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RC-09-1922 Miami Shores Village 10050 N.E. 2nd Avenue • '"• Miami Shores, FL 33138 -0000 3 Phone: (305)795 -2204 .t z L�� - Expiration: 06(3 1201 Project Address Parcel Number Applicant 358 101 Street 1132060135280 LAWRENCE SPRINGER Miami Shores, FL 33138- Block: Lot: Owner Informati Address Phone Cell LAWRENCE SPRINGER 358 NE 101 ST MIAMI SHORES FL 33138 -2425 Contractor(s) Phone Cell Phone HOME OWNER Valuation: $ 8, 000.00 Total Sq Feet: 40 Approved: In Review For Inspections please call: Comments: (305)762 -4949 Date Approved:: In Review Available Inspections: Date Denied: Inspection Type: Type of Construction: BATHROOM REMODEL Occupancy: Single Family Final PE Certification Stories: Exterior: Drywall Front Setback: Rear Setback: Miscellaneous Left Setback: Right Setback: Window Door Attachment Bedrooms: Bathrooms: Tie Beam Plans Submitted: Certificate Status: Final Certificate Date: Additional Info: Framing = Bond Retum : Classification: Residential Insulation Trusslnsp Fees Due Amount Invoice # Total Amt Paid Amt Due Columns CCF $ 4.80 Foundation RC -11 -09 -36462 $ 261.20 $ 211.20 f Window DBPR Surcharge $0.20 and Door Bulk Education Surcharge $1.60 RC-1 I- M36462 $ 261.20 $ 261.20 $ 0.00 Fill Cells Columns Notary Fee $5.00 Check #: 6837 Wire Lathe Permit Fee - Additions/Alterations $240.00 F. Termite Letter Radon Surcharge $0.20 F. Elevation Certificate Scanning Fee $3.00 Submittal Fee $50.00 Submittal Reversal Fee ($50.00) Technology Fee $6.40 Total: $261.20 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 taws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. December 02, 2009 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy December 02, 2009 1 11130cq Miami Shores 'Village Building Department g 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ' LNSPEC (305) 762.4949 BUILDING Fm�:!9 2009 � Permit NJ C-11 • PERMIT APPLICATION �j�G 'Master Permit No. FBC 20 Z Pe mit Type: BUILDING ROOFING- J05 6(p . Bag— VOwn er's Name (Fee Simple Titleholder) �l�f� P p ) hone # 3O Owner's Address -45 City _ ML6Mj SiClOtES State FL.- dip 3313 Tenant/Lessee Name IN /a_ Phone # 46L Email d55jPr% be -nf Job Address where the work is being done 3�g /l/E j p j ( g ) City Miami Shores Village County Miami -Dade Zip .33 8' FOLIO 1 PARCEL # << - 1 204 D 1 -` 5 0 Is Building Historically Designated YES NO X Flood Zone Contractor's Company Name ©41yt• t4J 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 # id V Value of Work For this Permit_ $ ? 00 0 Square l Linear Footage Of Work: 2e scribe f Work: QAddition Alteration EINew Repair/Replace [xLleaiDlition • • • • •' �j �f Work: I �I '� y� �e"' -�-f (, • .' . . • `6(��t • i� (� r4-- A- All • •... • �r� �x����* �r�: ��r�r��r�xx *�a�xx *��rx *:ax,���� �r�a��x��y' ��a��r, ��**, ����r :���x�r�x��a����xx���,�x�k • •• nbmittal Fee U Permit Fee $ (� CC $ �[` • • 'L�CC .$ . • • • ' • Notary $ Trainfng/Fducation Fee $ I • Techno! lu $ • • . • Scanning $ Radon $ 0 DPBR $ 0 Bond $ • Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ See Reverse side > i 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 certed 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 approved and a reinspection fee will be charged. Signature Signature Owne or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20� , by l _ p 1� f tJ day of , 20 by who is ersonally known a or who has produced who is personally known to me or has produced i entification and who slid take an oath. as identification and who did take an oath. •: O...NOTAUX NOTARY PUBLIC: • .... 0000 0 • - �.,0�� Sign \� •0024 Sign: 0000 0 Print —� S bI ��� E2 y rtcx �-� c�L_ Print — r 00000 My C.0wission Expires! My Commission Expires: 0 .00.0 0,000 • • • . 0000... .. .. 00 000 0 00 0 so x *} S+r �tDO6M . �r�x��'iFR�x,xx �. � i "• • • • • • •' Ba�etliiwTrgF�n X19 • APj hff ED P airs xaminer Zoning l> r Clerk checked (Revised 07 /10 /07)(Revised 06/10/2009) 3 NOV 3 0 2009 CITY -,e- cry-� GUV-V--3 X+Z4,Ul a Shores an �- p,PPRO�ED O® ZON ING DEPT BI DG DEPT AL1- FEDERAL SU6J W llj -r C)NS ECTTOG SA ND REGU�' STATE AND COUNTY RULE G ���, ' mol Ir 5 t^ I P® rain 0 0 e ® m LP° m m a =� co i • 4 so 0 f ••• • • •s • • • • • • f • t • •• f • • 4 I i .� 1 • ee••ef •fwffe • • e • f • • f e f f ffe•ff f•ffef f •• f•efwf ••�fe• • f f ••fief cell• fe•fe• flee • • loll l •fif lle•l• • • e •left• AML dr VOPY fe • ff f f eeelf lfle•f ��a ° �7 -ao 2 �leee. •eel • f Pvl'a.mi S Ores Village f f l • fe lf A�PR O�!ED _ BY DATE :( P.!I^JG DEPT L D G D PT SUBJECT TO COMPLIANCE WITH ALL FEDERAL STATE AND COUNTY RULES AND REGULATIONS � C. Miami shores Village Isom n „ Building Department 10050 N.E.2nd Avenue �, Miami Shores, Florida 33138 ,p R Tel: (305) 795.2204 Fax: (305) 756.8972 Permit No: 09- ��- Job Name: 2009 Page 1 of 1 Building Critique Sheet 9 /l�vi e Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. Norman Bruhn CBO 305 - 795 -2204 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. 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 homeowners 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. Initia 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 taws, ordinances, building odes, 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 ba:ll www. myfloridaticense .comidbor /prolcilbind 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 for t he p activity at the following address: /) I Initial 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. �f 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 stators 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 owners 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 LA day of 20 By who was personally known to me or who has Produced there License or identification. S 0 NER NOTARY NOTAU PUBLIC- f".'A'' OF FI�DR sel"11g4 /t CJAU� � {i• 1105 ADD71323 nrarrn SP rrau�x:�b;e kb�,taccr,�o. 3•SH 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: DATE: ADDRESS: 0I or FL - 3 5) 3�' 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 entities 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 fora 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 one4amily 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 75,00. 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 er 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. 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. d In InI iat 4 41J 4. 1 understand that I may build or improve a one family or two-family residence or a farm outbuilding. f 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. 1 understand that as the owner - builder, I must provide direct, onsite supervision of the construction. Intial -� , 6. 1 understand that I may not hire at 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 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 137591 Permit Number: RC -11 -09 -1922 Scheduled Inspection Date: March 11, 2010 Permit Type: Residential Construction Inspector: Bruhn, Norman Inspection Type: Final Building Owner: SPRINGER, LAWRENCE Work Classification: Addition /Alteration Job Address: 358 NE 101 Street Miami Shores, FL 33138- Phone Number Parcel Number 1132060135280 Project: <NONE> Contractor: HOME OWNER Building Department Comments Remodel Bathroom Inspector Comments Passe 1 U Failed Correction Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. March 10, 2010 For Inspections please call: (305)762 -4949 Page 15 of 20 ON ,0 "A" +� Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 ? a '" f'„ n Phone: (305)795 -2204 r N �I Expiration: 05131201 Project Address Parcei Number Applicant 358 101 Street 1132060135280 Miami Shores, FL 33138- Block: Lot: LAWRENCE SPRINGER Owner information Address Phone Celt LAWRENCE SPRINGER 358 NE 101 ST MIAMI SHORES FL 33138 -2425 Contractor(s) Phone Cell Phone Valuation: $ 1, HOME OWNER Total Sq Feet: 0 Type of Work: PLUMBING For Inspections please call: Type of Piping: BATHROOM REMODEL (305)762 -4949 Additional Info: Available Inspections: Bond Return: Inspection Type: Classification: Residential Top Out Re Pipe Main Drain Underground Rough Heater Water Service Final Water Main Lavatory Fees Due Amount Invoice # Total Amt Paid Amt Due CC F $0. Edu cation Surcharge $0.2 0 PLA1- 09-36520 $ 109.60 $ 109.60 $ 0.00 Edu cation Notary Fee $5.00 Check #: 6839 Permit Fee - Additions/Alterations $100.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $109.60 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. December 02, 2009 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy December 02, 2009 1 Miami Shores Village Building Department r� NOV 3 0 00g Li J . 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY 4.._ Tel: (305) 795.2204 Fax: (305) 756.8972 "....... INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING permit No. Pl nq - . i 9 (09 R PERMIT APPLICATION Master Permit N o. N) e7 FBC 20 Permit Type: PLUMBING Co g k Cp 3 Owner's Name (Fee Simple Titleholder) 1 r�—� I y'e Phone # ' 30S_ - 75 - 7 - 7 Owner's Address T City V � State � Zip 1 Tenant/Lessee Name Phone # Email Job Address (where the work is being done) . City Miami Shores Village County Miami -Dade Zip 3 , 31 3� FOLIO / PARCEL # — __ Is Building Historically Designated YES NO Flood Zone Contractor's Company Name �J 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 $ l cc c� Square / Linear Footage Of Work: Type of Work: ❑Addition ❑Alteration ❑New ❑ Repair /Replace ❑ Demolition Describe Work: I Submittal Fee $ Permit Fee $ ` CCF $ CO /CC $ Notary $ Training /Education Fee $ Technology Fee $ -� Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ tffl 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 approved and a reinspection fee will be charged. Signature Signature Owner Agent Contractor The fore ing instrument was ac w ged be re e this � /1 / The foregoing instrument was acknowledged before me this I day of `' 20 nq by � rl tr� , ray of 20 _, by who is personally known to me or who has produced who is personally known to me or who has produced A S Q S �4c eentification and who did take an oath. as identification and who did take an oath. NOTAR PUBLIC: NOTARY PUBLIC: �� °s Sign: (" /� ! >��� �1,��� Sign: V . Print: v C#� 4 L ' ©�� °' Print: My Commission Expires: My Commission Expires: Bo APPROVE 'BY la s Examiner Zoning Engineer Clerk checked (Revised 07 /10 /07)(Revised 06/(0/2009) ,gH Miami Shores Village Building Department 10050 N.E.2nd Avenue 4 Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 1 OWNER BUILDER DISCLOSURE STATEMENT NAME: � l f C� DATE: — 0 ADDRESS: 1 � -S ` a � 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 fora 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 two­family residence. You may also build or improve a commercial building at a cost of $25,000.0 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 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. �n Initial v"� 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 �� 3. 1 understand that as an owner builder, I am the responsible party of record on a permit 1 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. .0 / n Initial �`'✓ 4. 1 understand that I may build or improve a one family or twafamity 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 teased within 1 year after the construction is complete, the law will presume that I built pr substantially improved it for sale or lease, which violates the exemption. Initial 5. 1 understand that as the owner: builder, I must providedirecL onsite supervision of the construction. Initia 6. 1 understand that 1 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. 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 homeowners 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. Initia 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 d4 _ 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:/ Awm. mvWdalicense .com/dbpr /Droldlbrindex.htmi Initia 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: ��� ►� In Initial 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. Initia 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. �0 W as acknowledged before me this day of 20 Oq_ I r B f lI ( '� h who was personally known to me or who has Produced there License or T Q YRWO ' S - identification. R NOTARY C�: LJy' ° ��.� � 3 011 e C s . Inspection Worksheet Miami Shores Village Itov 40 0, 10050 N.E. 2nd Avenue Miami Shores, FL f Phone: (306)796-2204 Fax: (105)766-8972 Q� Inspection Number. INSP-130332 Permit "Number: EL-11-09-I970 Scheduled Inspection Date: March 08, 2010 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: SPRINGER, LAWRENCE Work Classification: Addition/Alteration Job Address: 358 NE 101 Street Miami Shores, FL 33138- Phone Number Parcel Number 1132060136280 Project <NONE> Contractor: HOME OWNER Building Department Comments ELECTRICAL WORK FOR BATHROOM REMODEL Inspector Comments Passed Failed �� Correction Needed Re-inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid. March 05, 2010 For Inspections please call: (305)762-4949 Page 5 of 30 gg Miami Shores Village t� 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795- 2204 3 xpir E atton• 061 Project Address Parcel Number Applicant 358 101 Street 1132060135280 Miami Shores, FL 33138 Block: Lot: LAWRENCE SPRINGER Owner Information Address Phone Coll LAWRENCE SPRINGER 358 NE 101 ST MIAMI SHORES FL 33138 -2425 Contractor(s) Phone Cell Phone Valuation: $ 1, HOME O Total Sq Feet: 0 Type of Work: ELECTRICAL For Inspections please call: Additional Info: BATHROOM REMODEL (305)762 -4949 Classification: Residential Available Inspections: Inspection Type: Underground Rough Final Meter Box Alteration Relocation Fire Alarm Service Change W. W. Fees Due Amount Invoice # Total Amt Paid Amt Due CCF $0.60 EL- 11- M36521 $ 169.60 $ 169.60 $ 0.00 Education Surcharge $0.20 Notary Fee $500 Check #: 6839 Permit Fee - Additions/Alterations $160.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $169.60 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 December 02, 2009 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy December 02, 2009 1 V Miami Shores Village Noll 3 v 2009 Building Department BY:_..1� -. 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fag: (305) 756.8972 INSPECTION'S PHONE NUMBER: f305).762.4949 BUILDING Permit No. A-Z a � PERMIT APPLICATION Master Permit No JF-k . FBC 20 Permit Type ELECTRICAL Owner's Name (Fee Simple Titleholder) ( Phone # 3 Q�7 j 7 S_ Owner's Address 35 0a 2 ..City -- -�y��(.�� State �-- Zip <.J3( TenantlLessee Name Phone # Email Sf Job Address (where the work is being done) 3� IV !'✓ ''� City Miami Shores Village County Miami-Dade Zip 3 �� FOLIO / PARCEL # J®`Z p --- - - , 2> —S Is Building Historically Designated YES NO Flood Zone Contractor's Company Name Phone # Contractor's Address City State Zip Qualifier Name Phone # State Certificate or Registration No. Certificate of Competency No. Contact Phone Email Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ ` Q UP Square / Linear Footage Of Work: . Type of Work: DAddition DAlteration ONew D Repair/Replace El Demolition Describe Work: Submittal Fee $ Permit Fee $ CCF $ CO /CC $ Notary $ Training/Education Fee $ �' Technology Fee $ OlJ Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: ++ Wq Structural Review. $ Total Fee Now Due $ t 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 " I i 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 approved and a re- inspection fee will be charged. Signature Signature Own or Agent Contractor The fore oing instrument was acknow ge efore me this The foregoing instrument was acknowledged before me this day of (! 20 �Iby day of , 20 by who is p rsonally known tome or who has produced who is personally known to me or who has produced 5q iS ) identification and who did take an oath. as identification and who did take an oath. � NOTAR UBLIC: NOTARY PUBLIC: Sign: 1A C' 1"��1%�,c Sign: Print: ��, Print: My Commission Expires: My Commission Expires: �h:aec��� �k�Y: F9t3c9C3eAtk�Yk3r�Y�Y�t�YdC�ik3ek�Yk 7YsY: Y3c4tk�YdC�Y4t9Cik�4�YtYaF�1r9e3r3z�YiYsY9F�r9esCSY3:* 3e9ik�k��Y3: 3tkkdS�Y: Yk3: k4ek3:: Y9tkk�k: F4t4C *�Ydtk�Yk9tdeiroY4Cdc9t4t *4t7Yk APPROVED BY - /� �� ' Plans Examiner Zoning Engineer Clerk checked (Revised 07 /10 /07)(Revised 06/10/2009) a Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 130332 Permit Number: EL -11 -09 -1970 Scheduled Inspection Date: March 08, 2010 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: SPRINGER, LAWRENCE Work Classification: Addition /Alteration Job Address: 358 NE 101 Street Miami Shores, FL 33138- Phone Number Parcel Number 113206013528 Project: <NONE> Contractor: HOMEOWNER Building Department Comments ELECTRICAL WORK FOR BATHROOM REMODEL Inspector Comments Passed Failed Correction Needed ❑ Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. March 05, 2010 For Inspections please call: (305)762 -4949 Page 5 of 30