RF-14-132Miami Shores Village
Building Department
I� 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
f Tel: (305) 795.2204 Fax: (305) 756.8972
` INSPECTION'S PHONE NUMBER: 30
( S) 762 .4949
BUILDING
PERMIT APPLICATION
Permit Type:
JOB ADDRESS:
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JANE 014
Lw- t - - -- - -
FBC 20
Permit No.
Master Permit No. F- ! Li — 13'7—
ROOFING
_ .
City: Miami Shores County: Miami Dade Zip: �� )
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO Flood Zone:
1_
OWNER: Name (Fee Simple Titleholder): Phone #: 3 L 5� S Cl co 2
Address:
city: S -�-e_� State: L_ Zip: - v
Tenant/I.essee Name: Phone #:
Email: C� '�5 A-L4 .� J � 62- y
CONTRACTOR: Company Name: —I�Ot A.la ,10 . Phone #:
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: $ 200 Square/Linear Footage of Work: 2c i
Type of Work: Addition DAlteration ❑New ORepair/Replace ODemolition
Description of Work: o Svc ': .6 >& !/1� �,, .. vc� :.�+ tic/
Color thruu tile:
Submittal Fee $ " 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 $_ L(- 6 0
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
zip
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 roust
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 b proved and a reinspection fee will be charged.
r\
Signature \ y y.. Signature
Owner or Agent
The foregoing instrument was acknowledged before me this
day of kWUQq, 20 &, by der 0 S ii' IJ - ,
who is personally known to me or who has produced016
7 l 10`1?—d As identification and who did take an oath.
NOTARY PUBLIC:
s 11F
OWED _
My Commission NOWY Public State Of "a
• Joanna M FellCiano
MY COMMi"Im FF 082753
EVIMS 01/122018
Contractor
The foregoing instrument was acknowledged before me this
day of . 20 _, by
who is personally known to me or who has produced
as identification and who did take an oath.
APPROVED BY U l I ' Plans Examiner
Structural Review
(Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06110/2009)(Revised 3/15/09)
NOTARY PUBLIC:
My Commission Expires:
Zoning
Clerk
NAME:
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
OWNER BUILDER DISCLOSURE STATEMENT
/gyp
01114ly1d;l DATE:
A
ADDRESS: 7 t �✓ be Y ,r) L�I��P: �/.e°'7 > � ' j A GAP
Tel: (305) 795.2204
Fax: (305) 756.8972
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.CA 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. 1 understand that state law requires construction to be done by a Gcen ed 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, a 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 res Ie for the
construction and is not hiring a licensed contractor 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 tiled in his or her name hrsfe'ed of my own
name. I also understand that the contractor is required by law to be licensed to Florida and to Ist h or Goe tubers on
s , 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 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 aver the construction Is complete, the law will presume that I built bstaptialiy
Improved it for sale or lease, which violates the exemption.
Initial
5. 1 understand that as the owrter- buider, I must provide direct, onssite supervision of the construction.
Initial
$� I understand that 1 may not hire an unlicensed person to act as my contractor or to supervise persons work*mvy ng or
i eAence. it Is my responsibility t6, ensure that the persons whom I employ have the license required by law and by county or
municipal ordinance.
Initial
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 Amer- 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 acti as an
owner - builder and am aware of the limb of my insurance coverage for injuries to workers on my property.
Initial
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
I agree that as the party legally and financially responsible for this proposed Construction activity, I will abi4byvapplicalble
lams 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 J1J
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 hbJMw.myto4dWicanse.com/dbpr/proldibrmdooLLidm
Initial
11. 1 am aware of, and consent to, an owner-builder building permit applied for in my name and understands that the party
legally and fln dal res Ible for th proposed construction activity at the following address:
9,
Aboml' lnftwa
12. I agree to notify Miami Shores Village Immediately of any additions, deletions, or changes to any of the inform I
have provided on this disclosure.
InWal
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a
license, the Constriluction 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 cMI 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 requiried when
z the permit is issued.
Was acknowledged before me this �' day of of 20
By nO Q �.5- DOQQ - who. was personally known to me or who has
Produced there L cnse or Ll6 4 �� as identification.
e j NOrary PUW `
: ,loanna M
�iMYMy COmmisabn FF 082783
Expi 6 71112/20181 i_i
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7 JAN; 2 2014
BY:
X14 -13Z
Miami Shores Village
APPROVED
BY
DATE
ZONING DEPT
BLDG DEPT
e
SUBJECT TO COMPLIANCE WITH ALL FEDERAL
rATF- AND COUNTY RULES AND REGULATIONS
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