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32660Date 1 J 11 Job Address be4 (si Q6Sr Legal Description if f oll �O l Owner / `Lessee /Tenant Owner's Address C `3rsr A Contracting Co. Qualifier State # Municipal # Architect /Engineer Bonding Company Address Mortgagor Address Permit Type(circle one): BUILDING 'ELECTRICAL PLUMBING MECHANICAL ROFING /® WORK DESCRIPTION Notary as to Yfwner and/ My Commission Expires: ** * PERMIT APPLICATION FOR MIAMI SHORES VILLAGE APPROVED: R ®I.ePfT. CC, Tax Folio // .$62.4 /1( ' Master Permit #E ,0 to Phone Address 0211 ,2 t Ai (Ai l .29 r I T 9c r SS,# Phone 6 8.5 Co # ?6cq / Ins.Co. Address 1 PAVING FENCE SIGN Estimated Cost(value)a 4 , 0 WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT 'AND YOUR FAILURE TO DO SO MAY RESULT IN YOUR ;PAYING 'T'WICE FOR IMPROVEMENTS TO !OUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING, WITH YOUR LENDER OR AN ATT1RNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.) - Application is hereby made to obtain a permit to do work and installation as indiciated above, and on the attached addendum (if applicable). I certify that all work will be performed to meet the standards of all laws regulating Construction in this jurisdiction. I understand that separate permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL, WORK. 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 constructio • Furthermore, I authorize the above-named Apr to do the work stet atu ► of owner ar Condo Priesident Date: g �¢;fMeLM. UNDA S SA TARY WYER SE COMMISSION NUMBER AA447794 MY a OMMISS1ON EXP. JUNE *19,1995 * . 1- _ Ka ti rca:• " ;Jac, State of Florida o y • Eaao. AoaIn i9 Signaturp x " - Builder Date Date:/*V4 VIMEW tary h as to Co q __ 4011, " My Commission Expires: / , .ODD take an oatil, or DEDINGratheiamb. ** FEES: PERMIT / 7�/ RADON C . C . F . /,51) NOTARY ' ''JI TOTA1 DUE ) k" Fire Other Zoning Building 7 Electrical t,at I Mechanical r � /�' ��?! l lambing Engineering Per 489.103(7) F.S.S. DISCL State law requires co contractors. You have appli that law. The exemption property, to act as your ow have a license. You must You may build or improve a o a farm outbuilding. You ma building at a cost of $25,0 your own use and occupancy lease. If you sell or lea built yourself within one an unlicensed person as your be done according to buildi is your responsibility to m have license required by s licensing ordinances. c/ Date Village Use Only Owner's name (print) , PeN A Permit No . ,V (> S RE ST ENT strtiction to be done by licensed d for a permit under an exemption to allows you, as the owner of your contractor even though you do not upervise the construction yourself. e- family or two - family residence or also build or improve a commercial O or less. The building must be for It may not be built for sale or e more than one building you have (1) year after the construction is complete, the law will preume that you built it for sale or lease, which is a violation of this exemption. You may not hire contractor. Your construction must n g codes and zoning regulations. It a ke sure that people employed by you tate law and by county or municipal )40 Art Ps Owner's signature L/' �' 5 1' -rnfrJ You have, this date, made application for a building permit as an owner - builder. You should be advised of the following provisions and requirements that apply to owner - builder. Proof of Ownership - Prior to a building permit being issued to you, you must submit proof of ownership of the land concerned in the application in the form of a recorded deed, showing you own the property, or a copy of mortgage or warranty deed of the land, or a Dade County tax receipt, statement to contain legal description of property and indicate property is in your name. Legal description and name on document of proof must correspond to the name and legal description on the application. Responsibility - You will be responsible for all work done by your day labor employees, and you must either employ licensed contractors or persons to be paid on an hourly or per diem basis. Any one contracting (including labor) with you, verbally or in writing, on a fixed fee basis for any work, who is not properly licensed, will be subject to a fine of $500.00 and /or imprisonment for six months. Insurance - You should be advised that if your day labor employees cause any damage to persons or property, or if any of your day labor employees are injured on the job, you are liable. Your regular home insurance policy ordinarily does not cover this type of liability. Withholding Taxes, etc. - You should be advised to investigate your responsibility for withholding Social Security, Federal and State Unemployment Insurance Taxes and Federal Income Taxes from the wages of employees working for you on the proposed construction, and for making returns thereof to the proper agencies. Work Permitted Owner - Builder - An owner - builder subject to the foregoing provisions and requirements, is limited to constructing one single family residence each year for his own use and occupancy; or maintaining, altering or repairing his own single family residence. If you do not intend to do the work involved yourself, or with day labor, please list below, the name of the individual or firm with whom you have entered (or will enter) into a contract for the work. NOTICE: SEPARATE PERMITS REQUIRED FOR ELECTRICAL, PLUMBING, ROOFING AND MECHANICAL WORK N Ckd x-101 'm ,Air / lam "l a 1 4 . 91 Name of Individual or Firm Address MIAMI SHORES VILLAGE BUILDING AND ZONING DEPARTMENT INSTRUCTIONS TO OtWNER- BUILDER I, the owner of property described as do hereby certified 622 v •' j � L '' >` a ( Owner that I have read the foregoing instructions, and am aware of my responsibilities and liabilities under my application for a building permit for construction work on the above described property. 577 -*) Date L7 IMP! OP INSURANCE POLICY IERASEI r POLICY TflE DATE GAUDONM PRICY ED/NIATION DATE GAMIDONY) • LIMITf GENERAL LIAUEJTY EVE FORM PREINEEMOPERATIONS g p�pp II LAPSE HAZARD DILO SIO PRODUCTSICOMLETED CPHR. CONTRACTU I. U BIDEPEADEIT CONTRACTORS BROAD FERIA PROPERTY DIIMMIE PERSONAL INJURY t irO sow s6 ~ • 7/13/92 ` • !' 7/13/°93 BODILY INJURY OCC. i BODILY INJURY AGO. $ Y PROPERTY DAMAGE OCC. 1 - PROPERTY DAMAGE AGG. 1 X a Po COLUMNED OCC. OW/ WU — BI & P0 CIMABINED AGO. SSW A — PERSONAL INJURY AGO. 1300 jP V >JU Fy ; .y.. q 4 Yi i T, ••• . AUTOMOMLE I TY ANY AUTO AU. OWNED AUTOS ( Pas. Pap. ) ALL OWNED AUTOS (Ma Man Pass HIVED AUTOS NONOINNE0 AUTOS GARAGE LYIBiLR Y BODILY INJURY _ BODILY INJURY (Pet ) i PROPERTY DAMAGE S BODILY ROPERTY DAMAGE COMBINED S EDCESS w1NUTT FORM OTHER THAN UMBRELLA PORE • EACH OCCURRENCE $ R UMBRELLA AGGREGATE ,*;, * <f.•. MOMOWII COMPENSATION AND !LOYERB' UABEftY STATUTORY UNITE • EACH ACCIDENT IS DISEASE— POLICY LINT i DISEASE —EACH EMPLOYEE S OTIIlR ,AA INS. ASSOC. & CONS. CORP 16817 WEST DIXIE HIGHWAY N. MIAMI BEACH, FL 33160 . PH. (305) 944 -2886 FAX (305) 949 -5222 INSRJED Dnvid P Potter Uri:p on Ina. 1320 MI 119 St. �ss.aai rt. 33150 PQ Om 600425 9ie r1 33160 INISCRIPTION OF OPERATIONSILOCATIONSAIMGCLEEMPECIAL ITEMS THIS CERTIFICATE IS ISSUED AS A MATTER OF INF • T TION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANY A LETTER counter 9 LETTER COMPANY C LETTER COMPANY D LETTER COMPMAY E LETTER COMPANIES AFFORDING COVERAGE • Arlen Imunime Oa. COVERAGES THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT. TERM OR CONDITION OF Eft CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. !mammon AND CONDITIONS OF SUCH POUCHES.. • CERTIFICATE HOLDER - CANCELLATION t:<l:CORV6OR - CRATILONN 1 9.9 Metro Dade Bld3 /Zonir)g 111 NW 1 St. Suite 1010 Miami Fl. 33128 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO TFE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL. SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABIUTY OF I0ND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.