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EL-13-2357U Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-201438 Scheduled Inspection Date: December 05, 2014 Inspector: Naranjo, Ismael Owner: JOANNE NORDONE KETLLE JTRS, Mf1O/_A1,1 0 Ur%0nnA1C MOO Job Address: 725 NE 91 Street 3-D Miami Shores, FL Project: <NONE> Contractor: HOME OWNER Building Department Comments MOVE ELECTRICAL PANEL BACK TO ORIGINAL FORM Permit Number: EL -10-13-2357 Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition/Alteration Phone Number Parcel Number INSPECTOR COMMENTS False Inspector Comments Passed EJ_ Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. 1132060440170 December 04, 2014 For Inspections please call: (305)762-4949 Page 1 of 26 Miami Shores Village . Building Department 117050 N.E.2nd Avenue, Miami Shores, Florida 33138 9 plu Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING AUG 21 2014 FBC 20 j® Permit No. ZY 03 " PERMIT APPLICATION Master Permit No. Permit Type: Electrical JOB ADDRESS: -I �t':5 (\e q t -1%1 -'� --u:) City: Miami Shores County: Miami Dade Zip: Folio/ParceW Is the Building Historically Designated: Yes NO Y Flood Zone: OWNER: Name (Fee Simple Titleholder): �-A b SZ!3 G✓a%.. Phone#:__� Address: 2� �� - . �'S - l City: ` (A," 1 6��A 0 ':�D State: Zip: TenandUssee Name: Email: � nl-) CONTRACTO Address: City: ZL c Qualifier Name: State Certification or Registration #: X99 i Zip: J /h q.nl— Phone#: Contact Phone#: Email Address: DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 1 b b ` o SgoareaAnear Footage of Work. Type of Work: OAddress L Wteration ONew ORepair/Replace ODemolition Description of Work: �A o y--� '*'Y_'!� V"k 1 fl L (L (4 6 C. h D V\, 2-0m laPQ, Z1,j Submittal Fee $ Permit Fee $ 14 110,0 CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 153'(Z 1101 �Kll 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. "WARMING 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 properly 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 approve and a reinspection fee will be charged. o Signature Signature q",-�� Owner or Agent Contractor The fore omg instrument was acknowledged before me this �g day, of , 2o-14, by �CYA ii�iCV® , who is perso ly known to me or who has produced As identification and who did take an oath. NOTAK�BLIC: Sign: Print: "rAo•• Erika Bueter 9x:;�;:COMMISSION#FF 047731 My Commission Expires: ,�'t?4c EXPIRES: AUG. 22, 2017 •ap;;.` www.AARONNOTARYcom The foregoing instrument was acknowledged before me this day of who is��to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Mycominissinfill ro�6S Notary Public State of Florida Michelle Perez My Commission FF 000321 OFp p4c Explres 04/08/2017 APPROVED B Z Plans Examiner Zoning Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) llAl E (A1�®/llL+ s s s i � ►c® �� 4119/2x14 CERTIFICATE LIABILITY INSURANCE THIS CERTIFICATEIS ISSUED AS A MATTER OF INFO TION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOLDER THIS CERTIFICATE DOES NOT AFFIRMIATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_ THIS CERTIFICATE OF INSURANCE ddEt NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SD, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: If the holder Is an ADDITIONAL INSURED, the Policy(les) mist be en If SUBROGATION W sutrt�ect 6v the terns and conditions of the Policy, certain policies meat' require an endorsement- A stdoment on this certtflcate does not confer ruts to the cerIffkate holder in lieu of such endorsemrent(S)_ MpRA� PAYCHEX INSURANCE AGENCY INC (AU .ft.0 (M.SMAIL (888) 443-6112 210705 P: F:(888) 443-6112 PO BOX 33015 ""$" �O1�aG `perms SAN ANTONIO TX 78265 irisuaEnA: Twin City Fire Ins Co 91SURM INSURERS: MWPXR C: LONGMAN ELECTRIC INC "OURERD: 844 NE 98TH ST IaSURER E: MIAMI FL 33138 IZURFA F: CEATIFICATE IMUNU - REVISION NUMBER GOVEKAGEEs HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY RE0002EMENT, TERM OR CONDITION. BY THE POLICES DESCRIBED HEREIN is SUBJECT TO ALL THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED AND CONDITIONS OF SUCH POLICES. LNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TERMS,EXCLUSIONS fim TPPEOFR%WVAAfflC ADDL SVBR POL[G7NUA98ER POLKYEFF POLZCYEAP tl%tI� EACH OCCURRENCE N COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS -MADE ❑OCCUR PREMISES (Ea ocgyaerrce} MED EXP (Arty one person) S PERSONAL & ADN' INJURY g C,ENERALAGGREGATE r GEN'L AGGREGATE LIMIT APPLIES PER POLICYPRO- F1 LOC PROD UCTS-COMP/OPAGG OTHER COMBINED SINGLE LIMIT AUTOMOBIJE. LIABILITY (Ea accident) BODILY INJURY (Per Arson} S' ANN AUTO ALL OWNED SCHEDULED BODILY IN JURY (Per acakW) g AUTOS AUTOS PROPERTY DAMAGE $ HIRED AUTO NON -OWNED AUTOS (P�accident) c EACH OCCURRENCE $ UMBRELLA LIAB OCCUR AGGREGATE $ EXCESS LIM CLAIMS -MADE 5 D REMM-10PSX AER OTH- WORSbRSCOAMEPSAT"V Anu) EalPI.OYERS+�1' •an m STATUTE ER E.L. EACH ACCIDENT 1, 000, 000 ANY PROPMETORIPARTHEREXECUTiYBRN OFRCER/MEMBEREXCLUDED? NA 05/01/2014 05/01/2015 E.LDISEASE-EAEMPLOYEE $1, 000, 000 A (Nand3to+Y h, A" ❑ 76 IdEG IX1296 POUCY LIMIT $1, 0 0 0, 0 0 0 If yes. destaFe under EL DISEASE - DESCRIPTION OF OPERATIONS bekw DESCRFrION 0J=OPZRA7IONS/L®CAT10MS / MEffXPMRD 101. AddWwnA Rsntadrs Scheduta maY be cached it afore space is required) Those usual to the Insured's Operations. t�. rrAlMr-FLtATION Miami Shores Village 10050 NE 2ND AVE MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE ACORD 25 (2014101) The ACORD narne and logo are registered marks of ACORD reserve ACORD. CERTIFICATE OF LIABILITY INSURANCEDATE(MMIMM"YY) ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 09/0012013 PRODUCER Phone: 407.696-1333 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Pontell Insurance and Financial Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1484 Tuskawilla Road Oviedo, FL 32765 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE GOVERAGE AFFORDED BY THE POLNGIES BELOW. UNITS License #: P085436 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Nationwide Insurance Company of America 25453 INSURER B: Longman Electric Inc INSURER C. 844 N. E- 98th Street INSURER D: Miami Shores, FL 33138 INSURER E 'ei*11I =i -7Sd d 3 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ISR F INSURANCE POLICY NUMBER POLICY EFFECTIVE DATEMMIDDIM POLICY EXPIRATION UNITS A GENERAL LIABILITY AC05905107300 09/07/2013 09/07/2014 EACH OCCURRENCE $ 2,000,000 C COMMERCIAL CLAIMS MADE � OCCUR DAMA T E PREMISE R ocatmtce $ 100,000 MED EXP (Any one person) $ 5 000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2.000,000 AGGREGATE LIMIT APPLIES PEP, PRODUCTS -COMPIOPAGG $ 2,000,000 riGEML l POLICY sm LOC A AUTOMOBILE LIABILITY ANYAUTO ACPS905107300 09/07/2013 09/07/2014 COMBINED SINGLE IJMrr $ 1,000,000 X ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per Pin) HIRED AUTOS NON-OWNEDAUTOS BODILY INJURY (P�eaddeM) $ PROPERTY DAMAGE $ (Per eodderM GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR FICLAIMS MADE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND TH- WC STIMIT ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETORiPARTNER/EXECUTIVE EL DISEASE - EA EMPLOY $ OFFICERWEMBER EXCLUDED? Ifyes, describe under EL DISEASE - POLICY LIMIT $ SPECIAL PROVISIONS below OTHER A Inland Marine ACPS905107300 09/07/2013 09/07/2014 Unscheduled E 1 ,000/1,000 Ded DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Miami Shores Village DATE THEREOF, THE ISSUING Isummv"ILLENOEAvoRToMAIL 30 DAYSwRrrrEN P-305-795-2207 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO OO 80 SHALL 10050 NE 2 Ave IMPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE INSURER ITS AGENTS OR Miami Shores, FL 33138 REPRESENTATIVES. 25 (2001!08) n er-nran rnRanRATInw 4ARR Printed by SSD on September 06, 2013 at 04:37PM . . . . . . .......... R"- SCOTT, GOVERNOR KEN I.A- WSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL C"TRACTORS LICENSING BOARD EC1*3003713 The ELECTRICAL CONTRACTOR Y. Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Explikibn-dats: AUG -31 2016 tONGMAm,:MICHAEL 138 s ISSUED: 07/24/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1407240001832 Local Business Miami -Dade County, THIS IS NOTA BILL 6137004 BUSINESS NAME/LOCATION LONGMAN ELECTRIC INC 844 NE 98 ST MIAMI SHORES FL 33138 OWNER LONGMAN ELECTRIC INC 1Wo"r(S) I Tax Receipt State of Florida 00 NOT PAY LBT RECEIPT No. EXPIRES FENEWA - SEPTEMBER 30, 2015 41400147 Must be displayed at place of business Pursuant to County Code Chapter RA - Art, 9 & 10 SEC. TYPE OF BUSINESS 196 ELECTRICAL CONTRACTOR EC13DO3713 PAYMENT RECEIVED SV TAX COLLECTOR 845.00 08/10/2014 CREDITCARD-14-032079 This Law Business Tax Receipt only awym Paymeat of th Local Bnsimme Tax. The Receipt is sol a license, pmt or a eertificatios of the holder's qualitituttio>�, to do hsshmm Haldermustsompiy with any gmm mu mw or songovarsrsestal rmlamry laws and re9oi►emssts which apply to the hasiMss, The RECEIPT NO. above -must be displayed on an commercial veMcies- Miami -Dade Coda Sec 8a-216. For more hdonnedsn, visit mlemidad. gm ftxcollacmr Miami Shores Village Building Department 10050 N.E2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 7952204 Fm (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: Electrical JOB ADDRESS: FBC 20 Permit No. Master Permit No. City: Miami Shores 1 County. Miami Dade zip: Foho/Parcel#: Is the Building Historically Designated: Yes OWNER: Name (Fee Zone: City: &C Ag � r�, AAI State: zip: Tenant/Lessee Name: Phone#• kC-3g 2:W j Email: CONTRACTOR: Company Name: atu"r Phone#: Address: City: State: 7in: - Qualifier Name: Phone#: State Certification or Registration #• Certificate of Competency #• Contact Phone#: Email Address: DESIGNER: Architect/Engineer: # Phone#. Value of Work for this Permit: $ ®. Squaref[Aear Footage of Work: Type of Work: UAddress Al onONew ORepair eplace ODemolition Description of Work: --Rove6 e tCat ' ��;9,� �Cle �C Ar -,e n,. I a�,�**,x,�a,ra*,x,�,r�r�,�,x�r*a•�arra�*,rir,a+�**,rte*,x�*F�*a�+a*,�,x*,kir,�,�,x,��,�•x,►+a•,�**,r,k,a*,r�,x�*,x�r*,kr,�,r�r,� Submittal Fee $ Permit Fee $ fjsQ®i ®d!9 CCF $ CO/CC $ . Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ i . Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State M", 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 COMIVIENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR UNAPROVEMENTS 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 occur. even (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a einspecdon fee will be charged. Signature Agent I Contractor The foregoi &instrument was acftft'ledged before m/ e�this -L-L- The foregoing instrument was acknowledged before me this day of 20 I by w I% ian d e 1 U IV 9Uay of _ .20 by who is personally known to me or who has produced, � who is personally known to me or who 'has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: -- Sign: Print: Print: My Commission Expires: My Commission Expires: w,�,�,x�,x�*,�a�,�a�,rr�,k,k,►,k,k*«,�,�,�,x*,x,�,r,�ra�,t�,t«,�***,�,�r,�*�r,k,kr,�***,ti,k,��,x��ar�,�,�,a�,��r*�*,xr�,�r*,kt�,s�,�,x,�,� APPROVED BY Plans Examiner Zoning Structural Review (Revised 3/12/2012)(Revind 07/10/07)(Reviwd 06/10Q009)(RVAW 3/15/09) Clerk NAME: ADDRE Miami Shores Village WNW, Department 10050 N.E.2nd.Avenue Miami S hordis, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Do hereby petition the Vlltage of Miami Shone; to act as my own contractor pursuard to the taws of the State of Florida, RS 489.103{7). And I have read and undarQod the. following discoscre statement, wnicn er►es ma to work ae my arm contractor, l 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 ane -family or two-family residence. You may also build or improve a commercial building at a cost of $25;000.00 oriels (Ther new form states,75,000). Tlie building,mustbe for yourown use and occupancy. it may not Wbuilt for sale or lease: If yoarseil or bases building you have built yourself withlit brie year alter the construction is°cbfrrplete ftlaw wilt ung that -you WIN f0eiWe of Vie; which Is`a violation ofthis-Wit iption. 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 countyor municipal licensing ordinances. Any person working on your building who is not licensed must work under your supervision and must be employed bar you, which means that you must deduct FICA and with -holdings tax and provide workers' compensation forthat'enrpliiyee, all k p"bribed bylaw. Your bonstncction mustcomply-with all apple dyble laws, Ordinences, buildings codes and zoning 1,096letions. Please read and initial each paragraph. 1. 1 understand that state law requires construction to be done by a licensed contractor and have furan owner -builder permit under an exemption from the law. The exemption specifies that I, as the owner of the property), may act as my own contractor with certain restrictions even through I do not have a license. t 2. 1 w derstand that building penTb are not required to be signed by s property owner untw he or she Is responsible for the constructiorl and Is not ftg a eoensed contractor to Fume responsibility. 3. 1 understand that, as an owner builder, l am the respopsible party of record on a permit I understand that I may protect myself from potential Inandal risk .by " 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 Int his or koe tubers on permits 8nd contracts. I 4. 1 understand that I may build or improve a one family or two-imnlly residence or a farm outbuilding. I may also build or improve a commercial building If the costs do not excsed $75,000. The building or residence must Iia for my usi or oocuq)a'ncy. It may not be built or substantially improved for sale or lesse. If a building or residence that I have built or subste improved myself Is sold or leased within 1 year after the construction Is complete, tie law wM Pwme that I built r s ally Improved it for sale or West which violetes the exemption. . 1 5. 1 understand thud, as the owner -builder, I must provide direr, onsite supervision of the construction. T Initi 6, 1 understand that I may not hire an unlicensed sed person to act as my contractor or to supervise persons wodit on my building or residence. It Is my responsibility to ensure that the persons whom I emptoy have the license required by law an by county or mun*W ordineribe. initial 7. 1 understand that it is frequent practices of unlicensed sed persons to have the property owner obtain an owner -builder permit that .OrMnOddsly implies that the property owner is providing his or her own labor and materials. I, as an owner-bugders maw—Bald liable and subjected to serious financial risk for any Injuries sustained by an unlicensed person or his or emplo}rees-hAfle working on my property. My homeowner's Insurance a may not provide coverage for those Injuries. I am hwilffully. actiq as an ownet-builder and em aware of the limb of my insurance coverage for injuries to workers on my property. Inhw 8. 1 understand that I may not delegate the responsibility for supervising work to be a licensed contractor who Is not 1loerses to perform the work_beirg.done. Any person working on my building afro is not , licensed must work under my direct supervision and must be employed by me, whicti irieai 'that I mist comply with FIs-rdgtil* the withholding of federal income twx 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 Now these may subject to serious financial risk. initial - 9. 1 agree that, as the party legally and flnencieily responsible for this proposed Construction activity, I will abide by all applicable laws and requirement that- govern ownai-builders as well as employers. I also understand thet`the Construt fon must comply with elf applicable lows, ordinances, building codas, °-and zoning regulallons. lnkw 10. 1 understand that I may obtain more information regarding my obligations ass an employer from the Internal Revenue Service, the Untted StatesSmall Business Administration, and the Florida Department of Revenues. I also understand that) may contact the Florida Construction Industry Uomhg Board at 850.487.1395 or httoJlwww.mvflorldelioense.comtdborlorolcilblindes.html 11. 1 on aware of, and consent to; an owner-bullder building permit applied for In my name and understands that I am the party legally and fjnanddy responsible for the proposed construction activity at the following address: 12. 1 agree to notify Mimi Shores Village immedlalely of any additions, deletions, or changes to any of the information that I have provided on the disclosure Initial Licensed contractors are regulated by haws designed to protect the public. ff you contract with a person who does not have a Ucarnse, the Corstr4uction Industry Uconsing Board and Department of Business and Professional Regulation may be unable to asset you with any fifienclal loss that you sustain as a result of Contractor may be in civil court. It Is ate hrfporterd for you to understand that, if an unlicensed contractor or employee of'an Individual or firm Is Injured while working an yourproperty, you may be held liable for damages. H you obtain an owner -builder permit and wish to hire a noersed contractor, you will be responsible for vel tri 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 mast 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 ownbei'driver license, the notarized signature of the property owner, or other type of verifiiadon acceptable to the local penhtffting agency Is required when the permit Is Issued. Was acknowledged before me this day of �'— 20 Bya U ff d cre- who was personally known to me or who has Produced there License 6as identification. OWNER NOTARY 3 Z 0 o uX O ZZ m z O � / k X rn m co y�z D 7p -n Z C1 D N� r- z ° x0 �X� rn O C) n 0 �� z z m oW� � to ^Z V VI W rn �� g rn Z -< V 3 Z v rt 'D c uX O ZZ m z N O m O z Q O O w X �i0 A 0 . 6 O v H Lj w ~ to p c � z H � H H W H z I 8 n 3 o C M O T CL o m r _ o r m n v 3 Z .�+ m 0 ') m C7 O r � < y 'o m 0 o 8 00, 1 cn C LL, P Lli LL Ll "maw 7FT