RC-13-1855Miami Shores village
Building Department
10050 N.E.2nd Avenue, WMW EMM Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762,4949
BUILDING
PERMIT APPLICATION
Permit 7�p: BUILDING
JOB ADDRESS: - 12 a I Kl L. Ir? 11411( stl,t rl
AUG IN., 2013
FDC 20 7 -Permit No. ) 655
J�� 13
MaSter Permit No.
ROOFING
1►BA.." Shares Couaty: wrs,ni D
Is the BuNb* 8ftorfaft ate: Yes
OWNER: Name (Fee Simple Titlaoldea S I i� Ma! S f' i C ,fir - ,
): /. I I lam. _ ` r� � r• r
Address•FIS
TenantR.e�e Name:
zip: r
Emu: -SI fe- i i 1 C - Li \/a.
CONTRACTOR: Company Name. _ � +`1 L ()W IV 1= (Z
Address: Pho�9:
ckr. State:
QnahfwName:
Phor�:
State Certifation or Wstmdon #: CUtificat of CQ
mp y -= .
COntaCt�; E� Address: a
bE�G1�tt`r'Arcb�tatBngineas:
Value of Work for ft Per=k: 8 /1'l �� (Woo.
Type of Work: OAddition OAlteradon .:DNew air/Replace ODemotitton
Deacr Bon ali Work: n r. nt _ h -t' V_ i rCI I/ L�(y f" ,M i 1 1T'S I- (,()14. Iu)-&
apses*aetr�w**s,��,s�sssswsst+�tF�e+a�a��ws�ttest+stese�*+,s,�*,�s*
Md=UW Ree Permit Fee $ ccps.
CO/CC $
sawftFee s - Radoo Fee $ bBPB S 8$
Notary $ Th6 tag/E mden Fee $ Tedwoba Fee $
Domble Fee $
obvemral Review----�.��
TOTAL FEE NOW DUE S
Bonding Company's Name (if applicable)
Bonding Company's Address
m
State
ZIP
V
Mortgage Lender's Nance (if applicable)
Mortgage Lender's Address
City State s
Application is hereby made to obtain a permit to do the work and installations as indicted. 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 ELECIMICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACBS, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing infornnation is accurate and that all work will be done in compliance with an
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
ReROVEMENTS 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 perm* with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien lays, brochure will be delivered to the person
whose property is subject to attachment. Also, a cerVw' d copy of the recorded notice of commencement must be posted at the job site
for the ,first inspection which occurs seven (7) days i*er the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a rearspection fee will be charged
�ignauue - Sigaattrre
Owner or A Contractor
Tlm was ackm ed foregoing instrument was acknowledged before me this___,
day of 20
Of . 20 --., by
n kmo to me of who has pmdace h0 is personally known to me or who h"prodWW
fication and, who did take an oath. as identii;i Won and wbb did take an oath.
NOTARY C: NOTARY PUBLIC:
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my Commis Expires: Myc�yomOPu'C�O e ��2yoa�6ac1 Y
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My Commission-Rvhea:
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APPROVED BY
....�. Phos EMM
Y Zoning
Structural Review Ckrk
(Revised 3/12=20evised 07/10/07gRevW o6/10/20o9)(Revtsal 3n5/09)
Miami Shores Village
Striping Department
10050 N.E.2nd. Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME: DATE: 8/14 3
ADDRESS: i 7 "s- I G1 k
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 discloiure statement, which entities nm to work as my on contractor, I further
understand that I as the owner must appear in parson 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 ane -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 bulding'must be foryourown use and
occupancy. It may not be bulk for sale orleasar If you -sell or laws, a building you' have built yourself within onw'yeaf after the
construction is'bothplete ftlawwilLprasume #*you bult forsale or lease, which We violstlon -of thlaix6ftiption. 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 forthat employee, all *848'0 bed 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 licensed contractor and have.appiied for an owner-bunder
permit under an exemption from the law. The exemption specifies that I. as the owner of the property lift. may ad as my own
cordracor with certain restrictions even though I do not have a license.
2. 1 understand that bolding permits are not required to be soned by a property owner unless is or she Is respordA for the
construction and is not hiring a loensed cordrador to assume resporsiblity.
Initial - 2
3. 1w*
that, as art owner bolder, I am the responsible panty of recons an a permit I understarud that I may protect myselF
from potential tiruarxdal rtsk by hiring a noatsed contractor and having the permit fi� in hi& or h� narrue instead of my own
name. l also ur�erstand that ttre oordractor is required by Iso to be licensed in Florida and to Ilei hle or 8oerse numbers on
permits and txinu>scts.
Initial `�✓
4. 1 understand that 1 may build or improve a one family or tw&jm sly reskienca or a faun oulbuildhng. I may also build or improve
a commercial building 9 the costs do not wcoeed $75,000. The building or residence must be for my use or oannparcy. It may
not be built or substantially improved for sale or less. If a building or residence that I have built or sem+ improved
myself Is sold or leased within 1 year after the construction Is complete, the law will presume that I buil or substantially
improved it for sale or lease, which ylelates the exemption.
Irdtiai
5. 1 understand that, as the onner*Ader, I must provide direct, onsite supervtn of the construction.
6. 1 understand that I may not hire an unloersmi person to act as my contractor or to supervlee persons working on my building or
residents. it Is my responsibility to ensure that the persons whom I employ have the license required by law and by county or
munit4l and nonce.
Initial �,
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7. 1 understand that it is frequent practices of unlicensed persons to have the property owner obtain an oamer, buiider pem�it that "
erronedusty implies that the property owner is providing his or her own labor and materials. 1, as an owner-buiiders.may,be I I Id
Uable and subjecded to serious financial risk for any injuries sustained by an unlicensed person or his or emir s why
working on my property. My homeowner's insurance may not provide coverage for those injuries. I am wRLOy; acting as on
owner -builder and am aware of the limb of my insurance coverage for injuries to workers on my property.
Inifial
8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who Is not licenses to
periortn the work,behV done. Any person, working on my buidhrg wtro Is not licensed must work under my direct supervision
and must be employei by re, which mem that I mist comply with Iowa requiAg the withholding of federal income tax and
sodas security cmntrilbudors 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 finendal rsic.
Initis( [.- _--
I agree that, as the party legally and financially responsible for this proper Construction activity, I wc11 abide by afi applicable
lovas and requirement that govern owter-builders as well as employers. I also understand that`the
Construction must comply with all applicable laws, ordinanoes, erfiding off, , and zoning reguletfors. a
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. l ado understarnd that I may c ontect the
Florida Construction industry Lksnsing Lard at NO.487.1395 or hhftpl* m.mvtloridagom.coWdbaiW html
Initial ; . G'%
11. 1 an aware of, and consent to; an owner-bufider 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 Mowhg address:
Intfial
12. 1 Mree to notary Miami Shores Village immediately of any additions, deletions, or changes to any of the Information that I
have provided on this disclosure.
infital
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a
license, the Comt4uction Industry UcensN Board and Department of Business and Professional Regulation may be unable to
assist you with any thandal kss that you sustain as a result of contractor may be in civil count. it Is also Wortant for you to
understand that, If an unlicensed contractor or employee of an individual or firm is injuued while wodit on your property, you may
be held Gable for dame. if you obtain an owner -builder permit and wish to hire a licensed contractor, you will be responsible for
velft whether the contractor Is property licensed and the stats 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 pennii A copy of the property ownbee driver license, the
rmtarized signature of the property owner, or other type of verification accopiable to the local Wmitfing agency 18 required when
the permit Is issued.
Was a9 clmowrledged before me this I day of A 24
B SIM who was personally known to me or who has
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ADD SMOKE/CARBON MONOXIDE DETECTORS.
ANY AND ALL CLOTH AND RUBBER
INSULATED CONDUCTORS To BE REPLACED.
No POINT ALONG COUNTER TO BE MORE THAN
2FEET FROM G.Fl PROTECTED RECEPTACLE .
PUT D/W LANCES
ALLFIXED APPLON DEDICATED CKM.
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NAME:
ADDRESS:
VILLAGE OF MIAMI SNORES
OWNER BUILDER DISCLOSURE STATEMENT
WARM. IV
i
it f
Do hereby petitiorr the Village of Miami Shores to -act as my own contradtor 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 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 responsib it ity to make sure the people employed
by you have licenses required by state law and by county or municipal licensing ordinances. Any
of licensed must work under your Supervision and must
person working on your building who is
be employed by you, which means that y u must deduct F.I.C.A and with -holdings tax and
provide workers' compensation for that a ployee, all as prescribed by law. Your construction
must comply with all applicable laws, ornances, buildings codes and zoning regulations.
Please read and initial each paragraph.
1. I hold title to the above property and I am planning on doing this construction -4-
Initial til
2. 1 understand that as an owner -builder I must abide by all zoning ordinances and
building regulations in effect at the time of permit application
Initial
3. :1 have ,an .understanding of the 2004 FBC & FRC and andrstand that this
department Arid `its inspectors are there to help enforce and interpret the code.
There is a copy of the code in this office for review.
Initial
4. I understand that the building official and inspectors are not there to design,
alter or give advice on how to meet code - only if the structure meets the
minimum code.
Initial -V
5. I understand that as an owner -builder, that any contractor disputes with sub-
contractors and myself must be handled in a civil court with the advice of an
attorney. The department will not mitigate'any contract disputes.
Initial
6.. I understand that if I compensate any person or company for irk performed
they are required to have a business license in the county. If -for any reason they
do not posses a business license I will be responsible and liable for any wrong
doing from this unlicensed company -or person.
Initial
7. I. understand that if any person gets injured on my constructionPoJect—they are
entitled to workmen's compensation. And if they do not posses a workmen's
policy I could be held liable for all doctor and related cost which could include
loss of wages during recovery from injury.
Initial
8. I understand that under state and local laws I can not do y Electrical,
Plumbing, Heating, Air & Roof work on my -property with out first obtaining
the proper permits by licensed contractors.
Initial
Was acknowledged before me this d -U day of �OVC� , 20
6
By_(� 1U10��YIwho was personally known to me or who has
Produced there License or b�C.i� �'�2Q as identification.
NOT