DS-13-2145lb
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
Permit Type:
JOB ADDRESS:
BUILDING
SEP 2 3 2
FBC 20 L'C:>
Permit No.
Master Permit No.)S 13 e -2, 145
ROOFING
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
OWNER: Name (Fee Simple
. . IN . .
NO Flood Zone:
3S-6__ V"3L C
City: Q hA.;— State: Zip: 'aB l
Tenant/Lessee Name: Phone#:
CONTRACTOR: Company Name: _ 1kA �2— "� Phone#:
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
ti
Value of Work for this Permit: $ U&n , ey Square/Linear Footage of Work: 1 I iq
Type of Work: OAddition OAlteration . ONew ORepair/Replace ODemolition
Description of Work: _ 1:y Q (L 6:g
Color thru tile:
Submittal Fee $ Permit Fee $��)1 , 00 CCF $ ° 6C) 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)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
Zip
Zip
w
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
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this � The foregoing instrument was acknowledged before me this
oiG
day of V �`� t , 20� 3 , by MQrIHt 'O day of .20 _, by ,
who is personally known to me or who has produced �t— k 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:
APPROVED BY
Plans Examiner
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Zoning
Structural Review Clerk `
(Revised 3/12/2012)(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
• •
i Y /) in
NAME: -LLOL A DATE:z
• • •
Do hereby petition the Village of Mlaml Shores to act as my own contractor pursuant to the lawns of the State of Florida, RS 489.103(7).
And I have read and understood the following disclosure statement, which entities IM to work as my own contractor, i further
understand that I as the owner must appear in person to complete all applicators.
State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception m 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 $26,000.00 or less (The new form states 75,000). The building°must be for-yourown use and
occupancy. It nary not be built for sate or leaseIf yotrsall or tease a building you`have built yourself within one• year after the
construc#ion is'cdtnptete the iawwcli:POM that^you built for -sale or lease, which Ws violation df thitex6tgftn. You may not hire
an unlicensed person ;;a contractor. It is your responsibility to make sure the people employed by you have licenses required by state
law and by county 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 ftiat niployee, all as pr ibed bylaw. Your construction must complywrith all applicibie 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 properly listed, may act as my own
contractor with certain restrictions even trough I do not have a license.
laks —1q
2. 1 understand that building pemb are not required to be signed by a property owner unless he or she is responsible for the
c ornstruc t oq and Is riot hiring a licensed contrSCtor to mm responsibility.
infusi
--kA.
3. 1 understand that, as an owner builder, I am the responsible party of record on a permit. I understand that 1 may protect myself
from potential financial risk by hhing 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 Ikcersed In Florida and to It his or license numbers on
permits and contracts.
I
4. 1 understand.that I may build or Improve a one family or Wofamtiy rsstdence or a farm Ma—W ding. I may also build or Improve
a commercial building If the cats do not exced $75,0W. The buikttrg or residence must be for my use or Occupancy. It may
not be built or substantially Improved for sale or fie. If a building or residence that I have built orsubste ri ielly Improved
myself Is sold or lased within 1 year after the construction Is complete, fie lawn will presume that I, built or sully
Improved it for sale or Ise, which vbWas the exemption. A
Initial .
5. 1 understand that, as the owner -builder, I must provide direct, onske supervison of the construction.
' chit
6. 1 understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working g on my buff ft 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.
. t
I understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner builder permit that
erronedusty Imp ilei that the property owner is providing his or her own labor and materials. I, as an owner-builderi,may<,4e het Ir ,
Gable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or emle
working on my property. My homeowner's Insurance may not provide coverage for those Injuries. I am willfully acting as an
ownet builder and am aware of the limits of my insurance coverage for injuries to workers on my property.
I understand that 1 may not delegate the responsibility for supervising work to be a licensed contractor who Is not licenses to
perform the work being-dorre. Any person working on my building `aho ds not licensed must work under my direct supervision
and must be employed by me, which means that I must comply with laws requi ft the withhhokMg of federal income tax and
social security contributions under the Federal Insurance Contributors Act (FICA) and must provide workers compensation for
the employee. I understand that my failure to follow these may subject to serious financial risk
(nidal-- rRq
i agree that, as the party legally and fineroially responsible for this proposed Construction activity, l will abide by all applicable
lows and requirement that govern owner -builders eswellas employers. I also understand that'the
Construction must comply with all applicmble laws, ordinances, 'butiding cam, °'and inning regulations.
lnhw-..?
14
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 undu3rsrorrd that I may contact the
Florida Construction Industry Lioenft Board at 850.487.1395 or httolMsy.mvtiodddm se.comldbnrH mk b/index.htmI
Initial,
11. 1 ran aware of, and consent to; an gamer -builder building permit applied for in my name and i marstarttls that I am the Prlyy
legally and lirsndally responsible for the proposed construction activity at the following address.
Initad
12.. 1 agree to nothly Mani Shores Vlbp immediately of any additions, deletions, or changes to any of the Information that I
have provided on this disclosure. pp N
Inftal
Licensed contractors are regulated by laws designed to protect the public. if you contract with a person who does not ``haav� a ��a
license, the CorsMcton Industry Licensing Board and Department of Business and Professional RegWation 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, ff an unlicensed contractor or employee of -an individual or tirtn is injured while working oh your property, you may
be held Gable for damages. If you obtain an owner -builder permit and wish to hire a licensed contractor, you will be responsible for
verdyhng 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 sletement must be completed and signed by the property caner and
retuned to the local permlthing agency responsible for issuing the permit A copy of the properly orcin Ws driver Gcerse, the
notarized signature of the properly owner, or other type of verification acceptable to to local permitting agency IB required when
to permit Is issued.
was acknowledged before me this day of 5KPI �, 20—!-3
By aJT ft, isr1 HL't n1 who was personally known to me or who has
i
SCALE 1° =20'
PROPERTY ADDRESS_ 511 NW 112th STREET, MIAMI SHORES, FLORIDA, 33188
LEGAL DESCRIPTION: (FURNISHED BY CLIENT)
LOT 12 AND 13 BLOCKS SUBDIVISION WEST SHORES
L`
ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOOK 42 AT PAGE 18
OF THE PUBLIC RECORDS OF MIAMI-DADE COUNTY, FLORIDA.
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LOCATION SKETCH (ND DD)
1
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11.
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IVAIW 112th STREET
- - - -
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arm mra 3 (50.00' TOTAL R/W)
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FIELD WORK REVISIONS
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MIGUEL JESUS GARAY
ID= F006Y AW/OR itNUMM6 No/aN MOM== Erxalo=M OF
19830 FRAN,b RD
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AW Nm1RL s 90ft WAM An RD MU 10 Ni I== 1 s=W ■ Nott
CUTLER BAY, FL 33197
am0amis AW PumaD 10 Nava OF Ion A6 cum" IN AE WINsifl' EORwr s
AWX MOM Am SURW s Nor mma6 FOR WHEN DUM RR 0D1SImI = PURPOM
PHONE: ;,,� 283—G932
MIGUEL JESUS GARAY P.S.M. 8594
FOR flN6L PUROe.s A AFOm01Mim 67RP61• B R0711sFD. FFNrE OmtE NOT DE1mNR16
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