DS-10-344BUILDING
PERMIT APPLICATION
FBC20
Email d e w edcv t D'e4 .- V
Job Address (where the work is being done) 1 t$ -
City Miami Shores Village
FOLIO / PARCEL #
Contractor's Company Name
Contractor's Address
City State
Qualifier Name
Contact Phone
Architect/Engineer's Name (if applicable)
Submittal Fee $
Notary $
Scanning $ Radon $
Double Fee $
Structural Review. $
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
Permit No 2 )
Permit Type: BUILDING ROOFING
Owner's Name (Fee Simple TitleholderTho. \e ,lxXr )v-e 1 Phone # 305 15 ? t' 5S
Owner's Address Q me 1O4 .s
City ‘C(1 trz m t S't'25 State `r L Zip 3J � 3 S
Tenant/Lessee Name Phone #
County
Is Building Historically Designated YES
State Certificate or Registration No. Certificate of Competency No.
Training /Education Fee $
E -mail
Value of Work For this Permit $ 1E00 , o d Square / Linear Footage Of Work: •
Type of Work: ❑Addition ❑Alteration ❑New 1 Repair/Replace El Demolition
Describe Work: 1VQ..p1 St CQ.. cr o.34 t�.xa` 1{ wwk Cbna∎-lc tAxx s r no Y> cG-
1 V vs,. ■ N N°2.. ,r l {- ) of v..)Q, l
******** * * * * * * * * * * * * * * ** * * * * * * * * * * * * * ** F * * * * * * * * * * * * * * * * * * * * * * * * * * * ** **
Permit Fee $ /a tet-d CCF $ CO /CC $
Violation date:
Nc 104 s*
Miami -Dade
DPBR $
Master Permit No.
Phone #
Phone #
Zip '3313 s
Total Fee Now Due $ - 9.0
171, /DMITRI
MAR 0 5 2010
r >
131: � '.% .
Flood Zone
Zip
Phone #
Technology Fee $
Bond $
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.
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of , 20 , by - DR . .j WL__ c5' ` day of , 20 , by
who is personally known to me or who has produced who is personally known to me or who has produced
As identification and who did t k n,A0f}'. as identification and who did take an oath.
\`‘‘ 0110 ....... 1y �O '' %y am, NOTARY PUBLIC:
, /� o ./6s91 \fir
Sign: ' j ,v ii � 0 = Sign:
Print: ' co'• .,' 1 i . Print:
®''/ �4 `.4 \
$i1.18 0'
NOTARY PUBLIC:
My Commission Expires:
APPROVED BY
(Revised 07 /10 /07)(Revised 06/10/2009)
Q/
Plans Examiner
Engineer
Signature
My Commission Expires:
a6 Zoning
Clerk checked
OWNER BUILDER DISCLOSURE STATEMENT
NAME: R L es- DATE:
ADDRESS: I 6 1 - 1 0 I(O 5 ‘ . y 11 yv i CJ 'eS Fl 331
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; 1 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 properly 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.
Initiap
3. 1 understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself
from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own
name. I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on
permits and contracts.
Initial
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 byilior 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.
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
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.
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 1 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 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.
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:Uwww.myfloridalicense .corn/dbprlprolcilbr html
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:
l6cto NE (oy
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.
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a
license, the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to
assist you with any financial loss that you sustain as a result of contractor may be in civil court. It is also important for you to
understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your property, you may
be held liable for damages. If you obtain an owner- builder permit and wish to hire a licensed contractor, you will be responsible for
verifying whether the contractor is properly licensed and the status of the contractor's workers compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and
returned to the local permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the
notarized signature of the property owner, or other type of verification acceptable to the local permitting agency is required when
the permit is issued.
Was acknowledged before me this day of� �ii\ , 20 �0
who was personally known to me or who has
Produced there License or U �' � � °f %�1r �00I .s identification.
By NO o V\i
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OWNER
OWNER
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Initial
Initial
Initial
OTARY
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PAGE 03/03
01/02/2002 00:39 3055133472
Charlie Crist
Governor
Dale West
1640 NE 104 St
Miami, FL 33138
OSTDS
RE: Contingency Letter
Application Document No: AP9'.53642
Centrax Permit Number: 13-SC-1122403
OSTDS Number:
1640 NE 104 St
Miami, FL 33138
Lot: 22 Block: 4 Subdivision:
February 24, 2010
Ana M. Viamonte Ros. M.D., M.R.H.
State Surgeon. General
Dear Applicant:
This will acknowledge receipt of an application dated 02/23/2010 for a permit to use an existing
onsite sewage treatment: and dispc sal system located on the above referenced property.
There is no increase in sewage flow, no change in characteristics compromising the integrity or
function of the system.
From a review of your completed application, it has been determined that your existing system is
adequate for the proposed use..
This permit is granted for constriction of a walkway that will have no impact on the unobstructed
area.
If you have any questions on this niatter, please call our office at (305) 625 -2500.
Enclosures
cc:
Sincerely,
Miami -Da41c County Health Department
1765 NW 167 St, Opa Locka, FL 33056
Phone: (305) 625-2500 Pax: (786) 315 -2090
, Engineer Specialist 11
PAGE 01/03
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