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RC-10-167236 - Miami Shores Village Building Department 1. N E 2nd Avenue lldiami Shores,. Florida 33138 TeL (305) 795 Fax: (305) 756.8 INSPECTION'S PHONE NUMBER: (305) 762A949 BUILDING Permit NYC 1 ' f PERMIT APPLICATION Master Permit No FBC 20 PermitTYpet BUILDING. ROOFING Owner's Name (Fee Simple Titleholder) v eaLa -- L Phone # ' ) X2) 'cs '1 Owners Address C Ai e .�,et : 5 City ' 1 si-cc c State ` �- ' Tenant/ Lessee Name Phone # Email Job Address (where the work is being done) • A;6 -<---- "1 e Shores Village County Miami -Dade : Zip '7 t 11+liarni e County FOLIO / PARCEL # Is Buiidi3ng Historically. Designated NO Contractor's Company Name Contractor's Address City State Zi}i Qualifier Name Phone # State Certificate or. Registration No : Certificate of Competency :No. Contact Phone E- mail Architect/Engineer's Naxne (f applicable) r.3 Il:i��'l Phone # Phone .#' B Flood Zone Value of Work For this Permit $ 21 O - Square I Linear Footage Of Work: Type of Work. []:Addition ]Alteration . ONew 0 Repair/Replace Demolition Describe Work: 4 -i s - o'' Z ; ;. � .:-�✓L -c * * *. ******* * * * * * * * * * * *. * * * * * * * *** * * * * * * *F ******** * * * * * * * * * *, * * * * * * * * * * * * * * ** * * ** � _ Submittal Fee $ • +.( Permit Fee $ 00 CCF $ 'CO /CC $ Notary $ Training/Education Fee $ Technology Fee $ Scanning $ Radon $ DPBR $ . Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ (,) , See Reverse side a Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Nanie (if applicable) Mortgage Lender's. Address City State APPROVED BY (Revised 07/10/07)(Revised 06/10/2009) c Plans Examiner 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 seetired 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 inspection ill t be approved and a reinspection fee will be charged. Signature �. Signature Owner or Agent Contractor The foregoing me was acknowledged before me this `) at The foregoing instrument was acknowledged before me this day of ) , 201 by Oat") AIL ti et. day of . ; .20 , b who is personally known to me or who has produced 4 t Ai) who is personally known to me or who has produced as identification and who did take an oath, NOTARY PUBLIC: As identification NOTARY PUBLIC: and who didt , ,oath, • o ti co 5® ma • 2 Zip Sign: Print: My Commission Expires: .. . * * * *. ** * * *************************************************-k Zoning Engineer " Clerk checked Inspection Number: INSP - 151472 Scheduled Inspection Date: November 24, 2010 Inspector: Hernandez, Rafael Owner: CAROLINA CALDERON, JULIAN Job Address: 170 NE 94 Street Miami Shores, FL 33138- Project: <NONE> Contractor: HOME OWNER Building Department Comments Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 REAPLCE VANITY, FIXTURES AND SHOWER TOILET SINK Passed x Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments carolina 305 - 527 -3090 November 23, 2010 For Inspections please call: (305)762 -4949 Permit Number: PL -9 -10 -1674 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1132060132950 Page 9 of 27 Miami Shores Village Job Address (where the work is being done) City Miami Shores Vill FOLIO / PARCEL # BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING ef ,,6 Owner's Name (Fee Simple Titleholder) ` Owner's Address 1-)'o G City c1M,t S (PO State Tenant/Lessee Name Email C€ 4 Contact Phone Value of Work For this Permit Type of Work: ['Addition Describe Work: Building Department (305) 762.4949 SEP zoo INSPECTION'S PHONE NUMBER: 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 = Tel: (305) 795.2204 Fax: (305) 756.8972 Permit NO. RAU 1 (0114 Master Permit No. (pap ['Alteration E -mail reof u,AAH Phone # Zip a') ! 3? Phone # i X C.Wt- County Miami -Dade Zip 3(r = SZ4 clv Is Building Historically Designated YES NO Flood Zone Contractor's Company Name 3 .i i .tom _ Phone # Contractor's Address City State Zip Qualifier Name Phone # State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # Square / Linear Footage Of Work: /0 0 5c( 4 — ['New epair/Replace ❑ Demolition re, .p ID ;)c l -- / L,- l ,1c ******** * * ** ** * * * * * * ** * ** * * * * * * * * * * * *** F * * * * ** * * * * * * * * * * * * * * * * * * * * ** * ** Submittal Fee $ a Permit Fee $ / re CCF $ CO /CC $ Notary $ Training/Education Fee $ Technology Fee $ Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ 1 See Reverse side 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 inspection will not be a. oved and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowledged before me this 40 day of 9 , 2010 , by C4igad C a 4u , who is personally known to me or who has produced / /7 As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Sign: f � Print: �\\ � " \ •° �` � a��' My Commission Expires: a ��� <�R a My Commission Expires: APPROVED BY (Revised 07 /10 /07)(Revised 06/10/2009) 4 Engineer Signature Contractor The foregoing instrument was acknowledged before me this day of ,20 who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: 'Plans Examiner Zoning Clerk checked Please read and initial each paragraph. 5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction. M iami 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: u-i 2 C 6 1 DATE: o°l / 17 / 1 n ADDRESS: AJC "] 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. 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 contractor with certain restrictions even though I do not have a license. Initial_ 2. I 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. I 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 (Y 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 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 6. I 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. I 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. I 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. I 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 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. I 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.mvforidalicense.com /dbor /pro /cilb /index.html Initial 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 financially responsible for the proposed construction activity at the following address: Initial__ 12. I 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 contractors workers compensation coverage. Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and retumed 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 l `°' By e i a- who was personally known to me or who has ,0\ "' , 1 ,11111 1//// o �� i • Pre,. uced there License or as id ed ificligi !'s�'' °•• 0 /mow , r r i = OWNER Nic sio ... • urn11111 Scheduled Inspection Date: November 30, 2010 Inspector: Bruhn, Norman Owner: CAROLINA CALDERON, JULIAN D CGC Job Address: 170 N(_ E 94 Street Miami Shores, FL 33138- Project: <NONE> Contractor: HOME OWNER Building Department Comments November 29, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 153719 Permit Number: RC -9 -10 -1672 For Inspections please call: (305)762 -4949 Permit Type: Residential Construction Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1132060132950 BATHROOM REMODELING Pas,eV/A Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments Page 17 of 24 OWNER BUILDER DISCLOSURE STATEMENT DATE: ib/ Ulf /?ts ADDRESS: DO eve 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 contractor with certain restrictions even though I do not have a license. 5. I understand that, as the owner- builder, I must provide direct, onsite supervision of the construction. M iami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Initial Initial Initial Initial 2. I 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. 3. I 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. 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I may als 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. 6. I 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. 7. I 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. 8. I 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. 9. I 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 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. I 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.mvforidalicense.com /dbpr /pro /cilb/iindex.html 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 financially responsible for the proposed construction activity at the following address: 12. I 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. Wad =ck owledged before me this W Produ, -d t ere License or 11 OWNER 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 retumed 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. day of 6 ' , 2010 who was personally known to me or who has 01 0 a - 2i .O L identific.f on. �,o STATE st FLORIDA, 001 MTV OFDAMS 1 HE .; j ERTP, thr4 Fia,s 1 o kii is `'e _, k, 020 WO ESS Brand nc' Uhler:? a:. . Y fir PERMIT NO. STATE OF FLORIDA: COUNTY OF MIAMI -DADE: THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 1. Legal description of property and streett//address: �� �� IO NE "I�� 8freL. r PU C i Sh% rC 1 -Fl., '13 2. Description of improvement: 1 (Yy r°Arwo(` 3. Owner(s) name and address: efi s� Interest in property: ¶ 1A3VVOidt Name and address of fee simple titleholder. 4. Contractor's name and address: • 5. Surety: (Payment bond required by owner from contractor, if any) Name and address: 4J //4- Amount of bond $ 6. Lender's name and address: 7. Persons within the state of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7., Fnllori Statutes, Name and address: /vf4 8. In addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b), Florida Statute. / Name and address: �// 9. Expirati• • . •f this Notice of Commencement: (the expiration date is 1 year from the date of recording unless a differen • d pecified) Sig NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION Owner Prin Owner's Name Mgt D.G. <z •, °4 t s' TAX FOLIO NO. cA �r tier i \ jo C C v1 � u2c 33t . Its tU 7 T . 041 f . ,20 Notary Public Print Notary's Name `Oti �} : My commission expires: 123.01 -52 PAGE 4 8/02 Sworn to and subscribed before me this ''/ /rhrrrrr &�k F �` 111111111111111111111111111 11111 1 111111111111 CFN 2010806736198 OR Bk 27426 Ps 0932; (1>as) RECORDED 09/20/2010 11:09:35 HARVEY RUV'IHF CLERK OF COURT MIAMI -DADE COUNTY? FLORIDA LAST PAGE Prepared by --1.) C.-►*•- � Address: ( )L 4 ) ° � (jf • • orr 0 1 0/10, , , room 1V 7# dr 1 1 0 / 0i r ' iie►iiiu 1 / �J1, 1 4177 7 Ordr47 ":i ce %. ' i ' . J� 0 zdj / r , r , A re i 0 % e r ��i, • • • • • • • •• • . ••• .•••• INTERIOR RENOVATION 09/20/2010 OWNERS: JULIEN BERGIER AND CAROLINA CALDERON LOCATED AT: 170 NE 94TH STREET MIAMISHORES, FL. 33138 SCOPE OF WORK: BATHROOM RENOVATION REPLACEMENT OF PLUMBING AND LIGHT FIXTURES NEW TILES SCOPE OF WORK ^l Inspection Number: INSP - 153551 Scheduled Inspection Date: November 23, 2010 Inspector: Devaney, Michael Owner: CAROLINA CALDERON, JULIAN Job Address: 770°1 Street Project: <NONE> Contractor: HOME OWNER Building Department Comments REPALCE OLD FIXTURES Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments November 22, 2010 Miami Shores, FL 33138- Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -4949 Permit Number: EL -9 -10 -1673 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1132060132950 Page 24 of 31 BUILDING PERMIT APPLICATION FBC 20 Submittal Fee Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Teptuu Permit No. (61. Master Permit No. Permit Type: ELECTRICAL ccrouoG. orld.ez.-, Owner's Name (Fee Simple Titleholder) 31A-b• Phone # 57 3 Owner's Address HO /C, F CJ 111 ,_s` City ` U. CAW . ` C r& State . — Zip 331 A Tenant/Lessee Name Phone # Email Job Address (where the work is being done) City Miami Shores Village County Miami-Dade Zip ?3( FOLIO / PARCEL # Is Building Historically Designated YES NO , Flood Zone Contractor's Company Name Cam &) ESL Phone # Contractor's Address City State Zip Qualifier Name Phone # State Certificate or Registration No. Certificate of Competency No. Contact Phone E -mail Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ 1 r ° - C) 0 Square / Linear Footage Of Work: 1 O 01 Type of Work: ❑Addition [Alteration p New air/Replace ❑Demolition Describe Work: * *** * *** * * * * * * * * * * * * * * * * * * * * ** * * * * * * ** F ** * * * * * * * * * * * * * * * * * * * * * * * * **** Permit Fee $ /4 r ®l` CCF $ CO /CC $ Notary $ Training/Education Fee $ Technology Fee $ Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ 107 • 20 See Reverse side -4 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 AIIFWAVIT: 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 b ' a.' ;fved and a re- inspection fee will be charged. Signature %/' Signature Owner or Agent Contractor The foregoing instrument It) acknowledged before me this 1 j P The foregoing instrument was acknowledged before me this day of , 20 �, by ,[, Z1 day of , 20 _, by who is personally known to me or who has produced FL- / 0 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: ��``����lnllll iii "1,,, NOTARY PUBLIC: a .. ,, e . ... c ... b Sign: • o Sign: Print: �° 4 4 � t ,` Print: , P �q N � My Commission Expires: ,,, "111111 n I S 0 My Commission Expires: * * * * * * * * * * * * * * * * * * * *. . * * * * * * * * * ** ************************:*********** * * * * * *** * * * ** * *** * * * * * * * *** * * ** APPROVED BY ,):4 �� 7/ 7 P7 Plans Examiner Zoning (Revised 07 /10 /07)(Revised 06/10/2009) Engineer Clerk checked OWNER BUILDER DISCLOSURE STATEMENT NAME: Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 DATE: 6'1 1 7f1t ADDRESS: 1 c. i1/4.1 R 5 M�,kt StF��c�i . 313% 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 contractor with certain restrictions even though I do not have a license. Initial Tb 2. I 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. I 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. 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 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. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction. 6. I 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. I 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. 8. I 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. I 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 owner - builders as well as employers. I also understand that the Construction must comply with all applicable laws, ordinances, building codes, and zoning regulations. 10. I 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.mvfioridalicense.com /dbpr /pro /cilb /index.html od ced there License or OWNER Initial Initial 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 financially responsible for the proposed construction activity at the following address: Initial r' �� /l lII rl 1111N��� 12. I 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 43 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 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 acceptable to the local permitting agency is required when the permit is issued. Was acknowledged before me this i n day of , 20 1 By '5 B ( who was personally known to me or who has oluilllu//,, a,Stlentifiri � �. =m 1 -ig