EL-10-1831.4
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 152371
Scheduled Inspection Date: August 25, 2011
Inspector: Devaney, Michael
Owner: CANARY, JAMES
Job Address: 9835 NE 4 Avenue Road
Miami Shores, FL 33138-
Permit Number: EL -10 -10 -1831
Project: <NONE>
Contractor: HOME OWNER
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132060170180
Building Department Comments
RELOCATION POOL EQUIPMENT
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
August 24, 2011
For Inspections please call: (305)762 -4949
Page 2 of 18
(61,v2,1(0 c 'e2.3
142.�G,D 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
BUILDING Permit No.E I I OH4
e
PERMIT APPLICATION
FBC 20
Master Permit No.
Permit Type: Electrical
OWNER: Name (Fee Simple Titleholder): 6--;417-A 616'GVl✓ Phone #: 30 5--- Y9a VaJ‘
Address: 983 ti6- e��
City: /"�(/ , r 5 /-6,---- S State: � ra�-F Zip: 35/3
Tenant/Lessee Name: "'/- Phone #:
Email: ('C,4 7e-74 6e,773- lse714 nA
JOB ADDRESS: 9Y S'- Ne Z
City: Miami Shores County: Miami Dade Zip: 31/ P
Folio/Parcel #:
Is the Building Historically Designated: Yes NO 'c Flood Zone:
CONTRACTOR: Company Name: �N�� -- Phone #:
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ ZOO Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace
Description of Work: l/ ZG-4 -7 4./ O/ eJ of /r/ie7
Demolition
* *************x:a *** * * * * * ** *********** ** Fees**********+ x***x:* *****+ x+x*+x+x********* * * *** ****
Submittal Fee $ Permit Fee $ /ir ®, " CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 119+ V
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, BOIT FRS, 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
Owner or Agent Contractor
The fo (oi instrument was jow ed before The foregoing instrument was acknowledged before me this
day of�°L , 201®, by,Y! ►�k day of , 20 , by
onally known to me or who has produced I who is personally known to me or who has produced
L_. '.!identification and who did take an oasis as identification and who did take an oath.
who is p
NOTA
Sign:
Print:
My Commission Expires:
/c7
Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Zoning
Clerk
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: - r��/724 3 DATE: /0,
ADDRESS: 9e35---- 01,6
he/0
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.
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.
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 to be licensed in Florida and to list his or license umbers 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 built or sybstantially
improved it for sale or lease, which violates the exemption.
5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction.
Initial
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.
Initial
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 a9ting 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.
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 G'
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 ntact the
Florida Construction Industry Licensing Board at 850.487.1395 or http: / /www.mvfloridalicense.com /dbpr /pro /cilb /indexI
Initial
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
12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the information, at I
have provided on this disclosure.
Initial L
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 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 1,K day of N , 20 Q
Produced there License or
who was personally known to me or who has
as ident 'cation.
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LEGAL DESCRIPTION: LOCATION MAP
LOTS 1 AND 2, BLOCK 87, AMENDED PLAT OF MIAMI SHORES SECTION
No.4, ACCORDING TO THE PLAT THEREOF, AS RECORDED IN PLAT BOOK
15, PAGE 14 OF THE PUBLIC RECORDS OD MIAMI —DADE COUNTY,
FLORIDA.
ADDRESS: 9835 NE 4TH AVENUE RD.
SURVEYOR'S NOTES:
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1).No underground installations or improvements have been located.
2).No instrument of record reflecting easements, right of way, and/
or ownership were furnished to this surveyor. :�?
3).This survey has been prepared for the exclusive use of the entities
named hereon and the certification hereon does not extend to any
unnamed party.
4).Record and Measurement calls are in substantial agreement, unless
noted otherwise.
5).Ownership of fence is not determined.
6).Dimensions shown are per plat unless otherwise noted.
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BASED ON THE FLOOD INSURANCE RATE MAP OF THE FEDERAL EMERGENT MANAGEMENT AGENCY DATED OR
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BASE FLOOD ELEVATION VA__ COMMUNRY 120852 PANEL NUMBER $�7F IX 1 • .• • • • • •
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• ELEVATIONS(WHEN SHOWN) REFER TO N.G.V.D„ 1929 DATUM, : • • • • • •
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DW =DRIVEWAY .C.C. =POINT OF COMPOUND CURVATURE PG.
ER PAD F.B.C. F B C. =FOUND SOCK CORNER NGVD =NATIONAL GEODETIC VERTICAL DATUM p.C. =POINT OF CURVE K
DIST. =DISTANCE p N.D. =FOUND NAIL do DISC N D NAIL & D P.T. =POINT OF TANGENCY r K•M °PE
EL. =ELEVATION F.D.H =FOUND DRILL HOLE T.S. =NOT TO L.S =PROFESSIONAL
pp HH P.O.C. POC =POINT OF COMMENCEMENT
F I.P. =FOUND IRON F.N. A EL =GARAGE ELLEVATION /SO• OFFS E P.O.B. =POINT OF BEGINNING ERR =RECORDED
R F��ND I N ROD LP. =LIGHT POLE 0.K =OVERHEAD P.R.C. =POINT OF REVERSE. CURVATURE R/w
K STRUCTURE =fib B =LENGTH O.R.B =OFFICIAL RECORD BOOK P.P. =POWER POLE R
FENCE F.F.EL =FINISH FLOOR ELEVATION I(M =MEASURED L =PLANTER e C� P. = ERMANIN CONTROL POINT RGE.
FD. =FOUND MON. =MONUMENT =PROPERTY UNE UP. °PLAT S =SE
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MAIJENT REFERENCE MONUMENT S.I.P. =SET IRON PIPE U3. '9�$ •® • •
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S U.E. =UTILRY EASEMENT • • •
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DRAWING NAME
BOUNDARY SURVEY
JOB No. CH 08031
CERT1T7 T1ON
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LAND INC
PROJECT:
9835 N.E 4TH AVENUE
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CARLO —_S A HERNANDEZ, F.S.M. 5718
STATE OF FLORIDA
NOT VAUD WITHOUT EMBOSSED SEAL W. # 5004
`I M 33014 210
DATE F.WORK:
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PHA; 305 807 -8940 FAX:308 823-9808
PREPARED FOR:
J & K CANARY
DATE DWG: 09 13 08
DRAWN BY: A.A
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LEGAL DESCRIPTION: N.T.S.
LOTS 1 AND 2, BLOCK 87, AMENDED PLAT OF MIAMI SHORES SECTION
No.4, ACCORDING TO THE PLAT THEREOF, AS RECORDED IN PLAT BOOK
15, PAGE 14 OF THE PUBLIC RECORDS OD MIAMI-DADE COUNTY,
FLORIDA.
ADDRESS: 9835 NE 4TH AVENUE RD.
SURVEYOR'S NOTES:
Miami Shores Village
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1).No underground installations or improvements have been located.
2).No instrument of record reflecting easements, right of way, and
or ownership were furnished to this surveyor.
3).This survey has been prepared for the exclusive use of the entities
named hereon and the certification hereon does not extend to any
unnamed party.
4).Record and Measurement calls are in substantial agreement unless
noted otherwise.
5).Ownership of fence is not determined.
6).Dimensions shown are per plat unless otherwise noted.
ELEKAINEMMeglatk
BASED ON THE FLOOD INSURANCE RATE MAP OF THE FEDERAL EMERGENT MANAGEMENT AGENCY DATED OR
REVISED ON _MEL% THE HEREIN DESCRIBED PROPERIY IS SITUATED WITHIN ZONE X
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BASE FLOOD ELEVATION N/A commuNny 120852 PANEL NUMBER 0093 SUFFIX 4
,
ELEVATIONS(WHEN SHOWN) REFER TO N.G.Y.D., 1929 DATUM, ••••
• • •
•• • ••••
• • •
• • •
D.M.E. =DRANK-GE MAINTENANCE EASEMENT FT.- , M =MONUMENT LINE P.C.C. =POINT OF COMPOUND CURVATURE PG. =
LEGE:s10; A ,.. 1 • INV =DRNEWAY k i , ' -F;ELC. =FOUND BLOCK CORNER NGVD =NATIONAL GEODETIC VERTICAL DATUM P.C. =POINT OF CURVE
AG _ STY. =STORY • i 411 OR ANGLEee.•
=SIDEWALX • •
E •
N itrr REFERENCE MONUMENT s i p =SET IRON PIPE LB( MA' Eimi =colitriNETE •
ROFESS ONAL IAND SURVEYOR S.I.R. =SET IRON ROD LEI. 9904• • . co OEN CE
DISTANCE
LROAD T =TANGENT V:* sr .•' filNK FEMCIE:••
-OF-WAY 7WP. =TOWNSHIP .., =C.BS. WALL
U.E. =UTILITY EASEMENT • • ••% 1____ a
U.P. UTILITY POLE • V - 1'..OM ON
N. Iii W.M. =WATER METER U.C. •••• UNDER CONSTR§ZOOM•
, -
1 DV 2g DIST. =DISTANCE 5 , - - E.N.D.--, =FOUND NAIL & DISC r =NAIL & P T =POINT OF TANGENCY „ :
. • TEL =E1EVATION , - ' F.D,,H.' \ =FOUND DRILL HOLE .T.S. =NOT TO P.O.C. =POINT OF COMMENCEMENT P.L.S. =
• • ' ' F.N. ' =FOUND NAIL -NO. =NUMBD4 P.O.B. =POINT OF BEGINNING (170 =RECORDED
••• • F.H. =END I' *N PIPE , 11', C' ,', ' ' =GARAGE ELOATION 04S =OFFOLT R. =
: • 1 F.1§R. :WEIJgD:1.-: ROD c , \ _3, k 9 i ,•li .1-1FmGHTGTHPOLE , =OVERHEAD P.R.C. =POINT OF REVERSE CURVATURE =
RE O.R.B. =OFFICIAL RECORD BOOK P.P. =POWER POLE
-C441'''f.1' BLOCK STRUCTURE F.F.EL =FINISH FLOOR ELEVATION ' M =MEASURED PL =PLANTER :8:13. :0411MBAN CONTROL POINT RGE =RANG
CONC. • ,=1,1 itI..: FD. =FOUND M . =MONUMENT lt =PROPERTY LINE S =SE
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DRAWING NAME:
BOUNDARY SURVEY
JOB No. CH-08031
CERTIFI t" TIO
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By______-... r the firm
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140:160. AURVT141:3. • INC. • • •
PROJECT:
9835 N.E 4TH AVENUE
sem e.w. let seat St6t/to
MIAMI utas, re 33014
PH# 305 807-8840 FX5305 823-8805
F B.
CARLOS A. ,,P1ERNANDEZ, F.S.M. 5718
STATE OF FLORIDA
NOT VALID WITHOUT EMBOSSED SEAL LB. # 5004
DATE F.WORK•
DATE DWG: CWE3 (Th
PREPARED FOR
J & K CANARY
DRAWN BY: A-A
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Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 152380
Scheduled Inspection Date: August 26, 2011
Inspector: Hernandez, Rafael
Owner: CANARY, JAMES
Job Address: 9835 NE 4 Avenue Road
Miami Shores, FL 33138-
Permit Number: PL -10 -10 -1832
Project: <NONE>
Contractor: HOME OWNER
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132060170180
Building Department Comments
RELOCATION OF POOL EQUIPMENT
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
August 25, 2011
For Inspections please call: (305)762 -4949
Page 2 of 9
Miami Shores Village WggyMill
Building Department OCT 1 8 201'
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING Permit No. 1Ci
PERMIT APPLICATION Master Permit No.F L ) 0 —1 � \
FBC20
Permit Type: PLUMBING 11 I
OWNER: Name (Fee Simple Titleholder): cAe1� �5 kAV Phone#: 5^ o'*O 6 Co
Address: 3 Se- NLs - 2v
City: M ti` 5/1C?' 5 State: r(-49/e-r'del-- Zip: 3�/ .3�?
Tenant/Lessee Name: 4✓ /c'� Phone #:
Email: Cents �'e //o ( !S €ZLs17v724 . (V-Cr
JOB ADDRESS: 78 3 S— 4/ scr7/-
City: Miami Shores
County:
Miami Dade Zip: 3 3 / 3 i?
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO l< Flood Zone:
CONTRACTOR: Company Name: f�r/QjL Phone #:
Address:
City: State: Zip:
Qualifier Name: Phone #:
State Certification or Registration #: Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ ®®• Square/Linear Footage of Work:
Type of Work: DAddress OAlteration Poo DRepair/Re/place ODemolition
Description of Work: focA- 4,94t/ Poo Z eRcn�M& -*
******** ******** * ** ** ******* *********** Fees*************: ** **** ***** ** * * * * * ****** ** *** **
Submittal Fee $ Permit Fee $ /00 e CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 1 la' G
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 if r Signature
caner or Agent J Contractor
The for mg instrument was a owl d b e thins / The foregoing instrument was acknowledged before me this
day of , 2013 by day of , 20 _, by
who is r ersonally known me or who has produced V / who is personally known to me or who has produced
identification and who did take an oath. as identification and who did take an oath.
NOTA " !PUBLIC:
Sign:
Print:
My Commission Expires:
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
APPROVED BY itC Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
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: 61/1-5 �95 V1 DATE: '0C l Re/0010
ADDRESS: 9/ Ur /VG 4//A06— rZ)4(5/9'
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.
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.
Initial ��✓
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.
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 built or substantially
improved it for sale or lease, which violates the exemption.
5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction.
Initial
Initial /sT
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
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 agting 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.
Initial c�
. 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.
Initial C /f�
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 : / /www.mvforidalicense.com /dbpr /pro /cilb /index.htynl
Initial
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
Dally and financially responsible for the proposed construction activity at the following address:
Initial
12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the information at I
have provided on this disclosure.
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 properly licensed and the status 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 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 ;'f- , 2010
who was personally known to me or who has
Produced there License or
as iden ''cation.
NOTARY