MC-11-76Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 20
Permit t T MECHANICAL s_ 20
Owner's Name (Fee Simple Titleholder) ' 0 (t -Q (01
Owner's Address
at JAN i3 2010
BY:
Permit No. Yr\C" 1 1— 1 ce,
Master Permit No.
Phone #
mss- �FsY -1/6/
City //lei v''i Sit 0Y State fL
Tenant/Lessee Name
Email
l ec e , e c?
Job Address (where the work is being done) /2 �r`✓F (.75-14-
Zip
City Miami Shores Village
FOLIO / PARCEL #
County Miami -Dade
Is Building Historically Designated YES
Contractor's Company Name V (iU A)-(
Contractor's Address
Phone # - jam- 4/5-r- :/ ;/
NO
Zip 33/3
Flood Flood Zone
Phone #
City State Zip
Qualifier Name
State Certificate or Registration No.
Contact Phone
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ 00e). f ()
Type of Work: ['Addition ❑Alteration ['New
Describe Work:
Square / Linear Footage Of Work:
❑ Repair/Replace ❑ Demolition
Win_ e
***** l*** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $5P(]
Notary $
Scanning $
Bond $
Permit Fee $
Training/Education Fee $
Radon $
CCF $
Technology Fee $
CO /CC
DPBR $ Zoning $
Code Enforcement $
Structural Review. $
Double Fee $
Total Fee Now Due $
See Reverse side —>
Bonding Company's Name (if applicable)
Bonding Company's Address
City
It■
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 F1.F.CTRICAL 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."
l/otice 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 he approv and a reinspection fee will be charged.
Signature.
er or Agent
The foregoing instrument'' was acknowled/ ed before me this 13
day of 1 , 20 X1.1, by S[vt4 v -764443
who is personally known to me or who has produced 4._ i) '
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
`ee,`o:it.i `i
iiiij4r'
N.
•. 7,
vat
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
f,
Signature
Contractor
The foregoing instrument was acknowledged before me this
—
day of ,20 -,by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
*********** s**************** s***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY
Plans Examiner
Engineer
(Revised 07 /10!07)
Zoning
Clerk checked
4 1
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 7952204
Fax: (305) 756.8972
AIR CONDITIONING REPLACEMENT DATA
PERMIT NUMBER: MC
This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data
sheet. Multiple units on single sheets are not acceptable.
Job Address (where the work is being done): / 77 A../� 9 7s ?e=
City: Miami Shores Village County: Miami Dade Zip Code: 33/3
ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB
ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION
A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS
ARI (AHRI) DATA SHEET REQUIRED
Change Disconnecting means: YES ❑ NO ❑ ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑
UNIT BEING REPLACED
DATA
NEW UNIT
MANUFACTURER
AHU or PKG. UNIT MODEL #
COND. UNIT MODEL #
KW HEAT
NOM TONS
AHU CU
PKG
1) M.C.A
AHU CU
PKG
AHU CU
PKG
2) M.O.P
AHU CU
PKG
AHU CU
PKG
3) VOLTS
AHU CU
PKG
PKG UNIT
/
/
PKG UNIT
/ /
EER/SEER
YES
NO
REPLACING DUCTS
YES
NO
YES
NO
REPLACING THERMOSTAT
YES
NO
YES
NO
NEW 4 "CONCRETE SLAB
YES
NO
YES
NO
NEW ROOF STAND
YES
NO
YES
NO
NEW RETURN PLENUM BOX
YES
NO
1. Minimum Circuit Ampacity (Wire Size):
2. Maximum Overcurrent Protection (Fuse /Breaker Size):
3. Voltage of Circuit (208/240/480):
4. Size Disconnecting Means:
Contractor's Company Name: Phone:
State Certificate or Registration N. Certificate of Competency N.
Signature Date:
(Qualifier's signature only)
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: JOrj2 / 0/e{.4 DATE: / /13///
ADDRESS: ;Qft La 79 ' 7 5 31L-
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
permit under an exemption from the la T
contractor with certain restion
d have applied for an owner - builder
er of the property listed, may act as my own
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 '1"U
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 °aJ�
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
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. 1, 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. 1 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 Obr
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.
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 http: / /www.myfloridalicense.com /dbpr /pro /cilb /index.html
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:
•
i 2 7 /�// % 7 ;1- / %// t sal v, -2 / �J 3373
Initial "`�6
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
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.
Was acknowledged before me this r day of t 20
ByS(l AE 'C ()
crt_J
Produced there License or
who was personally known to me or who has
as identification.
■
RY