DEMO-13-2138 Miami Shores Village
Building Department
artment ' Z g p 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 SEP
Tel: (305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949
FBC 20-to
LTIL.DING Permit No.
PERMIT APPLICATION Master Permit No Mm I_I I�
Permit Type: BUILDING ROOFING
JOB ADDRESS: �S 5�1 c
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder).— .Kt- Phone#:
Address: ( �;So S'-
City�4_lnM( 5 State: Pt zip f
Tenant/Lessee Name: Phone#:
Email: V\4r-t C C CI A4- C c r1i
P
lkk
CONTRACTOR:Company Name: ', �� S�b� C °�` ✓e Phone#: r h L
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:$ Footage of Work: Sv`
Type of Work: ❑Additions "' ❑Alteration ❑New ❑Repair/Replace Demolition
Description of Work: !J� MO Ll/A C S 'T 2aeZfTCtj
Color thru tz'le:
Submittal Fee$7 0 AVp Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$' Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$
Bonding Company's Name(if applicable) 4
Bonding Company's Address
City State zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and AIR CONDITIONERS,ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. lso, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs en (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved an reinspection fee will be charged.
Signature Signature
Owner or Agent Contractor
The forego' instrument was acknowledged before me s The foregoing instrument was acknowledged before me this
day f 2 7 °� n l�YS 2
Y � �—�by ���.-i�G �X� 1'✓�', day of 0—,by
who is personally known to me or who has produced r who is personally known to me or who has produced
As identification and who did e an oath. as identification and who did take an oath.
�it1r1lUiJJJ///
NOTARY PUBLIC: •`�`:�S Silver ''�, NOTARY PUBLIC:
o
Sign: Sign:
Print: — �o� \o� J 1t' Print:
My Commission Expires: �� ,.. My Commission Expires:
APPROVED BY �°� Plans Examiner Zoning
Structural Review Clerk
(Revised 5!2/2012XRevised 3/12/2012))(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)
Miami Shores IIIIage
Bul(diing Department
10050N.E.2nd.Avenue
S91M.'a Miami Shots Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
J OWNER BUILDER DISCLOSURE_ STATEMENT .
MME: DATE: el �-Ul3
7
ADDRESS: ��'
Do hereby pet(tkui the Vd[lage of MUarrui S40MB to aql ag my open contractor pursuant to the taws of the State of Florida,RS 489.103(7).
And I have read and unders=god th a follou±ring disctosura , .erdiges roe to work as my own contractor,I further
understand that I as the owner must appear In person to complete all sppUcottons.
State Law requires construction to be done by a licensed contractor.You have applied for a permit under an exception to the taw.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 yourown use and
occupancy.it may not WWII for sale or,lease.I you'sell or a bulidlg you hove bWk yourself within ond'year after the
constriction lo'COWO e,ft4hV of that~you DO for°sole or Vie.which-We vMoh bfthWeX6h m.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 bar you,which moans that you must deduct FICA and with-holdings taut and provide workers'
compensation forthat ertiji�oyse,all"ar;prescribed bylaw.Your construction must comply with all applicable laws,ordinances,
buildings codes and zoning regulations.
Please read and initial each paragraph.
1. t understand that state law requires construction to be done by a licensed contractor aril have-applied for an awner-builder
permit under an exemption from the law.The exemption spedes that I,as the owner of the properly Imo,may act as my own
contractor with certain msft*ns even Bough I do not have a license.
Initlel `-'�!
2. 1 urN11enatand that building P9m1tts are not requrded to be signed by s property owner unless he or she Is rsible for
coq and Is not hiring a Hoersed contractor to assume responsibility.
initial.
3. I understand>het. an owner builder,I am respuibte party of record on a porrdt I umlerstarut chat 1 may prat myself
from pptetudal flnarxtad risk.by tiring a goesei contrator and the permit tiled in�or trer name hstead of my
nerraj.I.also uralersmn>d that the contractor�rpuked by law to be 8censed in F'lor�ark to Ilet hle a n on
pem8ts aridcorrtracts.
IniNai_
4. 1 understand that I may build or improve a one family or Wo4ornih►residence or a farm out uii ft.I may also bind or improve
a commercial building I the costs do not exceed$75,0tD.The building or reside must be for my use or occupancy.It may
not be bunt or substantially improved for sore or lam.9 a building or resftice that I have built or substarutialhr
myself Is sold or leased within 1 year after the corstruction le,corrob,the law will presume that I Or X=
Improved it for sale or lease,which vioWn the exemption. a
initial
5. 1 understand that as the owner-txirgder,I must provide direct,o stte supervision of the corstruoilm
1�
Initial
6. 1 understami that l may not hire an unlicensed person to act as my contractor or to supervise persons wort ft on my building or
retrace.it Is my responsibility to ensure trot the poisons whom I employ have the Own required by law and by county or
mun*d adir sift. l/`J
IniGct_
7. t understand that it Is itephrerht practices of unlicensed person to have the property owner obtain an owner rider permit that
error ly that the property owner is providing ht or her own lebw and materials.I.as an owner-buq&K. be;
Uable and subjected to serious financial risk for any injuries sustainer by an unlicensed person or his&enhpt `
woddrg"on my party.My homeowner's hsurence may rot provide coverage for t1e injuries.I am wiffful y,actin as an
owrW4iuitda and am aware of the limits of my Insurance coverage for hgudes to workers on my property.
Initial
8. 1 understand that I may not delegate the responsibility for supervising work to be a Ikoensed contractor who Is not 8oemee to
r perform the work.b dote.Arty arson worker on my p Adtng who Is rej.11m,sed must work under my direct supervision
and must be emjiyad by me,which rreah�'that 1 ft*comply i6 Iaiws=n tl 6%the withholding of federal Income tax and
social sem*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 fmanc ial risk.
9. 1 agree that,as the party Dally and finenclelly responsible for this prod Construction activity,I will abide by all applicable
caws and repui emerdthdt`'govern ownerbulidwas well as employers.I also understand tlreYttte
V
Construction mistcamply with all applicable laws,ordinary,btiifdhhg codes, 'slid zmft regular.
initial
10. 1 understand that I may obtain mom hhformaton regarding my obligations as an empioyer from the Internal Revenue Service,the
Unite States Small Bushess Adminfttetim,aid the Florida Depatrrwd of Revenues.I abo understerW fret I may corded the
Florida Construction Industry Lkeshg Board at 850.407.1395 or hto&wrr mvAoridalkremL=—M dbndmotdtbMdex.html.
i
11. 1 on aware of,and consent to,an owner-builder building permit apple for in my name anal understands that I am fire party
iepily and finerictaliy responsible for the proposed oonstructon activity at the foifowing address:
Initial
12. 1 agree to notify Miami Shores Village immediately of any addillors,deletions,or changes to mry of the Information that 1
have provided on We disclosure.
1
Licensed contracts are regulated by taws designer to protect the public.if you oontract with a person who does not have a
!Irons,the Constr4uction industry Licensing Board and Department of Business and Professional Regulation may be unable to
assist your wft h any ftr del loss that you sustain as a result of contractor may be In dull cxuut.It Is also hripo W for you to
understand that,f an unlicensed contractor or employee deri Ihrdhrldual or rani Is irhjumed while working h yoiir property,you may
be held liable for damages.If you obtain an owner:-builder permit andwish to hire a licensed contractor,you will be responsible for
verifyhsp whether the contractor Is property licensed and the status of the contractors workers compensation coverage.
Before a bu ldiitg permit can be Issued,this disclosure sitatensnt mast be c ompiefed and signed by the properly Amer and
returned to tine local penmitiIng agency responsible for Issuing the permit A�of the property ms`s driver Itcase,to
notarize!signature of the property owner,or other type of vaTodton aroeptable to the local pamnittirhg panty Is required when
the permit Is rued.
Was atCnowledged More me this day of .20 fl By ' V �' �'��"�` who ersonally kn to or who has
Produced there License or as i entifimflon.
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OWNER ��IQfit�'� 16 '•
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CUMULATIVE SUBSTANTIAL IMPROVEMENT
VERIFICATION WORK SHEET
In accordance with FEMA regulation and Miami Shores Village Flood Damage Prevention Ordinance the
costs of all improvements must be monitored. The costs of any improvements in the past 12 months and the
costs of any proposed improvements must be shown on the worksheet. The cost of improvements must
include demolition, raw and finished materials (include those donated), labor(including volunteer and self-
performed), construction supervision and management, and overhead and profit. A list of items the costs of
which are to be included as well as those excluded is attached for your reference. (A Copy of the Contract
must be attached) (�
PROPERTY OWNER:
PERMIT#
ADDRESS: 0 j S�
FOLIO NUMBER: FLOOD ZONE:
BASE FLOOD ELEVATION: FREEBOARD: EAST OF FL.CCCL:
COST OF PAST IMPROVEMENTS(12 MONTHS):
COST OF PROPOSED IMPROVEMENTS:
(ATTACH COPY OF CONTRACT) OLD
l
TOTAL CUMULATIVE COST OF IMPROVEMENTS(past and proposed)i rl I- �C)p
VALUE OF PRINCIPAL STRUCTURE(attach a M
OWNERS SIGNATURE: DATE:
PLANREVIEWER•
PLAN REVIEWER
SIGNATURE• DATE:
unit"
SUBSTANTIAL IMPROVEMENT/DAMAGE LIST
(NOTE: THIS LIST IS INTENDED FOR GUIDANCE ONLY,AND IS NOT ALL INCLUSIVE)
ITEMS TO BE INCLUDED
ALL STRUCTUAL ELEMENTS,
INCLUDING ALSO:
Foundations including;
Spread footing, Continuous footing, All Labor and other Costs associated with
isolated footing, piles and pile caps Demolition, Removing, Replacing,
Slabs including; Monolithic, floating, Ins ta ing Building or enng Building
elevated Components
Walls including; Exterior walls, Bearing Construction Management/Supervision
walls, Shear walls Overhead and Profit
Beams, Tie Beams, Columns and Posts Equivalent cost for:
Wood decking, Floor and Roof Sheathing Donated Materials
Trusses, Joist Volunteer Labor(including owners and
Windows/Doors friends)
ALL BUILDING ELEMENTS, INCLUDING Any Improvements Beyond Pre-damaged
Condition, including;
Interior Partitions,Walls, Columns
Utility Upgrades
Drywall, Ceilings, Code Upgrades
Built in Furniture, Cabinets, Vanities
All Fixtures ITEMS TO BE EXCLUDED
Flooring, Tile, Carpet, Stone, Linoleum,
ect. Plans and Specifications
All Finishes including Drywall, Paint, Survey Costs
Stucco Plaster, Paneling, Tile, Marble, Elevation Certificate Costs
and Moldings Permit fees
Roofing Material Debris Removal
ALL HARDWARE Items not considered to be REAL Property
Rugs, Furniture, `Refrigerator,
ALL UTILITY and SERVICE Appliances not Built-in
EQUIPMENT Outside Improvements, Including;
HVAC Landscaping
Electrical System and Equipment Sidewalks
Plumbing System and Equipment Patios
Security System and Equipment Fences
Central Vacuum System Yard lights
Plumbing Fixtures Sheds
Lighting Fixtures and Ceiling Fans Gazebos
Water Systems including Irrigation
Pool
Softeners/Filtration
Created on June 2009