RC-13-1531Miami 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
FBC 20 ( D
Permit No. A'd 7- 12—
Master
2
Master Permit No.
Permit Type: WELDING ROOFING
JOB ADDRESS: ^;t ";r x19
City: Miami Shores County:
Miami Dade
Zip: cl
Folio/Parcel#:
Is the Building Historically Designated: Yes
NO Flood Zone:
OWNER: Name (Fee Simple Titleholder):
Phone#:
Address: /42- Y61fP-
City: �`;%G � �i State:
,n
,C
Zip:
Tenant/Lessee Name:
Phone#:
"�,� "� �7
Email: L�ti�C.e� Lw a0l, g2o yw
CONTRACTOR: Company Name:
�� v Phone#:
Address:
City: State
P:
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 Footage of Work:
Type of Work: OAddition alteration
ONew *epair/Replace
ODemolition
Description of Work:
Submittal Fee $ Permit Fee
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $ CO/CC $
DBPR $ Bond
Technology Fee $
TOTAL FEE NOW DUE $ ®,
_ !2
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
i
C
Zip
is
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 r ��G Signature
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of �, 201't , by 121, f',' i � day of , 20 _, by
who is personally known to me or who has \B;ggWov #� who is personally known to me or who has produced '
As identificatic � p,did take- oath. as identification and who did take an oath.
• "
NOTARY PUBLIC: �+,�: ' . NOTARY PUBLIC•
Sign: �N "� ` Sign:
Print '% ���°.�� Print:
My Commission Expires: ''�ii��illiilnl��+��'`` My Commission Expires:
APPROVED BY �17, Plans Examiner 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
OWNER BUILDER DISCLOSURE STATEMENT
NAME: DATE: 451-r111
ell
ADDRESS: -I-' 9
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, RS 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.C.A 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. 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.
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 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 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 license numbers on
permits and contracts. f"' — /
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 'rf 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 after the construction is complete, the law will presume that I built or substantially
improved it for sale or lease, which violates the exemption.
Initial ydt---"
5. 1 understand that, as the owner -builder, I must provide direct, onsite supervision of the construction.
Initial
6. 1 understand that I may not hire an unlicensed person to act 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 by county or
municipal ordinance.
Initial
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Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement "for any construction project
prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees, including the owner, must obtain workers' compensation coverage. Corporate
officers or members of a limited liability company (LLC) in the construction industry may
elect to be exempt if:
1. The officer owns at least 10 percent of the stock of the corporation, or in the case
of an LLC, a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
3. The corporation is registered and listed as active with the Florida Department of
State, Division of Corporations.
No more than three corporate officers per corporation or limited liability company members
are allowed to be exempt. Construction exemptions are valid for a period of two years or until
a voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village
does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore,oy u may be
personally liable for the worker compensation injuries of M person allowed to work under this permit. Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner
Print Name: / r / if F1'r6T f'yl IQ &-,e 00 PV
Signature: c )
State of Florida )
County of Miami -Dade )
Sworn to and subscribed before me this \\ p
day of r� � , 20 1 �I ��`®�, "
L63Wo�
By
(SEAL)
Tvpe of Identification produced '%_ $a
rrunn��
Contractor
Print Name:
Signature:
State of Florida )
County of Miami -Dade )
Sworn to and subscribed before me this
day of , 20
By
(SEAL)
Type of Identification produced
SAN 0 ZOO
1125 NE 92nd Street
Miami Shores, Florida
January 3, 2014
Arlenis Silvera
Permit Clerk
Miami Shores Village
Ms. Silvera,
Regarding Permit Number: RC -7-13-1531
I am requesting a 30 day extension due to circumstances beyond my control and to
obtain the additional electrical and plumbing permit required for completion of our
bathroom.
Thank you for your consideration in this matter.
Respectfully,
v
Shirley Encarnacion
�- `15
-7115II3f-Icgvel0
Miami Shores village
Building Department
050 N.E.2nd Avenue, Nami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762A949
BUILDING
PERMIT APPLICATION
Permit Type: BUILDING
JOB ADDRESS: __ / /a? S— AL. 92 S7., -i
JUL ® 9 208
BY %-....
FBC 20
Permit No.
Master Permit No.
ROOFING
City: Nami Shores County: - Nami Dadezip: �/ 3
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder):_ �/ x,0644104 6 a k) phone#: %
City: xA/ �'y► s -" LA" State: C
Zip:
Tenand.essee Name: Phone#,
Email:
16MC)
CONTRACTOR: Company Name: Phone#:
Address:
City: State: zip:
Qualifier Name' Phone#:
State Certification or Registration #: Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Enginew.. Phone#:
TDo o
Value of Work for this Permit: $ -Square/Linear Footage of Work:
Typed Work: OAddition OAlteration ONew ! . ace ODemolition
Color thin tlx:_
Submittal Fee $ Permit Fee $ an CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ TrainingWducation 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
Zip
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 f g ing instrume as ac � wl ed bef me this The foregoing instrument was acknowledged before me this
day o 20 by 11 .20 _, by
who is)ersonal yaknown to me or who has du 1 who is personally known to me or who has produced
identification and w o did take an oath_ as identification and who did take an oath.
NOT.
Sign:
Print:
My Commission Expires:
APPROVED BY
ZIP
Plans Examiner
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Zoning
Structural Review Clerk
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10=W)(Revised 3/15/04)
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: ri..�,ATE• °?
ADDRESS: `—
M
Do hereby petition the Village of Miami Shores to act as my ours 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 buildingmust 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 wilt -presume that -you built for sale or lease, which Isa 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 Inhlal each paragraph.
1. 1 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 Rated, may act as my own
contractor with certain restrictions even though I do not have a license.
Inill
2. 1 understand that building permits are not required to be signed by a property owner unless he or sheis possible tDr 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 filed in his, or her new 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 license n on
permits and contracts.
Initial
4. 1 understand that I may build or improve a one family or Mo -family residence or a farts outbuilding. I may also build or improve
a commercial building lf the costs do not exceed $75,000. The building or residencs3 must tis for my use 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 I pro ad
myself is sold or leased within 1 year after the construction is complete, the law will presume that I but or su Ily
Improved it for sale or lease, which violates the exemption.
Initial
5. 1 understand that, as the owner -builder, I must provide direct, onsite supervision of the construction.
initial
—/_
6. 1 understand that I may not hire an unlicensed person to act 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 my, 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 owner -builder; maybe held
Gable 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 limits 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 -beim -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 amply 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 employes. 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 abide by all alp
laws 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
10. 1 understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the
United StatesSmall 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 httolkvww.mvflo4daUcerm.conildbor/pro/dlbrindex
Initial
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:
Initial
12. 1 agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the tnfomnation the
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 Constr4uclion 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, ti 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 owner's 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 .2015 _
By P�lvfaww'(---alho was personall known to me or who has
Produced there License or
1
V_ r,UBILLpS
Public of Florida
OWNER �ARY
ytaunrr Expue tE 12BB1p23, �5
Commission # Assn.
h Nalioaal Notary
''1;'F 01 f.q•�' Bonded 1broug
� �ova
�\ ®BA TUT TO BE
0
BATH
GUEST ROOM
Existing Floor Plan
SCME-
Proper Floor Plan
SCALE: 1/4•=i'-0'
SCOPE OF WOM
,- REPLACE EXISTING BATHTUB WITH NEW SHOWER.
, REPLACE EXISTING GLAZED TILES IN WALLS.
3- INSTALL NON ABSORBENT TDF IN NEW
SHOWER FLOOR.
4- REPLACE E,tl$TI G T ILET
` . [A D LAVATORY TO REI
CONSTRUCM WASIM FM
t3ATMIM! FA31AT:
1125 NE 92 STREET
MIAMI SHEIRES, FL., 33138
7
NEW SHOWER
TO BE BUILT
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Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-194895 Permit Number: RC -7-13-1531
Scheduled Inspection Date: September 05, 2014
Inspector: Rodriguez, Jorge
Owner: ENCARNACION, SHIRLEY
Job Address: 1125 NE 92 Street
Miami Shores, FL 33138 -
Project: <NONE>
Contractor: HOME OWNER
tsunaing uepanment comments
bathroom remodel
Passed
Failed
Correction
Needed
❑
Re -Inspection
❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
Permit Type: Residential Construction
Inspection Type: Final Building
Work Classification: Alteration
Phone Number
Parcel Number
INSPECTOR COMMENTS False
Inspector Comments
1132050270380
September 04, 2014 For Inspections please call: (305)7624949 Page 1 of 25