PT-10-870174 NW 109 Street
Miami Shores, FL 33168-
Owner Information
Miami Shores Village
10050 N.E. 2nd Avenue
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
Fees Due
CCF
Education Surcharge
Notary Fee
Permit Fee
Technology Fee
Total:
Amount
$0.60
$0.20
$5.00
$80.00
$0.80
$66.60
Address
VICTORINA PALOMO
174 NW 109 Street
MIAMI SHORES FL 33168 -4317
Type of Work: Exterior
Color.
Additional Info: paint
Classification: Residential
Color. Approved
Color. _Approved_
Code Comments: WALLS - BROWN / FASCIA, DRIP
Color. _Denied
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.
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
May 17, 2010
iss ue' at 5117120/ 0.
'e rt Type. Pai
lassifrca ort. Add itloM eratl
Pe
it Status APPROVED
Phone
Amt Paid Amt Due
Pay Date Pay Type
Invoice # PT -5-10 -37911
05/17/2010 Check #: 2406 $ 66.60 $ 0.00
Expiration: 11113 /2010
May 17, 2010
Date
CeII
Available Inspections:
Inspection Type:
Final
1
«•
Inspection Number: INSP- 143576 Permit Number: PT -5 -10 -870
Scheduled Inspection Date: June 30, 2010
Inspector: Bruhn, Norman
Owner: PALOMO, VICTORINA
Job Address: 174 NW 109 Street
Miami Shores, FL 33168-
Project: <NONE>
Contractor: HOME OWNER
Building Department Comments
Passed i 4e
Failed
Correction
Needed
Re- Inspection
Fee
June 29, 2010
op
�n �d
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspector Comments
For Inspections please call: (305)762 -4949
Permit Type: Paint
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1121360100230
Page 7 of 19
f
4.
Inspection Number: INSP - 143576 Permit Number: PT -5 -10 -870
Scheduled Inspection Date: June 30, 2010
Inspector: Bruhn, Norman
Owner: PALOMO, VICTORINA
Job Address: 174 NW 109 Street
Miami Shores, FL 33168-
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
Permit Type: Paint
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1121360100230
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
June 29, 2010
For Inspections please call: (305)762 - 4949
Page 7 of 19
BUILDING
PERMIT APPLICATIO
FBC 2004
Permit Type: PAINT PERMIT
Owner's Name (Fee Simple Titleholder)
Owner's Address / 14 Ai • cell
City 1•.•{ 0 JO t fLL5 State i
Tenant/Lessee Name ,
E -MAIL:
Is Building Historically Designated YES
Describe Work:
Application is hereby made to Main a permit to do the wor
and that all work will he performed to meet the standards o
ELI-CTRICAI. WORK. PLUMBING, SIGNS, WELLS. P
"WARNING TO OWNER: YOUR FAILURE. T
IMPROVEMENTS TO YOUR PROPERTY. IF VOl
RECORDING YOUR NOTICE OF COMMENCEMEN
Notice to Applicant: .1s a condition to the issuance o fa hui
notice of commencement and construction lien law hrochur
of commencement must he posted al the job site for the first
inspection will 1701 he approved and a reinspeclion fee will
Permit Fee $
Training /Education Fee $
Double Fee $ Zoning
1\4iami Shores Village
wilding Department
1 1)50 N.E.2nd Avenue. Miami Shores, Florida 33138
Tel (305) 795.2204 Fax: (305) 756.8972
Master Permit No.
o9S '�
Lc3rZ�`
00 A
Zip "3 3 , 6'?
Phone #
Job Address (where the work is being done) ` NHS ‘cD — 1 S
City Miami Shores Village County
FOLIO / PARCEL #
Miami -Dade Zip
Contractor's Company Name 0 (4t,;AJL Phone #
Contractor's Address / ? J • /U ' u'J e 0 9 5 e
City G-f ('3 ex/ i Pi-o As- 5 State f /o FZ i 44 Zip 3 3 / (0 1?
Qualifier Name 4 v i . S 50 (t I sz.A 0
Permit No. r lO — Cr
Phone # . 0 51 cP1 CI',/ / ro a 0 2
303) .7 . c/ci -fo o Z.
Phone # C 3 05 A s«, 6 al-
State Certificate or Registration No. Certificate.of Competency No.
OWNER BUILDER:
Value of Work For this Permit $ X 'd a ° Type of Work: ❑ Addition / ❑ Alteration / ['New / ❑ Repair /Replace
and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit
II laws regulating construction in this jurisdiction. 1 understand that a separate permit must he secured titr
)LS. FURNACES, BOILERS. HEATERS, TANKS and AIR CONDITIONERS, ETC
RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
INTEND '1'O OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
ding permit with an estimated value exceeding $2500. the applicant must promise in good faith that a cop} Olt he
will be delivered to the person whose property is subject to attachment. Also. a certified copy oldie recorded notice
k nspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice. the
e charged.
**************F
CF $ Technology Fee: •
Notary $ • . • Code Enforcement$ -
Total Fee Now Due $ (4 • 6O
See Reverse side --�
Signature
Directions: Please circle corresponding number to appropriat(
Walls:
Fascia:
Drip Cap /Drip Edge:
Soffit: I 2 3 4
Roof I 2 3 4
Flower Bins:
Shutters:
Awnings:
Chimney:
My Commission Expires:
Doors and Door Jams:
Garage Doors: I
Railings: l
Fences:
All brick (simulated or regular:
PAINT COLOR APPROVAL AND AGREEMENT
All elements on the site must be listed and indicate the color to be painted
3
3
3
4
Stucco Banding: 1 2 3
Any other Stucco Features:
Accessory Buildings Other:
4
4
4
4
4
4
4
Aw'i= �
=a•' i-
4
id
OWNER'S AFFIDAVIT: 1 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.
Signature
Owner or Agent � Contractor
The foregoing instrument was acknowledged hefore me this 1 ` 1 The foregoing instrument was acknowledged hefore me this
day of VN>e . 20 I \It Gl U 2t 4,-- 7kt-sYrxlay or . 20 . by
who is personally known to me or who (No iti9 d (.4._ D who is personally known to me or who has produced
As ides titisat \t? I. '�� . an oath. as identification and who did take an oath.
NOTARY
I'll ' -4 . i 0699LO a' • . <f ) NOTARY PUBLIC:
uoISSIW
Sign: _. = Sign:
Print: = = Print:
Z UCI9UI ;:
c o.•. saatk a�
My Commission Expires:
' "i; a 4/!.9 $ \
... * * * * * * * * * * ** * ** * * * ** * ** aY**** oka4*x a47:**** nlr* ***a'r****ire4+k #sYak********* :' r* ***kx*****4exx9e*ic9r3r******
ti
APPLICATION APPROVED BY: . Plans Examiner
Preservation Board
Code Enforcement
(Revised 04/24/0-i
s
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: iir+ /: Q rJ AF PA totuuo DATE: 57r 9 /2.0f 0
ADDRESS: / 0 S ;#10-1, ifu$
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.
l J
Initial 1/ `
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 V • P
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. a f
Initial t/ ° P
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 l/ P
5. I understand that, as the owner- builder, I must provide direct, onsite supervision of the construction.
Initial V - 1
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 V
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.
Was acknowledged before me this n day of iM , 20 i
Produced there License or
OWNER
0\\ 0 0 . 43 itit
p`ijtion.
s9/ i s s/ : N
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 V e P
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 htto://www.myfioridalicense.com/dbor/orokilb/index.html
Initial V. P
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 1/ P7
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 1
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 Toss 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.
By who was personally known to me or who has