ROOFINGMIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Application is hereby made for the approval of the detailed statement of me plans and specifications herewith submitted for the build •
ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami
Shores Village, Florida. and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kept at building during pregreu of the work.
Owner's Name and Address l " (? C' a . .. 2.......... — No... .": ,■St'reet._..2 .. .._.:
Registered Architect and /or Engineer iia ..••• ttt•tt.t,.,.,,..t. t•
Name and address of licensed contractor..L .1,,. !. 2 f 4.....tr:. r .1.2 6 (2 = Lai
Location and legal description of lot to be built on: � ? 0 : 6 P in L d e / ) i 5 ,7
L ot Block Subdivision ........... .. ...._......._...._._......
Street and Number where work is to be done _ _. .._. . _ .... ,.._.
State work to be done and purpose of building (by floors) f ; 42 ' e75
and for no other purpose.
New Building Remodeling Addition Repairs I No. of Stories _
To be constructed of Kind of foundation Roof Covering
Estimated Total cost of improvements $ -y tt Amount of Permit 3. A
Zone cubage required plan Cubage _.
Distance .to next nearest building Size of Building Lot
Maximum live load to be borne by each floor
I hereby submit all the plans and specifications for said building. All notices with reference to the building and its construction may
be sent to.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer
of labor under the 'Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Sipplcment,
anti has complied ith the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by hint
in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only such subepntractors, on work to be performed under this
pcnnit, as are licensed by Miami Shores Village.
STATE OF FLORIDA,
COUNTY OF DADE. 1 ss'
Remarks... � ..J`L 174 /1 6 - .. (Signed)
-
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally ap-
peared
to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the.
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all fads
therein by him stated a e..
Permit No ° .L Date ,6./ Read, Sworn to and Subscribed before me.
Disapproved .£�: _.`. ` Date — Notary Public, State of Florida
(Signed)
Building Inspector My Commission Expires
PLANNING BOARD DATE
Chairman Member
Member Member
Member .. .. Member
Council Approved Date Disapproved Date
NOTE: A charge of $i.00 will be made for making corrections or changes to this application after approval has been obtained frn>tn
the I'lanniog Board.
A rc•in.peetiun fce of 31.00 will be charged when such re- inspection is made necessary by Improper notice for insp,tinn or faulty
materials and /or workmanship.
Ft.
Ft
Ii
123.01-78 9196
•
Contractor's Name:
•
❑ (Low Slope Applicaticin)
❑ (Asphalt/Fiberglass Shingle)
Q New Rodf b Re roofing
Deck type:;
Fastener type:
Field:
DETAiL 1 & 2
Appendix "E"
UN IFORM MOPING rfi i ll t A PPLICATION
No.
• • • ... • • • • ...
itel
• jDb : 1 li w
• ▪ • • • • • • • • •
... ... • • • ...
A
T TCHt1►tJ
YAC1NG
erimeter:
... . . . .. .
ROOF CATEGORY
•• • • . •• ••• ••
Q ovaa.4nfiiie):::. '. • • Q t Meta! Roofs \Wood STth g'les & Shakes) ❑ (Other)
ROOF TYPE
Q Recovering epair 0 Main
ROOF HEIGHT AND SYSTEM DETAILS
(Draw details as needed)
Corner:
❑ (Mortar- Adhesive Set' file)
Flat Roof Area (ft Sloped Roof Area (ft') Total (ft) Master Permit No.
Exposure category (per ACE 7 -48): Building Classification category (per ASCE 7 -88 table 1):
ROOF PLAN
HP OfficeJet • • • ""
Personal Printer • Fax • Copier
The HP OfficeJet, the personal all -in -one printing device for home offices and small
••• • • • 000 •
• •• • • • • • • ••
• • • • • • • • • • • •
• • • 000 • • •
• • 000 • • • • • • •
•
•
•
• • • •
•
•• 0,0 • • • • • ••
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date � _ Job Address 58 Nib) Tax Folio H- 3/O I -03 .3 - C IL 0
Legal Description tor to y1�CkQ> k/ I • ' --
Master Permit #3.5 UC
/ Lessee / Tenant Plank, L))0,0
Owner's Address
Contracting Co.
NZ 4 J' L
Phone
3531-gg
660 110.0 ,t Address 3 25 G ., l
Qualifier STIOLQ 0 9 iv i - Phone 757-7S =(
State # Municipal # Competency # /4 Ins .Co. Q A C-O L
Architect /Engineer Address
Bonding Company Address
Mortgagor / Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL OOFINg-/PAVING PENCE SIGN
WORK DESCRIPTION `i[ 0 p i,JLm) O V
3O AA 044 t pLetzlit.:".0
I
Square Ft.
7r
Signature of owner and /or Condo President
Date:
Notary as to Owner and /or Condo President
My Commission Expires:
APPROVED:
FEES: PERMIT :115 RADON C.C.F. r
Fire
Mechanical Plumbing
Estimated
Piumtic UPiu404 5O sild.t.
tL�
4* ./d of - la - .A-4,J
wo . ®C,
Cost(value)
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO
SO 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).
Application is hereby made to obtain a permit to do work and installation as indicated 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 construction and zoning. Furthermore, I
authorize thebove -named contractor to do the work stated.
S '
ate: a ture of Contractor or Owner- Builder
�^
Notary as to Contractor or Owner- Builder
My Commission Expires:
** * * * * * * * * * * * * * * * *
NOTARY TOTAL DUE ' r d ei
Other
'7 )r‘ Zoning Building I1 Electrical
Engineering
;
t •
4 I
/(7c.
I!,
cdU lyw,„54"1,
; : 1
rIL
7:CP-‘‘sx
‘")
rte
776 o'd //pc.
0 v
3 V7 cs'
4 PERMIT APPLICATION FOR MUNICIPALITIES OF DADE COUNTY
(OWNER TO RETAIN COPY)
l 3 oa/a
' Date �� mob Address Tax Folio
Legal Description 0Y fk ' /4;
uOwner / Lessee / Tenant �4`�< Cu - — Master Permit 4I: 6 3 .
3�-
Owner's Address ,, / / 4 ` / Phone
Contracting Co. Address
Qualifier 4,10 SS# - - Phone
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING PENCE SIG1
/ORK DESCRIPTION � EsswZ- c_LEf+il SEAL p1210-1c2
is C 2 r " �� et
Square Ft. C)O Estimated Cost(value) ' 60t
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DC
SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTENI
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUF
NOTICE OF COMMENCEMENT).
Application is hereby made to obtain a permit to do work and installation as indicated above, an
on the attached addendum (if applicable). I certify that all work will be performed to meet th
standards of all laws regulating construction in this jurisdiction. I understand that separat
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 wil_
be done in compliance with all applicable laws regulating construction and zoning. Furthermore,
authorize the above -named contractor to do the work stated.
Signature of owner and /or Condo - -i•e
D, e: 4 02-1(/99.2-, A
Signature of Contractor or Owner- Builder
Date:
Notary as to Owner and /or Condo President Notary as to Contractor or Owner- Builder
My Commission Expires: /jeee,,, cco l - /'( My Commission Expires:
NOTARY PUBLIC STATE OF FLORIDA
MY COMMISSION EXPIRES 5/09/94
** * * * Anded thruttembleAdams &Sweet * * * * * * * * **
FEES: PERMIT. // py S O RADON C.C.F. l - 0 . NOTARY 57I' TOTAL DUE ff C/
APPROVED:
Fire
Other
Zoning Building / / . Electrical
Mechanical Plumbing Engineering
Per 489.103(7) F.S.S.
Village Use Only
Owner's name(print) /nn Sr
Permit No.3.2b5°
DISCLOSURE STATEMENT
State law requires construction to be done by licensed
contractors. You have applied for a permit under an exemption to
that 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 or
a farm outbuilding. Your may also build or improve a commercial
building at a cost of $25,000 or less. The building must be for
your own use and occupancy. It may not be built for sale or
lease. If you sell or lease more than one building you have
built yourself within one (1) year after the construction is
complete, the law will presume that you built it for sale or
lease, which is a violation of this exemption. You may not hire
an unlicensed person as your contractor. Your construction must
be done according to building codes and zoning regulations. It
is your responsibility to make sure that people employed by you
have license required by state law and by county or municipal
licensing ordinances.
CA/
Date Owner's signa ure
PROPERTY OWNER
Name n ^// 4 �
1
C e ) I
Address
Home Telephone
,p 0 S �- „ ( (Fs
Business Telephone
Fax
S `" — 7 -S - R— 7 / -cr
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'1 Attachment
Other
Add'l Detachment
Other
INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village:
Step 1.
pc Job Address:
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must he notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submitted
along with this permit application.
Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
5'9 P W
Address
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
ci is
Apt.
Folio Number
Lot Block
Subdivision PB PG
Current Use of Property
Proposed Use of Property
Tenant Information
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
City
/ Description of Work
K
State
PERMIT APPLICATION
Master Permit No.
Subsidiary Permit No.
Zip
Zoning Linear Feet
Square Feet Units Floors
X Value of Work
Bldg Value
Tax Assessed/Appraised Value
Flood Zone Base Floor Elev.
ENGINEER
Name
License No.
Address
Telephone
Fax
CONTRACTOR
Name 9 , /1),614,
� l" gp
License No.
Address
Telephone
Fax
Qualifier Name
Page 2
IMPORTANT NOTICES
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
AFFIDAVIT - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, 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, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other governmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, 1" Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
TATE OF FLORIDA, COUNT OF MIAMI -DADE
Signature oTOwner
M RT( -'
Print Name
Sworn to and subscribed before me this
Signat e
SEAL:
kihCHAEL WILSON
My Comm EN). 5/1/04
No. CC 930003
11sonafy Known O Other I.D.
f tl�'t -� ,
Personally known OR, Produced Identification
s t-
Type of Identification Produced:
ORIDA, C
PERMIT APPLICATION
ADADE
Sign ' ure of Contractor / Qua ".11111.-- /L 1 Gl
Print Name , /
to and subscribed before me this c7 2 6 day of A/at/
of
otary Pub l - S! <te .f lori
SEAL: N S n0. , r',
= O Y.. fi 1.
c ^ t
Personally kh r ` " / OR, f Produced Identification %'�
Type of Identification Produced 17' V.) Z 4 5' ' V��
Lik"-'••
ELECTRICAL
TYPE
Minimum Fee
QTY
TYPE
Dryer
QTY.
TYPE
Outlet, Appliance
QTY.
TYPE
Service Repair
QTY.
A/C Central 1 -3 Ton
Miscellaneous Fixture
Fan
Soakage Pit
Outlet, Wall
Bath Tub
Service, Temporary
Drinking Fountain
A/C Central 4 -7 Ton
Miscellaneous Repairs
Fire Pump
Solar Water Heater
Outlet, Switch
Bidet
Signs
Filter Replace
A/C Central 8 -15 Ton
Pool Piping
Fixture - Fluorescent
Sprinkler Repair
Oven
Cap - Fixture
Space Heater (kw)
Fountain
A/C Central 16 -20 Ton
Pump and Abandon
Fixture Light
Sprinkler System
Parking Lot Lights
Cap - Water
Spas/Hot Tubs
Gas - Appliance
A/C Central 20+ Ton
Pump, Domestic
Flood Lights
Supply, AC Well
Plugmold/Strip
Cap - Sewer
Subfeeds, No. of Amps
Gas - Natural
A/C Window
Pump, Fire Stand
FPL - Load Central
Temporary Toilet
Posts
Catch Basin
Swim Pool, Commercial
Gas - Propane
Air Conditioners
Pump, Re- circulate
Garbage Disposal
Temporary Water Closet
Range/Range Top
Clothes Washer
Swim Pool, Residential
Gas Piping
Chiller
Pump, Replace - Pool
Generators, etc.
Urinal
Receptacles
Dental Chair
Switchboards
Grease Trap
Clear Violations
Pump, Sprinkler
Heat Recovery
Utility - Sewe
Refrigerator, Comm. (p/PH)
Discharge Well
Temp Serv., Construction
Ice Maker
Compactor
Pump, Sump
Low -volt, Burglar
Utility - Water
Refrigerator, Domestic
Dishwasher
Temp for Test - 30 days
Indirect Wastes
Deep Freezer
Relay Repair
Low -volt, Fire
Vacuum Pump
Renew - Temp Service
Disposal
Interceptor
Demolition
Roof Inlet
Low -volt, Intercom/Teleph.
Water Closet
Repair Circuits
Domestic Well
Laundry Tray
Dishwasher
Septic Connection
Low -volt, Television
Water Heater
Service, Number of Amps
Drainfield, 4" Tile/Res.
Lavatory
MECHANICAL
TYPE
Minimum Fee
QTY.
TYPE
Condensate Drain
QTY.
'1'1'PE
Generator
QTY'.
TYPE
Refrigeration, Tons
QTY.
A/C Central, Tons
Miscellaneous Fixture
Cooling Tower
Soakage Pit
Heating Strips, each
Bath Tub
Vent Hood, Cost
Drinking Fountain
A/C Wall/Win. Tons
Miscellaneous Repairs
Dryer Vents, Number of
Solar Water Heater
Paint Booth
Bidet
Ventilation, Cost
Filter Replace
Air Handler, Tons
Pool Piping
Ductwork, Cost of
Sprinkler Repair
Piping, Flammable Liquid
Cap - Fixture
Periodic Inspections
Fountain
Barbecue
Pump and Abandon
Fire Sprinkler System
Sprinkler System
Process/Pressure Piping
Cap - Water
Gas - Appliance
Bath Fan - Vented, #
Pump, Domestic
Fireplaces, Number of
Supply, AC Well
Pressure Vessel
Cap - Sewer
Gas - Natural
PLUMBING
TYPE QTY. TYPE
QTY.
TYPE
QTY.
TYPE QTY.
A/C Condensate
Drains, Roof
Miscellaneous Fixture
Soakage Pit
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewe
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 3
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
SECTION
BY
DATE
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
/�
Building Official
i°1`
�" �
Page 4
OFFICE USE ONLY
CHECKLIST
❑ OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi- family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
❑ PROOF OF OWNERSHIP
(Attach)
❑ HRS / DERM APPROVAL
(Septic / Sewer)
❑ IMPACT FEE
(New Construction)
❑ OTHER
(Specify & Attach)
PERMIT FEES
$3.00 per page (Scanning Fee) $
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.) $
Inspector State Educational Fund $
State DCA (Radon) $
Code Enforcement Fine $
Zoning Review
S ,DD
(sq.ft. = x/1000
x ¢.60)
(¢.005 /sq.ft.)
(¢.01 /sq.ft.)
REVIEWED AND PREPARED BY:
PERMIT APPLICATION
❑ CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
TOTAL $
ISSUING OFFICIAL
DATE:
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com
MIAMI SHORES VILLAGE BUILDING AND ZONING DEPARTMENT
INSTRUCTIONS TO OWNER- BUILDER
You have, this date, made application for a building permit as an owner -
builder. You should be advised of the following provisions and reauirements
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
1T moo . 5;)5(a.— <;
ame of Individual or Firm Address
I, the owner of property described as
hereby certified
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.
& / (1 0.40
Witness Owner
\//,0%ate