DS-19-1218Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Permit NO.: DS-05-18-1218
dL�
Permit Type: Driveways/Sidewalks/Slabs
Work Classification: Addition/Alteration
Permit Status: Approved
Issue Date:09/06/2019 1 Expiration: 02/03/2020
Parcel Number
285 NE 103RD ST, Miami Shores, FL 33138 1121360130440
Contacts
KENNETH & DEENY LORBER Owner CBJ CONSTRUCTION INC Contractor
285 NE 103 ST, MIAMI SHORES, FL 33138 JOHN WIGGINS
7 NW 3 AVE, DANIA BEACH, FL 33004
Business: 9545204405 ASLEN@BMPDINC.COM
Description: INSTALL BRICK PAVERS OVER LEVELING SAND BED Valuation: $ 15,800.00 on Requests:
Inspection titi4949
Total Sq Feet: 2,800.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$9.60
Concrete/asphalt/pavers, slabs, dways,
$175.00
swalks
DBPR Fee
$3.38
DCA Fee
$2.25
Education Surcharge
$3.20
Planning and Zoning Review Fee
$35.00
Scanning Fee
$9.00
Technology Fee
$5.63
Total
$293.06
Payments
Date Paid Amt Paid
Total Fees
$293.06
Credit Card
05/29/2019 $50.00
Credit Card
08/06/2019 $243.06
Amount Due:
$0.00
Building Department Copy
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 accep is permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are require for LECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OW4R FFIDAVIT: rtify that all the fore oing information is accurate and that all work will be done in compliance with all applicable laws
tructi zo o. Futhermo authorize the above named contractor to do the work stated.
Signature: Owner
/ Applicant / Contractor / Agent
Date
August 06, 2019 Page 2 of 2
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
Miami Shores Village
Building p De artment �ECEIVEO 10050 N.E.2nd Avenue, Miami JUL 3 0 201�3
Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2011
Master Permit NoT)s os— 19- I 21v
Sub Permit No.
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
�% �j CONTRACTOR DRAWINGS
'�/
JOB ADDRESS: �(!�✓ �� I D3
Folio/Parcel#: �./ (/541d� Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type::: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): // �/ /io/'!� ► W' Phone#:
Address: zasull /� M 1
City: State: r/017 - Zip: 9/
Tenant/Lessee Name: Phone#:
Email:
i? / nrl�i�/��A_�%li� '/ice
CONTRACTOR:
Address:
City: �.
Qualifier Name:
State Certification or Registration #: Certificate of Competency#/"
DESIGNER: Architect/Engineer: Phone#:
�1-240
Address: TQ//�� City: State:: Zip:
Value of Work for this Permit: $ /jAm • Square/Linear Footage of Work: �V D
Type of Work: ❑ Addition Alterati nNew, / J�' /❑ Repair/Replace ❑ Demolition
j
N
Descri tion of Work: r%� % wy'eTy V e; l eo/ 12 I&
�v
Specify color of color thru tile:
Submittal Fee $ /bl Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $
Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
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
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 se (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved an reins ction fee will be charged.
Signatu
OWNER or AGENT
The foregoinIk instrume t was acknowledged before a this
oh
day/of 20 by
4 who i personally k own to
me or who has produced u as
identification and who did take an oath.
NOTARY PUBLIC:
Signatu
me or who has produc
is personally known to
as
identification and who did take an oath. _
o A EN RODRIGUEZ
Print: Print:
iEx5pires
GG 002423
Seal:
Sea :Myom Jun 14, 2020 MY COMMISSION # GG254808
��F,o�° EXPIRES September 25, 2022
r
APPROVED BY fJ Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
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q-ULAmu''u
Ron Desentls
IlYsdoa: Governor
To protect, promote & improve the health ' Scott A. Rivkws, MD
of all people in Florida through integrated �rt G►� State Surgeon General
state, county & community efforts. HEALTH
Vldm : To be the Healthiest State in the Nation
July 25, 2019
Aslen Rodriguez
2234 Wiley Court
Hollywood, FL 33020
RE: Contingency Letter
Application Document No: AP1418703
Centrax Permit Number: 13-SC-1966554
OSTDS Number:
285 NE 103 St
Miami, FL 33133
NO OBJECTION
Florida Health Mid mi-Dade County
O.S.T.D.S, & ,Well Program
Application No,:!
Date: 2
Signature �9"—�--
Lot:NA Block:NA Subdivision:
Dear Applicant:
This will acknowledge receipt of an application dated 06/12/2019 for a permit to use an existing
onsite sewage treatment and disposal system located on the above referenced property.
Review on 7/25/2019 by Gerard Philizaire.
NO OBJECTION LETTER issued for a new circular DRIVEWAY INSTALLATION AND A
TRAPEZOID SHAPE IN THE BACK.
From a review of your completed application, it has been determined that your existing system
appears to meet the minimum standards of F.A.C. 64E-6 for the proposed use. it is approved for
use with the plans submitted to this office. If this system should fail, causing an unsanitary
condition to exist, steps must be taken to bring the system into compliance immediately.
Department approval of the system does not guarantee satisfactory performance for any specific
period of time. Any change in material facts which served as a basis for issuance of this approval
requires the applicant to modify the permit application. Such modification may result in this
approval being made null and void. Issuance of this approval does not exempt the applicant from
compliance with other Federal, State, or Local Permitting required for development of this
property.
If you have any questions on this matter, please call our office at (305) 623-3500.
Sincerely,
Gerard Philizaire, Environmental Manager
Florida Department of Heakh www.FlaridasHoalth.eom
in DADE COUNTY TWITTER:HealthyFLA
1725 NW 167 St, Opa Lodca, FL 33056 FACEBOOK:FLDepartmentofHealth
PHONE: (305) 623-3500 . FAX: (305) 623-3645 YOUTUBE: tldoh
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: eonp/fi 1-Qi�/� logbeDATE: 2�
ADDRESS: ��J /v /02Ie_S -TL 33i3g
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 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
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. G?��
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 license numbers on permits and contracts.
Initial tot l__
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 ",7_ (/ �r.�
,`��' a 5�'k ;I �i�drerstandat, as the owner -builder, I must provide direct, onsite supervision of the construction.
. �, f�J F Initial
6. understand tha"i I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence. It
r " is my responsfblUty to ensure that the persons whom I employ have the license required by law and by county or municipal ordinance.
Initial_
�l tr
'�r.:air>itit4�i�•
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 Val *—
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
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:/Iwww.mvfloridalicense.com/dbpr/pro/ciIb/index.htmI
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 forth)
construction activity at the following address:
7a 5 I�i C I o3 _ S
INA ►nro KOv o L _1 1 Initial tyr4
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 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 2 h day of KhA 20 t
By�RVI'(46 LO f b4 who was personally known to me or who has _
FffZ
as identification
�s m n7ne
ARY i
rI kcV
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
SURVEY AFFIDAVIT
STATE OF (FLORIDA)
COUNTY OF (DADE)
The undersigned Affiant, K•jjjf /j,7� && f. , does hereby attest that
The attached survey, performed by
For address: '20�5 10�
(Property owner)
of surveyor's mpany)
tam) 0�DrQSL �l
Performed on (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 ect I ins ections as applicable to this or other permits.
Fu nt sa t.
Property Owner Signature Property Owner Print Name
SWORN TO AND SUBSCRIBED before me this 2"�Q day of m gW —
,� , p
Affiant is personally known to me, produced , t t a u (m ► �"'(as ide0ification.
ASLEN RODRIGUEZ
+ . Notary Public - State of Florida Notary
Commission # GG 002423
Revised on 5/22/2009/ Revised on 6/12/09 My Comm. Expires Jun 14, 2020
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