PL-13-1710 08-28-'13 06:39 FROM- T-701 P0012/0017 F-970
inspor ion.W iketiot
itiiiatil ~.*Shone Viila•gd
900.1; 0 N.E:.2nd.Avenua. Mlaml$horee,.FL
Phone: (306)7954.104 Fax (30q)76&8972
ir}spectlQri.Numbt r. INSP-196170 Petriit Numb. r: PL-7- 3-1710
Stetiadu[ed CnspeO#iron Rote:August 27,201.E Permit Type: Plumbing.- RoWdentfal
lospector: Diaz,Osvaldo
Insp.ectioin Type: Final
Owner:. CHEE-AWAI,CAMILLE W6rk Cfaa,i�f�a4itilri: �ptit�ikiet'.Sysiem
,lob Address:'lM No 103 Street.
:tVii ttii Shore ,FE, Phbrie Nurriber 305 7,10.3339
Parcel Number $2b5tt3t10066
Project: <NONE>
Cohirobtor: HQ.ME.OWNER
Building bop'ai tment,Cotrtftt'o its
SPRINKLER REPAIR DUE TO SEPTIC TANK to€r�*ttio a��ect �Qmments
INSTALLATION DAMAGE- NSPWTOR COMMENTS Faire
Inspector Comments
Passed
GorrectiQn
Needed
Re-inspection
Poe
No Addit nai Inspections can be scheduled uritii
re-inspection tee is paid.
August 26,2013 For inspections please call:•(30 )762-4949
• page 19 of 38
/ 7/0
utvasloN OF
?< Environmental Health
Florida Department of Health �
®, Miami-Dade County Health Department ®4
OSTDS/Well Division
11805 SW 26 St.•Miami,FL 33175
inspector
Date
Address
1,t . 1+D 3.,�2�STDS# .-----�- -
Comments: r ,?
Signature
�I
e � � �- ��
M
CE
iami Shores Villa 11 l\
Village 9 JUL 3 0 2u'i3
Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER:(305)762.4949'
T'BC 20 I
BUILDING Permit No.
PERMIT APPLICATION Master Permit No.
Permit Type: PLUMBING
JOB ADDRESS: l ° '0 a
City: Miami Shores County: Miami Dade Zip;
Foho/Parcel#:
Is the Building Historically Designated:Yes NO Flood Zone:
OWNER:Name(Fee Simple Titleholder): f L t,6 C/-IC—f2= *Lo Phone#: r�0)_—
Address: f 3 &)!Z-- t C A rE
City: State: —f"Z__ Zip: 3�3 3
Tenant/Lessee Name: Phone#:
Email: ►�^ a !' .� ��%v f�a V.,_ cz-v,
CONTRACTOR:Company Name:
Address:
City: —State: Zip;
Qualifier Name: Phone#:
State Certification or Registration#: Certificate of Competency#:
Contact Phone#: Email Address:
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ ® Square/Linear Foo age of Work:
Type of Work: ❑Address DAlteration ONew 2epair/Replace ODemolition
Description of Work: a
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$ I �
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,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 Signature
Owner or Agent Contractor
The for o' instrument was a owledg efo this The foregoing instrument was acknowledged before me this
day of ,20l ,by e of .20_,by ,
who is personaly known to me or who has produc is personally known to me or who has produced
As identification and who di aft 5 as identification and who did take an oath.
NOT PUBLIC: . - �P �S��e z3 2�o NOTARY PUBLIC:
. Sge41,L�6 �SSp.
Sign: Sign.
aQ�NIt
Print: Print:
My Commission Expires: 97E 0 My Commission Expires:
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revise,0/12/2012XRevised 07/10/07)(Revised 06/10/2009XRevised 3/15/09)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME: c-- nL-Lt;- -f4i�e -.4A tl DATE: 30 _>o
ADDRESS:_ 13-+0 xD 4�_ oo a 1-4 <;T- 4, P-� 9 3 l
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 yourown use and
occupancy.It may not bia built for sale or lease.,if you°sell or lease a building you have built yourself within-ono yew after the
construction Is complete,:the law will:presume thatryou 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.CA and with-hoktings tax and provide workers'
compensation for that employee,all as prescribed bylaw.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. 1 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 c o*acdor to assume responsibility.
initial
3. 1 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 licens numbers on
permits and contracts.
Initial
4. 1 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 usi or occupancy.If 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 ubstantially
improved it for sale or lease,which violates the exemption.
Initial
5. 1 understand that,as the owner-builder,I must provide direct onske supervision of the construction.
Initial
6. 1 understand that I may not hire an unlicensed person to ac 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 y county or
municipal ordinance.
Initial
7. 1 understand that it is frequent practices of unlicensed person to have the property owner obtain an owner-builder permit that
erroneously implies that the property owner is providing his or her own labor and materials.1,as an owner-builder,maybe held
Gable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or employs`uvh!Is
working on my property.My homeowners insurance may not provide average for those injuries.I am willfully,acting as an
owner builder and am aware of the limits of my insurance average for injuries to workers on my property.
Initial
8. 1 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 mwi M' that I must comply with bas requiring the withholding of federal income tax and
social security contributions under the Federal Insurance Contribution Act(FICA)and must provide workers am nation for
the employee.I understand that my failure to follow these may subject to serious financial risk
Initial
9. 1 agree that,as the party legally and financially responsible for this proposed construction activity,l will abide by all applicable
laws and requirement that govem ovine%builders as well as employers.I also understated that'the
construction must comply with all applicable laws,ordinances,building codes, and zoning regulations.
Initial
10. 1 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 httodhwm.mvnoldallcerise.00midbprffiroldIbAndexd,ftI
Initi
11. 1 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:
i3 a i m 3 `4 � 330 3
initial
12. 1 agree to notify IYtiaml Shoms Village immediately of arty addition,deletions,or changes to any of the Informatlo 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 ComNuction 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 property 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 owners driver license,the
notarized signature of the property owner,or other type of verification acceptable to the local permitting agency is required when
the permit Is issued.
Was acknowledged before me this_ day of 20
Y ac IIh rsonall known to me or who has
By � who was personally
Produced there License orr4 't 4��' �s identifica'on.
AQ �y gUbiic-State o
OWNER f Florida_ T`iVcR res Sep 23.2015
- � •=MY Go'nm ExR 128810
issron #EE
v p Comm h Nagional Motary Assn.
%,.",;e oc c.�•' Bonded IWO