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RC-10-1171Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 146962 Permit Number: RC -6 -10 -1171 Scheduled Inspection Date: September 22, 2010 Inspector: Bruhn, Norman Owner: DAVIS, JADE Job Address: 115 NW 109 Street Miami Shores, FL 33168 -4316 Project: <NONE> Contractor: HOME OWNER Permit Type: Residential Construction Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1121360030230 Building Department Comments KITCHEN REMODEL Inspector Comments Passedy( /4' Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. September 21, 2010 For Inspections please call: (305)762 -4949 Page 5 of 20 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 115 NW 109 Street Miami Shores, FL 33168 -4316 1121360030230 Block: Lot: JADE DAVIS Owner Information Address Phone Cell JADE DAVIS 115 NW 109 Street MIAMI SHORES FL 33168- i Contractor(s) HOME OWNER Phone Cell Phone Valuation: Total Sq Feet: $ 10,000.00 130 1 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: KITCHEN REMODEL Stories: Front Setback: Left Setback: Bedrooms: Plans Submitted: Yes Certificate Date: Bond Retum : Occupancy: Single Family Exterior: Rear Setback: Right Setback: Bathrooms: Certificate Status: Additional Info: Classification: Residential Fees Due CCF DBPR Surcharge Education Surcharge Notary Fee Permit Fee Radon Surcharge Scanning Fee Technology Fee Total: Amount $6.00 $0.85 $2.00 $5.00 $300.00 $0.65 $9.00 $8.00 $331.30 Pay Date Pay Type Invoice # RC -6 -10 -38277 06/25/2010 Check #: 2681 $ 50.00 $ 281.30 07/28/2010 Check #: 2686 $ 281.30 $ 0.00 Amt Paid Amt Due Available Inspections: Inspection Type: Final PE Certification Shutter Final Window Door Attachment Tie Beam Slab Termite Letter Framing Insulation Drywall Screw Shutter Attachment Window and Door Buck Ceiling Grid Fill Cells Columns Declaration of Use 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. July 28, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date July 28, 2010 1 Miami Shores Village Building Department '0050 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 Type: BUIE NG R HNG C1 ' Name (Fee Simple Titleholder) �G l/�S ? one .# 44* , , ___ - l i -0- Addre City l"tla-VLY 1Ofiv' State '1 C--- Permit No CAC In Master Permit No. Tenant'Lessee Name Email Job Address (where the work is being done) II Zip _31� City -,.:,r y �.� =Miami Shores Village County Miami-Dade FOLIO / PARCEL # �� - bQ 3 - 3 Q Is Building Historically Designated YES NO 1� Contractor's Company Name Contractor's Address Phone # Zip tate Phone # Flood Zone fv Zip 4,4011 x -r; Phone # 5' #afe C`ertifi`cal or Registration No. Certtite of Competency Contact Phone E -mail Architect/Engineer's Name (if applicable) Phone ■ Value of Work For this Permit $ Type of Work: EAddition Pi 000 Square/Linear Footage Of Work: eration []New O Repair'Replace Describe Work: s % (r../.17(rVef War ❑ Demolition Submittal Fee $ Permit Fee $ Notary $ ,E) Training/Edtl ion Fee $ 9C'00 Scanning $ Radon $ 0-(0S- - (Qs DPBR $ 04,VS--- Double Fee $ Violation date: Structural .Z0 Total Fee Now Due $ See Reverse side --> Bonding Company's Name cif applicable) Bonding Company's Address Cry State :Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address ; City Stag: Zip r...�» Application is hereby made to obtain apertnit :to 40 the work . and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that ally work will: be performed to meet, the standards of all laws regulating construction in this jurisdiction.:- I understand that a separate perthtt ninst he secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable,-.1 regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEME1OS 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: A, 'a•condition to the issuance of a building permit with an es' fed value exceeding $2500, tl u2` (1 cop r of the notice of commencement and construction lien law brochure will be delivered to the person attacl tt, Also, a certified copy'.df the recorded notice of commencement must he posted Czt the job site ch oeclt ser n: � - .c�ys. uft�r 14e: building pernnt • is issued. 1n the absencc of suela posted notice, tlae Ved and a reins. fe0;w00:-ckk irged, Signature Signature... Contractor The fbr-egoing instrument was acknowledged before me this to me or who has produced o1 is identification and who did take an oath, as identification Owner or Agent The fore day of . who is oin istr urnent was a ersonaily NOTA Sign: Print: My Commission Expires: ow dged before the .hi , 20 , by who is personally known to me or who has produced YiPUBLIC: NOTARY PUBLIC: Sign: - `:;' "` c'•• Pmts ter;. ;500-• My Commission Expires: who did take a iris*•k******* *x** *** -k**** *k- ,t..--k* **** **k ',.* *** ***k;*:-: c**** * ***'k,k *****;kk****k* *** k-k**,;. *k?`k APPROVED BY Plans Examiner' (Reined 07,10 /07)(Rcvised 00/10;2009) :Engineer NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO. `° F 1' TAX -FOLIO NO. STATE OF FLORIDA: COUNTY OF MIAMI -DADE: THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 1. Legal description of prope and street/address: k ) JA L �L 111.0.°7111111 2. Description of improvement: 3. Owner(s) name and address: dr do — 111111111111111111111111111111111111111111111 CFN 20108)524 29 OR Bk 27366 Ps 0908i Ups) RECORDED 07/27/2010 13:39:38 HARVEY RUVIFi► CLERK OF COURT MIAMI -DADE COUNTY, FLORIDA LAST PAGE 0 C3 tf OW 0 ditfr‘ Interest in property: TI1V -- Name and address of fee simple titleholder: 3 wbg, 4. Contractor's name and address: 5. Surety: (Payment bond req Name and address: Amount of bond $ 6. Lender's name and address: r Z. -1`• • 0, . u.;: .::.� .nom «. by owner from contracttr 4 7. Persons within the state of Florida designated by Owner u provided by Section 713.13(1)(a)7;, Florida Statutes, Name and address: y,t iP. Mathis Is e office rzo S kand -, • OaYI Sae2 of Clad latexA `tea ✓Ff.D118 whom notices or other documents may be served as 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 and address: 'ration date of this Notice of Commencement: (the expiration date is 1 year from the date of recording unless a //Pt Signat '= of Owner -' S Print wner's Name Sworn to and subscribed before me this 1 t day of 4., , Notary Public' Print Notary's Name My commission expires: 123.01 -52 PAGE 4 .8[02 %NO "Uiij11 ! t� •..••— Prepared by R3-11.4 Addres 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: (71t09S DATE: (A c, l� ADDRESS: 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. Initia 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I 'ay 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 , a: se 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 th .y ;, 'It 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. Initia Initial 6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working n my building or residence. It is my responsibility to ensure that the persons whom I employ have the license required by law d 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 prope Initi 8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is of 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 wor mpensation 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 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. myforidalicense .com /dbpr /prodex.html 11. I am aware of, and consent to; an owner - builder building permit applied for in my name and understands that I m the party legally and financially responsible for the proposed construction activity at the following address: 001(35f; 452,1 - Initial 12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the in 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. Was acknowledged before me this a5 day of / ) , 2010 By 0a4ho was personally known to me or who has Produced there License or L9t 01-0 04 • �� • 0 Ol es identification. OWNER NOTARY NOTARY 7-TUC-STATE 67 FLORIDA CJE+i1 ,01 V. Ci*! 1UOS �:o xt�'..1 SEEP. 23, 7 vf BONDED T}3RII ATLANTIC BONDliNG CO., INC. WO (NM) 4.5 9.80' b4.00' cfr Conc. 21.90 A/C ORS. 6.0' 12.70'.. FIRWO (N�*) 03 0 rip.r. Nato cb 0° ei 2.3 %NM 1111 111111 IW NM 11111 -.all MUM,. mi dU wain, .4•1/1• Drivewo UMW, AIMS •111111111111L .1111•111111111111P.' •11111111111111111111L •1111111111•1•" '11111111111111111 • Are 11E4. cO ••••••• • • • • • • • 1 • . • '6.4)(RY/.`..4:. Sidewalk* ••""• cv 12' Gross Parkway da) t.1`. 006'. 16. p. (400) 704.32' M R °Co) 8. •mar scale: 1"/20' 10' Asphalt • • • • • • • • • • ModJo Gross N.W. losth Street Property Address: 115 N.W. 109 STREET, MIAMI SHORES FLORIDA 33168 a • I HEREBY CERTIFY TIM MSS 'BOUNDARY MAW ATRUE AND CORRECT REPAESENIXTICX1 OVA SURVEY PREPARED UNDER MYDIRECTION. TONSCOMPME MTh • URNMIUSI TECHNICAL STANDARDS AS SET FORTH EY UPSTATE OF FLORIMODARD OF PROFESSIMAL IANDS SWAM FLORIDA ADMINISTRATIVE CODE PURSUANT TO NW?. FLORIDA ST SIGNED MIGUEL ESPINO STATE OF FLOR FOR THE FIR11 P.S.M. N0. 5101 NCIT VAL= lart..11,44 4.771.112AML 1.110.170,11Z UOU*U.flflU ALITHENT6C01112 M.11C,Ct4C1301. AMOR 'MS MAP hi/7MM ViratOUTTHESIGWVILAS 03.13,4HCRIMNAL RkI3E:13842. =Ex= SIZIWICP ANDI.I.PWL Notes: NO NOTES MIGUEL ESPINOSA LAND SURVEYING, INC. 10665 SW 1901.11 Street Suite 3110 MIAMI, FL 33157 PHONE:(305) 740-3319 FAX #:(305) 669-3190 LB # 6463 Accepted By ECIWYED JUN 15" f/Y /6,728 ,Pc'' ez J e p w-wre' A-01091 �- 6 LI 6-he'd-7/ iz s 4 /3 !t e- / f &'1 d ®i3O U'7O/ i 7 o JUN 202310 P E F T #: M ami Shores Village APPROVED BY DATE • • • • • • • •• •• • ••• • • sztr y40.4, ctiop/c..As.. 411 dimensions size designations riven are subject to verification on lob site and adjustment to fit job conditions. 72" TECHNOLOGIES 202 SUBJECT 1-0 CCMPIJANCE WITH ALL FEDERAL STATE AND CCUN 1Y riULES AND REGULATIONS This is an original design and must not be released or copied unless applicable fee has been paid or job order placed. SLUYTER, GREG - KITCHEN 1E15 Designed: 2/18/201C Printed: 2/18/2010 Drawing #: : IMP _ SIN r' N co (0 co M to ' 41 BP009 -3 DDCT36 • .•• • •.• • • • • • • • • • • • • • • • • • • • • • • • • •• • • •• • • • • • • • • • • •• • • • • • • • ••• • • • • • • • • • ..• • • • • • • • • • • .. •• • • • •• • • • • ••• • 1BM27 n 72" • iE dimensions _size designations given are subject to verification on job site and adjustment to fit job conditions. • • • • 20 0 j TECHNOLGIES This is an original design and must not be released or copied unless applicable fee has been paid or job order placed.] Designed: 2/18/2010 Printed: 2/18/2010 /' SLUYTER, GREG - KITCHEN 1 El 6 I Drawing #: 1 .. • • • ••• • • • • • •• • • • • • • •• ••• .• • • • •• • ••. • • • • • • • • • • • •• • • ••• • • • • ••• • ••• • • • • • • • • • • • • • • • • • • • • ••• • • • • • • • ••• • • • • •• •• • • • • • • • ••• • • • • • • • • • • •• • • • • • • • • • • • • •• •• • • ao 36" 73" 1D-RW371830BD UC309:024TEPF130 (ptt 34 2 " 37" UUl dimensions size designations riven are subject to verification on job site and adjustment to fit job conditions. 2HNO2 iES This is an original design and must not be released or copied unless applicable fee has been paid or job order placed. Designed: 2/18/201 Printed: 2/18/2010 .b5 SLUYTER, GREG - KITCHEN El 4 Drawing #: 1\143?-1, 1 C- --M-"- ' v u` •• ••• • • •• • • • • • •• ••• •• • ,. • • • • • • • • • • •• • • • • • • • • •.• ••• • • • • • • • . • • • • • •• •• ••• • • Nita ccF: ;Is N N W2412BD W2412BD :I- ;t- in is) • • • • • •• co WDLC2436L Oer .\ N N ••• • • • • •.• • • • • • • • ••• • • • ••• • • •�• • • • • • • • • • •• ••• • 11 RDSB42BD 72•, JQ dimensions size designations given are subject to verification on job site and adjustment to fit job conditions. • • • • 20 20 TECHNOLOGIES This is an original design and must not be released or copied unless applicable fee has been paid or job order placed. Designed: 2/18/2010 Printed: 2/18/2010 95 SLUYTER, GREG - KITCHEN 1E12 I Drawing #: 1 24" 304" 156" 24" / 30" 474" • • • WDLC2436L 1.111 W3036BD W2436R ■ W3036BWFR3 -36 at" geotta- 00 ETA 11'1' .1-211I,117=r B3OROTSB 00 U P01290 TOWD3159 C l ••• . • • . • • 42" .•. • • •• • • • • • • • • • • • • • • ••.•.• • • • • • • • • • • • • • • • • • • • • • • • • • • • . .• ••. • • • • •.• • • • • • • • • • • • • .•• • • • • • • • • • • • • •• • • • . • • .. ••• • • • • ••• • 3" 1lCdimensions size designations glen are subject to verification on job site and adjustment to fit job conditions. • • • • 20 20 TECHNOLOGIES This is an original design and must not be released or copied unless applicable fee has been paid or job order placed. Designed: 2/18,201) Printed: 2/18/2010 a SLUYTER, GREG - KITCHEN EL 3 1 Drawing #: 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 146974 Permit Number: PL -6 -10 -1172 Scheduled Inspection Date: September 10, 2010 Inspector: Hernandez, Rafael Owner: DAVIS, JADE Job Address: 115 NW 109 Street Miami Shores, FL 33168 -4316 Project: <NONE> Contractor: HOME OWNER Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360030230 Building Department Comments MOVE SINK LEFT TO CORNER MOVED SUPPLY LINES AND DRAIN ARPDXX 18 INCH NORTH, REPLACED ICE MAKER SUPPLY LINE FROM 1/4 TO 3/4 Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. September 09, 2010 For Inspections please call: (305)762 -4949 Page 4 of 14 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 115 NW 109 Street Miami Shores, FL 33168 -4316 1121360030230 Block: Lot: JADE. DAVIS Owner Information Address Phone Cell JADE DAVIS 115 NW 109 Street MIAMI SHORES FL 33168- I Contractor(s) HOME OWNER Phone Cell Phone Valuation: Total Sq Feet: $ 1,000.00 130 1 Type of Work: PLUMBING Type of Piping: KITCHEN REMODEL Additional Info: Bond Retum : Classification: Residential Scanning: 1 Fees Due CCF DBPR Surcharge Education Surcharge Permit Fee Radon Surcharge Scanning Fee Technology Fee Total: Amount $0.60 $0.65 $0.20 $150.00 $0.65 $3.00 $0.80 $155.90 Pay Date Pay Type Invoice # PL -6 -10 -38278 07/28/2010 Check #: 2686 06/25/2010 Check #: 2681 Amt Paid Amt Due $ 105.90 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Top Out Re Pipe Main Drain Heater Water Service Final Water Main Lavatory 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. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy July 28, 2010 Date July 28, 2010 1 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 Type: PLUMBING Permit No. Pt 10 J t t)2 Master Permit No. iO 11 ") 1 Owner's Name (Fee Simple Titleholder) (� ( 1 _ `% S Phone # 305- 1--.4?- -5Z41 State ft- Zip (eV g Tenant/Lessee Name Email Job Address (where the work is being done) te. Phone # City Miami Shores Village County Miami -Dade Zip 't31tgoK FOLIO / PARCEL # "l " Co3 -- Is Building Historically Designated YES NO Flood Zone Ni 0 Contractor's Company Name Phone # Contractor's Address City State Qualifier Name Zip Phone # State Certificate or Registration No. Certificate of Competency No. Contact Phone Architect/Engineer's Name (if applicable) E -mail Phone # Value of Work For this Permit $ 500 Square / Linear Footage Of Work: Type of Work: ['Addition ['Alteration []New Al Repair/Replace ❑Demolition Describe Work: n(J C©v(ief 11-N0A avty 1:4&.te, arri dtriir\ ("rVy 3 * * * * * * * * * * * * **** * * * * * * * * * * * * *** * ****** Fees************* * * * * * * * * * * * * * * * * * * * * *** * * * * * * ** Submittal Fee $ "' ( •p° Permit Fee $ /66 CCF $ D' CO /CC $ Notary $ Training/Education Fee $ 02.0 Scanning $ 3 Radon $ Q' DPBR $ 0 Double Fee $ Structural Review. $ Total Fee Now Due $ (P110 Violation date: Technology Fee $ 0 •k..1 Bond $ See Reverse side —* Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name l(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 AFFIDAVITt 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 aiicondition 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 insp ' ion which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will of b= approved and a reinspection fee will be charged. Signature Signature Owner or Agent oing instrument 'yeas a: u o ledge.; efore e this kno , to me or who has produced identification and who did take an oath. My Commission Expires: APPROVED BY r %o1 E.r� ;141 ca � b wTo r * * * * * * * * * * * ** ** **** * * * * ** *** * *, ter * * ** * **** * * * ** *** ** ** * ** * ** * * ** Contractor The foregoing instrument was acknowledged before me this VLy 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: idPlans Examiner (Revised 07 /10 /07)(Revised 06/10/2009) Zoning Engineer Clerk checked 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: C,e., . DATE: 6905) /0 ADDRESS: t h--' N L) 13 MI Sh S) F 40gY 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 list ay 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 responsible for the construction and is not hiring a licensed contractor to assume responsibility. Init 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I ay protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her ._ ' - 'nstead of my own name. I also understand that the contractor is required by law to be licensed in Florida and to list h . or li. -nse 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 al-'. 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 sui antially improved myself is sold or leased within 1 year after the construction is complete, the law will presume .t 1 bui . 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. 6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons residence. It is my responsibility to ensure that the persons whom I employ have the license required municipal ordinance. Initial Initial g on my building or and by county or 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 Ifully acting as an owner - builder and am aware of the limits of my insurance coverage for injuries to workers on my pro 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 provid :workers compensation for the employee. I understand that my failure to follow these may subject to serious financial risk. Initia 9. I agree that, as the party legally and financially responsible for this proposed Construction activity, I will abi e 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 . ' at I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or http: llwww .myfloridalicense.comldbprlpr. index.html Initia 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: ll ) 12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the i ormation 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 a5 day o , 200 gligheduced there License or T 1 ./ OWNER who was personally known to me or who has (01.0101-• O # "/) as identification. t I NOTARY s®Tr _ J/F0�1{.Ry!( q C +� ` 3 'yl M" rriR u•U 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 115 NW 109 Street Miami Shores, FL 33168 -4316 1121360030230 Block: Lot: JADE DAVIS Owner Information Address Phone Cell JADE DAVIS 115 NW 109 Street MIAMI SHORES FL 33168- i Contractor(s) HOME OWNER Phone Cell Phone Type of Work: ELECTRICAL Additional Info: KITCHEN REMODEL Classification: Residential Scanning: 1 Fees Due CCF DBPR Surcharge Education Surcharge Permit Fee - Additions/Alterations Radon Surcharge Scanning Fee Technology Fee Total: Amount $0.60 $0.65 $0.20 $150.00 $0.65 $3.00 $0.80 $155.90 Pay Date Pay Type Invoice # EL -6 -10 -38279 06/25/2010 Check #: 2681 07/28/2010 Check #: 2686 Amt Paid Amt Due $ 50.00 $ 105.90 $ 105.90 $ 0.00 Available Inspections: Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Underground W. W. , 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 July 28, 2010 July 28, 2010 Date 1 Miami Shores Village a C Building Department B MN 2 6PJ • BY: 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 Type: ELECTRICAL Owner's Name (Fee Simple Titleholder) � �.,, l%1.S Phone # 1 '` Owner's Address City c State Zip 1 (o Tenant/Lessee Name Phone # Email )Q —k✓LI Cf vis O. 61131_ ea. Job Address (where the work is being done) 6 f�- City Miami Shores Village County M smi =Dade Zip 3 J b Flood Zone k--)6 Permit No "' 11 3 Master Permit No. FOLIO / PARCEL # -- e '— t 0 Is Building Historically Designated Contractor's Company Name Contractor's Address City State Zip Qualifier Name Phone # State Certificate or Registration No. Certificate of Competency No. Contact Phone E -mail YES NO t/ Phone # Architect/Engineer's Name (if applicable) Phone # Value of Work. For this Permit $ Square / Linear Footage Of Work: Type of Work: Addition []Alteration [New Repair/Replace Describe Work: -- lelcact - ' a 61,4e5 I.' i l� ► t:�v • 9r* aYir r* 4e *tiFyk+U*** Submittal Fee $_ *dri str�Ya�r�trlrk�rat�I�iY�t l , 6' ;_ �. i �r4fskse9e�Y9t�r.Vr.nFdksk3nk9 t4r9e.4titArie ,k3t....irdr,k4e�iro$ Permit Fee $ CCF $ CO /CC $ Technology Fee $ t_J' Bond $ Notary $ Training/Education Fee $ ". Scanning $5.00 Radon $ �'(rn DPBR $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ )0090 See Reverse side Bonding Company's lame (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, FUTACES, 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 i t be iproved and a re- inspection fee will be charged. Signature Owner or Agent The fo oing in }strun ent was a 0 •, o . ledged dayo J ,2d,O,b (Or wh • is personall known to me or who has produced efore this a/e As identification and who did take an oath. - . . £-..1 ,�. � O� ,< : Sign: a �, �C ..,t . -4, �i 10,,, c;c ,t • e, a Y Print: My Commission Expires: J sr� /ePans Examiner NO AR PUBLIC: Sign: �C Print: My Commission Explires: APPROVED BY 1l' Signature Contractor The foregoing instrument was acknowledged before me this ,20_,by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: V; . Engineer {Revised 07/!0/07) (Revised 06/10/2009) ** Zonin Clerk checked 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-e. /Q(U 1S DATE: bic -5J /O ADDRESS: ( I U I i prbaat4 ST'JQ& T 316j0 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 ,..: i ay act as my own contractor with certain restrictions even though I do not have a license. Ini 11 2. I understand that building permits are not required to be signed by a property owner unless he i responsible for the construction and is not hiring a licensed contractor to assume responsibility. Initia 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her nap instead of my own name. I also understand that the contractor is required by law to be licensed in Florida and to list hi: ' h-e numbers on permits and contracts. Ini • Art 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I may a so 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 • substantially improved myself is sold or leased within 1 year after the construction is complete, the law will presume 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. 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 byy4aw and by county or municipal ordinance. In 7. I understand that ft 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. (willfully acting as an owner - builder and am aware of the limits of my insurance coverage for injuries to workers on my pro 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 ers compensation for the employee. I understand that my failure to follow these may subject to serious financial risk. 9. I agree that, as the party legally and financially responsible for this proposed Construction activity, I will abide by all applicable laws and requirement that govern owner - builders as well as employers. I also understand that the Construction must comply with all applicable laws, ordinances, building codes, and zoning regulations. 10. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States Small Business Administration, and the Florida Department of Revenues. I also understand t, •t I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or http : / /www.mvfloridalicense.com /dbpr /pro / index.html Initiate 11. I am aware of, and consent to; an owner - builder building permit applied for in my name and underst. nds i ' at I am the party legally and financially responsible for e proposed construction activity at the following address: 12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of r ormation that I have provided on this disclosure. Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a license, the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial loss that you sustain as a result of contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your property, you may be held liable for damages. If you obtain an owner - builder permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed and the status of the 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 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 uced there License or who was personally known to me or who has 4" 1,--) ® as identification. NOTARY NOTARY. 173 tL1c err E47FLORIDA „..,.N. L 12 t Da 2011 BONDED TERU AT1,A.NT bOND1NG CO.,