell JEAN & BERTHA LAURORE 11110 NW 6 Avenue MIAMI SHORES FL 33168-3312 Contractor(s) Phone Cell Phone OWNER ments: Approved: Denied: of Construction: Wire Fence sification: Residential Fees Due Amount CCF $1.20 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.40 Permit Fee -Wire & Wood $100.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $110.20 Additional Info: REPAIR AND ADD NEW Scanning: 1 Valuation: $ 1,800.00 Total Sq Feet: 100 Pav Date Pav Tvoe Amt Paid Amt Due Invoice # FW -4-11-40642 04/14/2011 Cash 05/18/2011 Cash $ 50.00 $ 60.20 $ 60.20 $ 0.00 Available Inspections: Inspection Type: Final Foundation 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 zoning. Futhermore, I authorize the above-named contractor to do the work stated. May 18, 2011 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy May 18, BUILDING Miami Shores Village Y T P7 T Building Department �:q 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 APR 14 2011 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BY: ..... Permit No. /�6 /—//7 5; ®� PERMIT APPLICATION FBC 20 Master Permit N Permit Type: BUILDING ROOFING -410.3 OWNER: Name (Fee Simple Titleholder):Phone#. .�� - �'.� (jZ - Address:( L City: State: I— Zip: -:�p:� 7' Tenant/Lessee Name: Phone#: Email: 9! JOB ADDRESS: 1► 1 r� %� ,� City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes jp;;i CONTRACTOR: Company Name: Address: City: Qualifier Name: grc State Certification or Registration #: Contact Phone#: Email Address: Certificate of Competency #: Zone: DESIGNER: Architect/Engineer: Phone#: .0 Value of Work for this Permit: $1e� Square/Linear Footage of Work: Type of Work: DAddition DAlteration Description of Work: DNew2epair/Replace ❑Demolition Submittal Fee $ Permit Fee $ Com" ®� CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ lU - L� J My Commission Expires: APPROVED BYI 91/ (Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) 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 4' NAME: _�� rf 1, e �a �„ r_ 'HATE: 1,2 ,2 ADDRESS: r=� Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to 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 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 1, 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 61�2� /, 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 I� 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 ? r ,o 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 dor 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, f 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. 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. Initial ? 6- 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,�L 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.myfioddalicense.com/dbpr/pro/cilb/ind%htmi Initial L_ 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: Initiate 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 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 property 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. q Was acknowledged before me this day of �,, 20 who wasersonall known to me or who has p Y rtt C —AlC-UbLAr �la�a�aon��� ,7`�S3 �Co,g.?.3,2°11 a� I ��gpt7DIR®Cfl,+n�^ °Q4cnffi..�stt eturn t6771 Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Bill To JEAN & BERTHA LAURORE 11110 NW 6 Avenue MIAMI SHORES, FL 33168-3312 Invoice Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795-2204 Fax: (305)756-8972 For Inspections please call: (305)762-4949 Invoice Number: FW -4-11-40642 Invoice Date: April 14, 2011 Permit Number: FW -4-11-662 Bond Number: Comments: Date Fee Name Fee Type Fee Amount 04/14/2011 DCA Fee Calculated $2.00 04/14/2011 Scanning Fee Calculated $3.00 04/14/2011 Permit Fee - Wire & Wood Calculated $100.00 04/14/2011 CCF Calculated $1.20 04/14/2011 Technology Fee Calculated $1.60 04/14/2011 DBPR Fee Calculated $2.00 04/14/2011 Education Surcharge Calculated $0.40 Total Fees Due: $110.20 Payments Date Pay Type Check Number Amount Paid Change 04/14/2011 Cash $50.00 $0.00 Total Paid: $50.00 Total Due: $60.20 Thursday, April 14, 2011