RC-11-1040Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 160720 Permit Number: RC -6 -11 -1040
Scheduled Inspection Date: September 08, 2011
Inspector: Bruhn, Norman
Owner: ESSINGTON, MICHAEL & DOROTHY
Job Address: 55 NE 100 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: HOME OWNER
Permit Type: Residential Construction
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132060131420
Building Department Comments
BATHROOM REMODEL
Inspector Comments
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
September 07, 2011
For Inspections please call: (305)762 -4949
Page 11 of 47
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 APPLICATION
FBC 20
Permit No.
JUN 0 7 2011 Li
Master Permit No.
Permit Type: BUILDING �,�,^ a
OWNER: Name (Fee Simple Titleholder): �'J OrOT 36 1 1 { ' 1 O ` Phone #: 305 76 + ^ 71-1
JJ 306 °ate& --44L9-7 3
Address: 6 w IW:s 100 P�
City: U1 �� Qt �Me 61/115-10-S State: F L Zip: 33 15ff
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: &5 r V L 1 OD 64- . , 1
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel #: 1 1 3 ^R f 1.0 n1.43 (42()
Is the Building Historically Designated: Yes
NO
Flood Zone:
CONTRACTOR: Company Name: th/v r yr / ci 1' 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: $ �`l 000
Square/Linear Footage of Work:
Type of Work: DAddress 7 ❑Alteration New ,n ,�
Description of Work: 21`p DLa- QP.pia c cm�U
L4
epair/Replace UDemolition
_i5.. n wct h ✓ -
COLOR THROUGH ROOF TILE IS REQUIRED acknowledged by:
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * ** * * * * * * * **
Submittal Fee $ Permit Fee $ /16 aG CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
'SfJ
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) VJe'J S r ar o )-)o - trk-0 aq -e
Mortgage Lender's Address Y', D • AMC (p rp D 5 J
city 1)02 106
State —r-5c
Zip 75A6(0- 0456
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 fel a reinspection fee will be charged.
Signature
Signature
7 er or Agent Contractor
The foregoing instrument was acknowledged before me this 4, The foregoing instrument was acknowledged before me this
day of %) VW, , 20 1 , by iii f. t-, tLa ,- , day of , 20 , by
who is personally lcnown tom or who has produced who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign:
Print:
Lk.
w\ %: (f\ ck
My Commission Expires:
Sign:
Print:
My Commission Expires:
NOTARY PUBLIC -STATE OF FLORIDA
"..6 Henry Mairena
**** ** ** * * * * * ***** * * * * ****& iaB ffsi7914 D.B684.28*:r * * * *** * ****** ::: *x ** :: * *** * * *** * * *****x ********* r*** **
s'qx Expires: JUNE 10, 2011
APPROVED BY �C�—/ c�nunTTnxlzcsoxnnvahxaminer Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/1 5/09)(rev6/4/10)
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: h0(0-11-1,/ DATE: ( /1
ADDRESS: 65 NG 160 ��}) ICI AjtAi areS
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. 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 1 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 • 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
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 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.
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
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.mvforidalicense.com/dbpr /pro /cilb/iindex . t iI
Initial /\ j
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:
56 NG ( 00 Si- 1•t; ot-►k -hoteS
12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the inform on that 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 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
retumed 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.
v
Was acknowledged before me this -7 day o k---) , 20 11
Produced there License or `1 I
who was personally known to me or who has
cc O1 �J U � � `,) ' 2 aS identification.
NOTICE OF COMMENCEMENT
A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION
PERMIT NO. TAX FOLIO NO. 1 3 ®t0o'5I200
STATE OF FLORIDA:
COUNTY OF MIAMI -DADE:
THE UNDERSIGNED hereby gives notice that improvements will be
property, and in accordance with Chapter 713, Florida Statutes'
is provided in this Notice of Commencement. I Ned In t4
11111111111111111111111111111111111111111111
CFN 201 1 Rat p,. 58929
OR. Bk 27705 Ps 1724 Ups)
RECORDED 06/02/2011 11 :45 :12
HARVEY RUVINr CLERK OF COURT
MIAMI -DACE COUNTY? FLORIDA
LAST PAGE
1. Legal description of property and str address: Jai N E 100 GS1re(4,
Witt -1-e Res; clnylCe
2. Description of improvement:
Griifu. 11
r
Space above reserved for use of recording office
MI altill Shares . FL 33(38
3. Owner(s) name and address: ri ;that§ boroilt- 6 /? tVA , 55" A/E 100 Si-' /21`td:Y,U Ours
s
Interest in property:
Name and address of fee simple titleholder: 11-1)
4. Contractor's name, address and phone number. &t4JY)e_f, i� / E /06 1st , ar1 j 45'btr ,
5. Surety: (Payment bond required by owner fro contractor, if any)
Name, address and phone number i J /i3
Amount of bond $
6. Lender's name and address:
7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by
Section 713.13(1)(a)7., Florida Statutes,
Name, address and phone number:
8. In addition to himself, Owners designates the following person(s) to receive a copy of the Lienor's Notice as provided in Section
713.13(1)(b), Florida Statutes.
Name, address and phone number:
9. Expiration date of this Notice of Commencement:
(the expiration date is 1 year from the date of recording unless a different date is specified)
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED
IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE
FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK
OR RECORDING YOUR NOTICE OF COMMENCEMENT.
Signature(s) of Owne s) or er(s)' Authorized Office r/Director/Partner/Manager
Prepared By �"" °° Prepared By
Print Name 1#11 i c.>tic ( g 55 I t" Print Name
Title /Office Title /Office
STATE OF FLORIDA
COUNTY OF MIAMI -DADE -�-
The foregoing instrument was acknowledged before me this 4:44-1 day of
By fY\ it Mk e \ Es.soA i h r�
4dividually, or ❑ as J for
L Personally known, or ❑ produced the following type of identificati
Signature of Notary Public:
Print Name: 7 ! /✓etgcy ,f6SrreS
SEA J "��„
(SEAL) �tiyc.cv� NANCY JONES
MY COMMISSION # 00720821
VERIFICATION PURSUANT TO SECTION 92.525. FLORIDA STATUTES EXPIRES:November6,2011
Under penalties of perjury, I declare that I have read the foregoing and �ij ;; °.' Borabditvu Notary Pubic Unsrwrfars
that the facts stated in it are true, to the best of my knowledge and belief.
Signature(s) of Owners or Owner(s)'s Authorized Officer/Director /Partner/Manager who signed above:
By
123.01 -52 PAGE 3 3/10
55 IDO &-a
Ivy i kry1 i
EXISTING
BATHROOM #1
101 (3
n /Pe, d fir-
GrZ.
EXISTING
MASTER
BEDROOM #1
101,
EXIST.
CL.
COPY
EGG 11 04(
1/4,,
Miami Shores Village
APPROVED
BY
DATE
ZONING DEPT
BLDG DEPT
�
�j c vj
l.� ‘10-0
SUBJECT TO COMPLIANCE WITH ALL FEDERAL
STATE AND COUNTY RULES AND REGULATIONS
L, JUN 0 7 2011 L.-,
ADD SMOKE/CARBON MONOXIDE DETECTORS,
ANY AND ALL CLOTH AND RUBBER
INSULATED CONDUCTORS TO BE REPLACED.
ECG ole _ K' 6— e—
• •
• • •..•
• •
• • •
.. • •. •• •
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•
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•
•••• . • • .... • • •
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• • ..
•• •• ..
• •
•
• • • •
• • •
• • •
• .•
•• • • • • .
•
BATHROOM RECEPTACLE ON 20 AMP CKT
AND G.EI PROTECTED
-zokaktkaN
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c
• ... • •
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' u`. O O ( 3 N -„
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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- 164188
Scheduled Inspection Date: September 07, 2011
Inspector: Devaney, Michael
Il -Ib'io
Permit Number: EL -6 -11 -1044
Owner: ESSINGTON, MICHAEL & DOROTHY
Job Address: 55 NE 100 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: HOME OWNER
Permit Type: Electrical - Residential
Inspection Type: Final
Work Classification: Alteration
Phone Number
Parcel Number 1132060131420
Building Department Comments
BATHREMODEL 1 OUTLET AND 1 SWITCH AND 2 LIGHT
FIXTURES
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
Cry 2C'
September 06, 2011
For Inspections please call: (305)762 -4949
Page 17 of 19
BUILDING
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. I —
PERMIT APPLICATION
FBC 20
Master Permit No. C-C., 1 1 - C `, VV
Permit Type: Electrical
OWNER: Name (Fee Simple Titleholder): bonioy Oa Ees y l
Phone #: 30* 7814. -071/
✓ &O 5 - 2 /& - 4do 7 3
Address: 5 /v 100%5i-reek
city: R1 1 a.fV1 i 5h071€6,
Tenant/Lessee Name: l Phone #:
Email:' Y I (kf j5 f� f .(�'y1 C a-S I 1 r
State:
Zip: 33 13r
JOB ADDRESS: 1 "J ) 6 Q 5i—re( t
City: Miami Shores County:
Folio/Parcel #: ) 1 390 U Di 3 I L-1- � 0
Is the Building Historically Designated: Yes NO
Miami Dade
Zip: •33)38
1(0
Flood Zone:
CONTRACTOR: Company Name: O W /S I 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: $ aroO - 00 Square/Linear Footage of Work: (0 + `ct . 2-
Type of Work: Address UAlteration UNew
Description of Work: 11 Ft. U and
CXYIk 113-0 t
Repair/Replace ❑Demolition
ct v L X i S�-1‘ i1 &GLlii _t 1 K -
d�C
LA LA-41 r-v
* * * * * * * * *** **** * * * * * *** * * * * * ** * * ** * ** Fees* * * ** * * ** *** * * * ** * * * * * * *** * * * * * * * * * * * * ** *
Submittal Fee $ D Permit Fee $ ii--c ) Fps CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) ,I \ 5 Fa. f� o t o G)cr t L1 ai -r
Mortgage Lender's Address 4 C _ E0x tO&, 0 1+55 (� J ff
City �, 5 %5 State Zip a CAP - °LI-5 S
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
Owner or Ag Contractor
The foregoing instrument was acknowledged before me this 4 The foregoing instrument was acknowledged before me this
day of�,20t\ ,by , day of ,20,by ,
who is personally known to me or who has produced
as identification and who did take an oath.
who is personally known to me or who has produced
As identific . tion and v tlii
1_)/.0%;%"
4 11
Z`1
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
APPROVED BY
ath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
o'ar---," Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10 /2009XRevised 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
NAMEa Of 011-k/ 0/1/4._ DATE: (0-7- 1
ADDRESS: 6-6 N E I �,->7 d`16
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 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 inst- • . of my own
name. I also understand that the contractor is required by law to be licensed in Florida and to list his or li.:r.,mbers 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 substan'..I improved
improved it for sale or lease, which violates the exemption.
myself is sold or leased within 1 year after the construction is complete, the law will presume that I buil antially
0
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 a 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 willful) cling 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 co sation 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 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 Intemal Revenue Service, the
United States Small Business Administration, and the Florida Department of Revenues. I also understand that I ma tact the
Florida Construction Industry Licensing Board at 850.487.1395 or http : / /www.myforidalicense.com/dbpr /pro /cilbfinde
Initial
11. I am aware of, and consent to; an owner - builder building permit applied for in my name and understands that I am
legally and Ft responsible for the roposed construction activity at the following address:
55 Ft l i .St 14.1��
Initial
12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the informa
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
retumed 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 day of , 20 LC
By who was personally known to me or who has
Produced there License or as identificiort" ` " ®'1/,,,,�i
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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
I l -i09:0
Inspection Number: INSP - 160766 Permit Number: PL -6 -11 -1046
Scheduled Inspection Date: September 07, 2011
Inspector: Hernandez, Rafael
Owner: ESSINGTON, MICHAEL & DOROTHY
Job Address: 55 NE 100 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: HOME OWNER
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132060131420
Building Department Comments
REPLACE TOILET, SINK AND SHOWER
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
September 06, 2011
For Inspections please call: (305)762 -4949
Page 4 of 19
Protect Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
NCBF
Type: Piumbinl
an: AdditioniAiteration
: APPROVED
Parcel Number
Expiration: 12/07 /2011
Applicant
55 NE 100 Street
Miami Shores, FL 33138-
1132060131420
Block: Lot:
MICHAEL & DOROTHY ESSINGT
Owner Information
Address
Contractor(s)
HOME OWNER
Phone
CeII Phone
Phone
CeII
Type of Work: BATH REMODEL
Type of Piping: TOILET, SINK AND SHOWER
Additional Info:
Bond Retum :
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$0.60
$2.25
$2.25
$0.20
$150.00
$3.00
$0.80
$159.10
Pay Date Pay Type
Invoice # PL -6 -11 -41168
06/13/2011 Check #: 4966
06/07/2011 Check #: 4960
Amt Paid Amt Due
$ 109.10 $ 50.00
$ 50.00 $ 0.00
Available Inspections:
Inspection Type:
Top Out
Final
Underground
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.
June 13, 2011
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
Date
June 13, 2011 1
Miami Shores Village
Building Department o
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.] L I —1 01-k,4=7
PERMIT APPLICATION Master Permit No. 11--1 040
FBC 20
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder): DDrO V- I (MO
Address: t4 i=_- 1 ern t5trert
City: Yf i i vv.) i Shrtres FL.
Tenant/Lessee Name:
Email: i%)
State:
.y1 Phone #: 305- 75q- - 67) °l
3o5 - -q- - cr-(,„ 73
Zip: 3313'
Phone #:
f n 4
JOB ADDRESS: 1�/ �. / be &TE C
City: Miami Shores
Folio/Parcel #:
Is the Building Historically Designated: Yes
CONTRACTOR: Company Name:
Address:
City: State: Zip:
Qualifier Name: Phone #:
State Certification or Registration #: Certificate of Competency #:
Contact Phone #:
DESIGNER: Architect/Engineer: Phone #:
County: Miami Dade
Zip: 3 i3 g
condla
NO
Flood Zone: 0
Phone #:
Email Address:
Value of Work for this Permit: $ (p - 00 Square/Linear Footage of Work:
New ARepair/Replace
Type of Work: ❑Address
Description of Work:
❑Alteration
ouA- avl
❑Demolition
* **:x t**** ******x:***** *** * * **** *** * *** Fees ******** ****** * * ** ****** * *** x**:x***** ******
Submittal Fee $ Permit Fee $ /5 ® CCF $ CO /CC $
_ - - -fig
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) ej �G( c / +JYYc) !0 taar .
Mortga a Lender's Address i . C .e'(i)( l0 (D o i-5 5 �J J"
City Cd 10,5 State Zip / 5Q /c - 6453-
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
Contractor
The foregoing instrument was ac owledged before me this The foregoing instrument was acknowledged before me this
day of —S ( , 20 u , by ,� CT ' ILS1 tA0-1P ay of 20 _, by
who is personally known to me or who has produced 1"L" who is personally known to me or who has produced
As identification and who d
.■
NOTARY PUBLIC:
Sign:
Print:
My Commission Ex ' ires:
!Ii 1,711511;; �'1tuil
w-
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
*:x **:x************* k****:k . * ** *********************************************** ************* ****** * * * **** * * * **
APPROVED BY // 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: D®rp1''h1 ess t n3i-On DATE: CD ' 7 - I 1
ADDRESS: e t f Ile *CeLT) Lit i a,rNl iI k5 f, FL
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.
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 ', tead of my own
name. I also understand that the contractor is required by law to be licensed in Florida and to list his or a mbers 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 bu i• substantially
improved it for safe or lease, which violates the exemption.
Initial
5. I understand that, as the owner- builder, I must provide direct, onsite supervision df the construction.
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 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 com,ensation 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.
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/dbor /pro /cilbfiind tml
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 informa hat 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 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 "J— , 20 \-k
By my " 13 was personally known to me or who has
Produced there License or
WNER
as identification.
oI
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