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RC-12-171Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 nspection Number: INSP - 169454 Permit Number: RC -1 -12 -171 Inspection Date: September 17, 2012 Inspector: Bruhn, Norman Owner: MENDEZ, JESUS & REINA Job Address: 143 NW 110 Street Miami Shores, FL 33168- Project: <NONE> Contractor: HOME OWNER Permit Type: Residential Construction Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1121360030530 Building Department Comments REPALCED TOILET, SINK, TUB Passed -- Inspector Comments Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until For Inspections please call: (305)762 -4949 September 18, 2012 Page 1 of 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 a -S u3 fry - BUILDING PERMIT APPLICATION FBC 20 Permit ROOFING RECEIVED JAN 31 20 BY: Permit No. RCt2fl 1 Master Permit No. OWNER: Name (Fee Simple Titleholder): -Sescrs itten de-Z- Phone #: L —1749 — 35 Address: (in Ar I V sZ - City: Al 4%02 i 3 Ve S State: PL Zip: 33168 Tenant/Lessee Name: Phone #: Email: dI- te/L(kZ.© 9eS 4re'sMai L / COP JOB ADDRESS: 1 1 )3 Alta / / S City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: C)S M e/ 1d€ Z Phone #: Address: City: State: Zip: Qualifier Name: Phone#: State Certification or Registration #: Certificate of Competency #: Contact Phone #: Email Address: DESIGNER: Architect/Engineer: /11. > / Phone#: Value of Work for this Permit: $ 5� • 03 Square/Linear Footage of Work: Type of Work: DAddition ❑Alteration DNew KRepair/Replace ODemolition Description of Work: Rep/ 7A) ®k -Fab *******+ **** * ***** ** +******** *+x***+x**** Fees** ** x**** ******** **x : ************************ Submittal Fee $ Permit Fee $ 7('c CJ a CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ (01'6(i) Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable)ei-S 13c Mortgage Lender's Address J ; City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature 5 Signature Owner or Agent Contractor The foregoing strument was acknowledged before me this .S4) The foregoing instrument was acknowledged before me this day of 1 3 ( , 20 IZ, by , day of , 20 _, by who is personally known to me or who has produced LOU = IC) who is personally known to me or who has produced As identification ea��ti!sttte �, oath. as identification and who did take an oath. NOTARY PUBLIC: \ • J f t.R ° �: NOTARY PUBLIC: Sign: w P_4 a Cfiry, = Sign: � ssw% Si zz Print: ? 6-1/::„....?. ° j6f9' f 4�� Print: '''o,, i ti R My Commission Expires: bhriolt! o'''ff My Commission Expires: * * * * * * * * * * * * * * * * * * * ** * * * * ** * * * * * * * * * * * * ****+k+k k****+ kds***+ k*+ k*******+ N*******+ k+ k*+ k+ k**sN* *q: ****sk******+k******** APPROVED BY ' -%/g<1 Plans Examiner yt._ 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: e 3 Re -A -PLC= Z. DATE: ADDRESS: Q L( 3 ij J tic Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the construction yourself. You may build or improve a one - family or two- family residence. You may also build or improve a commercial building at a cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I,C.A and with - holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances, buildings codes and zoning regulations. Please read and initial each paragraph. 1. I understand that state law requires construction to be done by a licensed contractor and have applied for an owner- builder permit under an exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. Initial 2. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. Initial 41 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts. Initial 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I may also build or improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may not be built or substantially improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I built or substantially improved it for sale or lease, which violates the exemption. Initial `i 5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction. Initial 3 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 I 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. -[ t� 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 14-'( 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. myfioridalicense .com/dbpdpro /cilb/iindex.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: +{3 4J J 1(0 5 Initial 1 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 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 l day of , 201 2J who was personally known to me or who has as identification. Produced there License or OWNER CLAUDIA V. Notary Public - State of Florida 3 My Comm. Expires Sep 23.2015 s ^9T1�. mar Commission # EE 128810 ........ '' Bonded Through National Notary Assn. • Permit No: 12 -171 Job Name: February 7, 2012 Miami Shores Village Building Department Building Critique Sheet 1) Provide an electrical permit application. 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Page 1 of 1 Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. Norman Bruhn CBO 305 -762 -4859 JAN 3 BYE t413 J o )1O 5 3eS 0S it4e e-2_ Frr ° Bed Win 07, Bed , n 1;1e ...14c0.0 Baigkfbain i 4-ckern ADO SMOKE/CARBON MONOXIDE DETECTORS. ANY AND ALL CLOTH AND RUBBER INSULATED CONDUCTORS TO BE REPLACED. JAN 3it;2 iflj Living 1oarl Roe> in BATHROOM RECEPTACLE ON 20 AMP CKT AND C.EI PROTECTED u ?i.doq) Cu; I.nrc Nv-t -To er- F' E _r1 a I #: \ — f arni Shores Village APPROVED BY DAI- ZONING DEP- BLDG DEPT /jam %Pi SUBJECT r'O CCMPLIANCE Wird ALL FEDERAL STATE AND CUJN I' Y RULES AND REGULATIONS / Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 178080 Permit Number: EL -2 -12 -350 Scheduled Inspection Date: September 13, 2012 Inspector: Devaney, Michael Owner: MENDEZ, JESUS & REINA Job Address: 143 NW 110 Street Miami Shores, FL 33168- Project: <NONE> Contractor: HOME OWNER Permit Type: Electrical - Residential Inspection Type: Rh Work Classification: Alteration Phone Number Parcel Number 1121360030530 Building Department Comments AFTER THE FACT ELECTRIC FOR BATH REMODEL Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP- 178000. Add smoke detectors. Bathroom receptacle to be next to the bason. September 12, 2012 For Inspections please call: (305)762 -4949 Page 21 of 31 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 RECEIVED FE@ 2 9 012 BUILDING Permit No. E. -XL-350 PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): SC S L I1 �` e > Phone#: 30 5 7�' ? 3 S Address: "i 3 kibu (® 5 Z City: i Qt?/l !� re� State: ?Z- Zip: 33/6' Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: 3 CLY7) e 1,4'5 Ntz k 0 ST City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: &- U asnte'Z--(--Z? Phone # 305^q FS-67-3-5 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: $ 2. Y 0 , Square/Linear Footage of Work: Type of Work: Address ❑Allteration UNew ORepair/Replace /j ODemolition Description of Work: ��e me" Cr / Pd P IC '1 /00,-y,— / y,— ? ecIir .i e Qs y2 ee4'ed Par So._ Me **** * ** *+x** **a:***** ****a:**+ + x***** *** **** Fees******* **+ x**+ xx: ** ****a: ***** ***a:**+r*********** Submittal Fee $ r7 ° ' Permit Fee $ ,/f Y a 2 CCF $ CO /CC $ �0 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) 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, BOTI.F,RS, 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 .71-4 �' —�� � Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this 2-1 The foregoing instrument was acknowledged before me this day of 'k-�—S , 20 rz, by •S�5 t{ J rf l (e..ni ► 2 , day of , 20 _, by who is personally known to me 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: 11111111110,�`i Sign: fro 'f .is ='� ,1 --: ✓ : ua Sign: . Print: - = - Print: My Commission Expires:! �' � My Commission Expires: /// //l11111tilo\ \\ ***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED BY ,e<9 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 DIS LOSURE STATEMENT � �2 rr M DATE: 2 ADDRESS: -7 Li-3 L / (0 5 Q AA tw aiv-t % S rem. Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the construction yourself. You may build or improve a one - family or two- family residence. You may also build or improve a commercial building at a cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and with- holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances, buildings codes and zoning regulations. Please read and initial each paragraph. 1. I understand that state law requires construction to be done by a licensed contractor and have applied for an owner - builder permit under an exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. Initial r7 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 s 1 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 - 1 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. r.✓/ Initial I 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 -3b1 . 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 2S iLlf 10. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the United States Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or http : / /www.mvforidalicense.com /dbpr /pro /cilb /index.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: 11/3 (Jcd 110 s Initial 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 141 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 c6.6 , 20 (2_. By X15 rt%,.NQf 2_ Produced there License or PLAT-._ OWNER who was personally known to me or who has 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 OWNER: Name (Fee Simple Titleholder): Address: f 143 APAI 110 5 City: 1■41 Q 2i) shoreS Permit No. Master Permit No e3c.rs it-1 L State: P.Iz—r12- .rlc42n Phone #: 34,5 - 97.6' - 3S zip: 33itrS Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: i 113 ' W I /0 - City: Miami Shores County: Folio/Parcel #: Miami Dade Zip:/ Is the Building Historically Designated: Yes :NO � Flood Zone: CONTRACTOR: Company Name: 7e,sCs Phone #: Address: City: State: Zip: Qualifier Name: Phone #: State Certification or Registration #: Certificate of Competency #: Contact Phone#: Email Address: DESIGNER: Architect/Engineer: 3ecY &? ,ems z Phone #: Value of Work for this Permit: $ 500- 151e) Square/Linear Footage of Work: Type of Work: UAddress OAltera 'on ❑New a1% ' epair/Replace ODemolition Description of Work: Re_ e ] l � � 5 Ad —ry 13 ****+ x�x********* �x�x +xx��x�x�:****a: *�x�x�x�u�x+x *� *** Fees�x�: �x�x�u* a�x: �x********* �x�xx� *a�x�+�+xx�+xu:x�****�x**** +x*** ��� Permit Fee $ `' ' ®--- CCF $ CO /CC $ Submittal Fee $`^' Scanning Fee $ Notary $ Double Fee $ Radon Fee $ DBPR $ Bond $ Training/Education Fee $ Technology 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) Mortgage Lender's Address City a State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. �i. Signature 3c� Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this 1 The foregoing instrument was acknowledged before me this day of "c' , 20 by day of , 20 _, by who is personally known to me or who has produced t_N1 ° (t) 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: P ri ( 'Jr/ �i/ NOTARY PUBLIC: Gip % Sign: w = 6j4)I1 co - Sign: Print: ' � = Print: �d� ss oo M Commission Expires: 6S g0� My Commission Expires: OA:* FL U RVO \,\ \`��\\ APPROVED BY oje� 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: ��' U"l ec e a DATE: 3 -o S^ 1 a l to s ADDRESS: 1 Ai Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7). And I have read and understood the following disclosure statement, which entitles me to work as my own contractor; I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the construction yourself. You may build or improve a one - family or two- family residence. You may also build or improve a commercial building at a cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the construction is complete, the law will presume that you built for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as a contractor. It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances. Any person working on your building who is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A and with- holdings tax and provide workers' compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances, buildings codes and zoning regulations. Please read and initial each paragraph. 1. I understand that state law requires construction to be done by a licensed contractor and have applied for an owner - builder permit under an exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. Initial 471 2. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. Initial 3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name. I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts. Initial 4. I understand that I may build or improve a one family or two- family residence or a farm outbuilding. I may also build or improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may not be built or substantially improved for sale or lease. If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I built or substantially improved it for sale or lease, which violates the exemption. 5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction. Initial Initial 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 —3 /1 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 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.mvforidalicense.com /dbpr /pro /cilb/iindex.html Initial ZS 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 LCS 0 s°( Initial 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 M 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 (2.91 day of /Q , 201. 2-- who was personally known to me or who has Produced there License orA vc..) )1k Le-c-Z-i OWNER as identification. (ZO NOTARY CLAUDIA V. CUBILLOS 'P" State of Florida °�'', Notary Public • 23, rids • °f.ireS Sep ;may.= p�yComm.Exp EE 128810 2015 p,,; Commission . n i•` Q, %4• o'� Bow Through National Notary Assn.