PL-12-2158 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
nspection Number: INSP-181561 Permit Number: PL-11-12-2158
Inspection Date: June 30, 2015 Permit Type: Plumbing - Residential
Inspector: Diaz, Osvaldo Inspection Type: Final
Owner: AGUIRRE, DIEGO Work Classification: Addition/Alteration
Job Address: 254 NW 92 Street
Miami Shores, FL Phone Number (305)646-1283
Parcel Number 1131010331260
Project: <NONE>
Contractor: CASTELLON PLUMBING CORP Phone: 305-553-1490
Building Department Comments
REPLACE EXISTING PLUMBING IN BATHROOM & Infractio Passed Comments
KITCHEN INSPECTOR COMMENTS False
Inspector Comments
Passed /
Failed
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
For Inspections please call: (305)762-4949
June 29,2015 Page 1 of 1
RECEIVED
Miami Shores Village MAY 19 2015
Building Department BY:
10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 w
BUILDING Master Permit No. n�))� ZI'" /Z--2.1-5-6PERMIT APPLICATION Sub Permit No. PL• /2
BUILDING F-1 ELECTRIC 0 ROOFING E] REVISION EXTENSION EJRENEWAL
®PLUMBING F-� MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION F-1SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: � J � /!O GL/ -/� s
City: Miami Shores ) County: Miami Dade Zip:
Folio/Parcel#: 1 1 3/ o 1y 3 > 1Z 6 U Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type:�/ Flood Zone: BFE: FFE:
WNER: Name(Fee Simple Titleholder): l Iez?d fLc, V7L Phone#: 30'T' X04 c, 2 3
Address:
Ci State: p'.
rs Zi
�3
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Phone#-
Address: Irk 41-1 z1y f A SYR O4 ,4
,,t 1 City: ! State: Zip:_ 3aj!p
/��� � fir�,�P f `�
Qualifier Name: (7l/Z!• To7 Phone# -Q��Z _ -S`/g�
��
AV
State Certification or Registration#: j�� CZM,S�Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ �� Square/LllnearFoetaV dP'V1i'ryrK -` 'd D
Type of Work: ❑ Addition //❑ Altera/tion 10 New ❑'RReWr/Replace: ❑ Demolition
Description of Work: zze A
fY of
S eci color color thru tile:
P
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ C3 IR /
(Revised02/24/2014)
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City 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 ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS,TANKS,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
`moi `or A smolt CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
Aday of 20 'i fpr S day of 20 1)7 by
who is gvson o _�i p-�b0 CO%S?-7;tt1,�(nlho is personally known to
me or who has produced as me or who has produced as
identification and who di t <e an oath. identification and who did take an oath.
NOTARY PUBLIC: DENA CRUZ TARY PUBLIC:
Nobry t�Ib•Stab of Florida
• CogMMatlon 0 FF 204543
Si n: M!F>BonMn.EaNna Apr 7,2019 n:
g Aasn.
Ak
Print: 4 int:
Seal: Seal: * P * MYCOMMISSION 1 IFF 194191
EXPIRES:Apol 2010
Bonded Thru Budpd No ry8r tt
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
. R
�° �s ti
Miami shores Village
"" Building Department
*,,R p'~ 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
Permit N.
Owner's Name (Fee Simple Title Holder): / e-t 0 `&Uj',rc Phone#: 5 64 'Z q-3
Owner's Address: 2-o5 4* d�(/ !% S
City: S State : Zip Code: (3
Job Address (Of where work is being done): 254 NW 92 ST
City: Miami Shores Stare:—Florida Zip Code:
Contractor's Company Name: Castellon Plumbing Corp. Phone#:(786)255-5195
Address: 9841 NW 130 ST
City: Hialeah Gardens State: Fla Zip Code:33018
Qualifier's Name : Giraldo Castellon Lic. Number. CFC 019059
Architect/ Engineer of Record Name: Phone#:
Address:
City: State: / Zip Code:
Describe Work: "'t
1 hereby certify that the work has been abandoned and/or the contractor/architect
is unable or unwilling to complete the contract. i hold the Building Official and the
Miami Shores harmless of all legal involvement.
Signature 1 Signature :�l . ^• _L ,eu�
Owner or ent Contractor or Architect
The foregoing instrument was aknowledged before me The foregoing instrument was aknowledged before me
this PC day of .24�y Ie D ��?•� this�( day of �`,�. 12015 y.
Who is, -- ally knewmto me or who has produced who is personally known to me or who has produced
as indentification. as indentificacion.
Notary Public: Notary.Public:
$1If, a��uy Sign. {l�i.E-ti'Cl:.f'
-�;`�; Not -Side of fbriQa 1 `
Seal: /, � Seal: ;•� BEATfliZ A BURt�OS
. , Commission#�FF 204543
rr)mm. Expires Apr 7,2019 * * MYCOMMISSION AFF194734
e Z �,,,• ,h NVInnal Notary Assn. 4� EXPIRES:April 7,2019
?ands BondedThNBudgetNaferySurlces ,
i
STATE OF FLORIDA
-.# DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
CASTELLON, GIRALDO
CASTELLON PLUMBING CORP
9841 NW 130 ST.
HIALEAH GARDENS FL 33018
Congratulations! With this license you become one of the nearly
one million Floridians licensed by the Department of Business and
Professional Regulation. Our professionals and businesses range STATE OF FLORIDA
from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND
and they keep Florida's economy strong. � ..- PROFESSIONAL REGULATION
Every
da s in order to CFC019059 ISSUED: 05/29/2014
v y we do business
serveyou we work to improve the wa better. For information about our services, please log onto
www.myfloridalicense. com. There you can find more information CERTIFIED PLUMBING CONTRACTOR
about our divisions and the regulations that impact you, subscribe CASTELLON, GIRALDO
to department newsletters and learn more about the Department's CASTELLON PLUMBING CORP
initiatives.
Our mission at the Department is: License Efficiently, Regulate Fairly.
We constantly strive to serve you better so that you can serve your �S CERTIFIED under the provisions of Ch.489 FS.
customers. Thank you for doing business in Florida, Expiration date AUG under
ua.489 FS.
and congratulations on your new license!
1726
DETACH HERE
RICK SCOTT, GOVERNOR KEN LAWSON;SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
CFC019059
The PLUMBING CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2016
0 0
CASTELLON, GIRALDO
CASTELLON PLUMBING CORP
9841 NW 130 ST.
HIALEAH GARDENS FL 33018
y
0a16
. mit
jw3ul
- ReceiptTax
Local Business
i-Dade County, State of Florida.
MIa171 _ DO NOT PAY
-THIS IS NOTA BILL
LE11
466748 EXPIRES
RECEIPT NO- Z07
BUSINESS NAMEn-OCATION RENEWAL SEPTEMBER 30,
CAMLLON PLUMBING CORP466748 Must be displayed at place of business
9541 NW 130 ST
Pursuant to County Code
HIALEAH GARDENS FL 33018 Chapter 8A-Art-9&10
SEC.TYPE OF BUSINESS B TAX COL RECEIVED
OWNER 196 PLUMBING CONTRACTOR $45.00 08/07/2014
CASTELLON PLUMBING CORP CFC019059
Workers) 10 CHECK21=14--045693
Receipt only confirm payment of theme n alines Ux. The s V
This Local Busin" 60 holder"s alifi catioat,to do b
Holdec+nustcomPly
permit,of a ceNfic ngal�at ly 1�anfe9uiromats which apply to the b �p-0.
or ao"P a ial vehicles-'
The RECEIPT N0.above must be displayed on all commerc
for mora information.visit +
a
ACC> CERTIFICATE OF LIABILITY INSURANCE DATE iAfMiDOIYYYY:
�a.r�' 05r 18 1 15
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVEL Y AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT! If the certificate holder is an ADDITIONAL INSURED,the policy(iesl must be endorsed If SUBROOATlON IS WAIVED,subject tc
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this cerdflcate does not confer rights to the
certificate holder in Lau of such endorsement(s).
PRODUCER CONTACT
NAME:
first Gass Insurance Market HON o EXq: k,3051441-2997F .no): (305)441.6443
4':01 NW 9th Street E-MAIL coin corn
ADDRESS:
Miami FL-33126 iNSURERi S)AFFORDING COVERAGE NAIL k
PhD,)e 1335)441-239; Fax (3051441-344 INSURERA: GR,ANADAINSUIRANCECO
INSURED INSURER B
CASTELLON PLUMBING CORP CFC 01909 INSURER C:
9BA i. NW 130 S1 INSURER D'...... -
HIALEAH FLORIDA 33018 INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER!
TF-IS IS?O CERTIF,(7HAT 7HE PO_ICES OF INSURANCE LISTCD 3ELOt'i HAVE BEEN ISSUED TO TI!E'•NSUR:D NAMCC ADOVL FCR 711C P0_CY nERIOD
INDICATED NOTSNITHSTANDING ANY RMUIREMEuT.TERM OR CONDITION OF ANY CONTRACT OP OTHER DOCUMEh7',NITH RESPECT TO k%1HiC i THIS
CER'!FICATE W,v EE'SSUFD OR MAY PERTA-N THE INSURANCE AFFORDED EY THE POLICIES DESCPIBED HEREIN IS SC60'ECT':0 ALL THE TEPMS
E>CLUSICINS AVC CONOsTICNS OF SUCH POLICIES LIMITS SHOJIN MAY HAVE 3EEN REDtICFD BY PAID CLA`h1S
INSR ADOLSUBR POLICY EFF POLICY EXP
LTR TYPE OFINSURANCE fNSR VNO. POLICY NUMBER (MMiDDiYYYY) 1&1,%kDDryYYY) LIMITS
GENERAL LIABILITYe •;,. ,,sa_ ,_ OOQ,COO CG
C ,Ge ct.— )!).JOQ OC
J LOts 1.RCI L 3.V=2AL LIA9 iTY ?F.Eh:I -
e ,.
A — -� 01034414 1012912G14 10!29,'2015 "EL= 5 000 CO
rkti r ti ;w( 000,000 CU
2 000.000.00
G__N ArrLl-.!PER PnvvV - E 2 OOQ.G00 CO
_
-
AUTOMOBILE LIABIL.TY ccNIF!J sr.GLE"..;"7
s-L ,r:E� - SCr OLEO -
+UTC". hi,LriY,rC-E_._7e'1 _.-
-- Nr.,Y-11fvT16D PRGFFFTY DAMA sF -
UMBRELLA LlAB OJ�.UR Ln.Ci-O tiURR_hCC c _ _
EX CESS LIAB _ CLAIMS-IAAOE iild:REr>ATE ..
'tet -._._rE IEP:_Q!I=
5
WORKERS CZWPENSA7104 ..._......_. - ...._..
AHD EMPLOYERS'LIABiUTY YJ TO4r LIMI T3 q
AN•"PZ ✓ i-T f XPi, TNeRi+-Xc'�.UTI`.'E E L FA F-AC,'
VT 5
0 1l -TIPOeLP.e'XCLUDEO'� NSA _.. ._ ..._.
INandetorp in NH)
DESCR P T4,JF Q"tdaTUNS EL Cis �,.E-'Gl. _J':7
DESCRPTYIN OF OPERA783NS i LOCATIONS 1 VEHICLES (Anacn ACORD 1 D7,Additlottal Remarks Schedule.N more space is required)
PI UA96fNG CONTRACTOR
CERTIFICATE HOLDER CANCELLATION
MIAMI SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
10050 NE 2 AVE ACCORDANCE WITH'HE POLICY PROVISIONS,
MIAMI SHORES,FLA. 33138 AUTHORIZED REPRESENTATIVE ., 111—T
FAX:( 05)756-8972
Z;1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010f05)OF The ACORD name and logo are registered marks of ACORD
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CHIEF FINMCIMUM�WOM ,
6APENMT'IDtj
pCATE OF OXCTION TO BE EXEMPT FROM FLORIDA W �COMPENSATION LAW
� ••
CONSTRUCTION INDUSTRY EXEMPTION
i
i This CeANles itlatlhe Indiddusl listed below has elected m be��p�m Flo;t�Workers'Compensation low,
8fWIWEDXTE 11122/2013 EXPIRA
pEFtSON: CASTELLON
GIRALOO
FEK 591676886
i BUSMESS NAME AND S:
CASTELLON pLUNBING CORP
I
r 9841 NW 130 ST.
• HIALEAH GARDENS
FL 33018
SCOPES OF BUSfi1 M OR TRADE'
LICENSED pLUNBING
CONTRACTOR ..rNa+�++,d,,,,,erw..e+�mu
� bOMp,01(NI.FS.b+dlo+d.aalv+b"'horeasw ►o�Msd+pr hWWH�
ud+6i.d+Pw•A�{bCh'p°ra10O6(��I.FB�(C+Ifro�wd d+.d+�MdW�owdeft rdo.o
dd9wkWdriGrW8b'1M+�iebFo�.��F+bmmAw" °aA�dablo.TM i+brtd+0�.�d.`�:o+tlea++ryYm.arw.dw
�w�al.robOb�r"�b�Miq�rnrrdll.rcem
�qM.deMarMau
OUESTIONSi(650)4131609
OFS.F24)WC•252 CERTIFICATE OF ELECTION TO BE E*%VT REVISEO 07.12
i
. ._.__,---4%R—uw ani?mta--Idwoinc9D703gH6TER6eP1IOAZ%2f5z5bXK "*eleESOPVy"ANPOPN42XeirDRGXWH*i... 112
S�OREs
logo .,,..� Miami shores Village
ras Building Department
��ORiDp' 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 and has acknowledge that he or she will not use
day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project. In these circumstances,Miami Shores Village does not require verification of
workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
caner
State of Florida JT4
NOta!v County of Miami-Dade Co My )irThe foregoing was acknowledge before me this day of20� .
By J)trg0 1j ulYtyl✓ who is nall kno to me or has produced
as identification. • '••s GENA ,
• AW&Y PWNk- ids
Notary: Coe Ilkn a i3
�eo+am.Ext. 20
SEAL: OdMMgh ti W
uYA
CASTELLON PLUMBING
9841 NW 130 ST
Hialeah Gardens, Fla. 33018
> e: 05/18/2015
Fla
County of Dade
Before me ihis day personally appeared Ginildo CastPllnn who, being duiv sworn. deposes and saes:
That fie or she will be the only person wotcing on the pruleci ai 254 NW 92 ST
r {_
[ii t ii[ :�11trtll,;t�t z�•a;::� St1s7�tit�r!�;;,I �i:'1111'- f'."'�°iil{_; ri,-�,'% "t MAY __- -- ''.__...__ h'3
Gr produced Identification
ident rc;al of" Pr,
BEATRQA BURQOSJ
* * My MWISSION t FF IW34
y r EXPIRES;Ap617,2019
NO 1100 &OldThruW*NoterySmka
i
i
Miami Shores Village r Pt�1 3
10050 N.E.2nd Avenue NW 19
Miami Shores,FL 33138-0000
IR
y4+ o� Phone: (305)795-2204
F�oR�oA Ex iration: 09/30/2015
-. yW2 P
Project Address Parcel Number Applicant
254 NW 92 Street 1131010331260
Miami Shores, FL Block: Lot: RONGINA COOKY
Owner Information Address Phone Cell
fRONGI.NACOOKY 254 NW 92 ST
MIAMI SHORES FL 33150-2231
Contractor(s) Phone Cell Phone Valuation: $ 3,200.00
ARMANDO PENA (786)255-5474 Total Sq Feet: 0
Type of Work: REPLACE PLUMBING FIXTURES Available Inspections:
Type of Piping: Inspection Type:
Additional Info:BATH AND KITCHEN Top Out
Bond Return : Final
Classification:Residential Scanning: 1 Rough
Underground
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $2.40
Invoice# PL-11-12-45933
DBPR Fee $3.38
DCA Fee $3.38 11/14/2012 Credit Card $50.00 $416.16
Education Surcharge $0.80 04/03/2015 Cash $416.16 $0.00
Permit Fee $225.00
Scanning Fee $3.00
Technology Fee $3.20
Work without Permit Fee $225.00
Total: $466.16
In consideration of the issuance to'tne of this permit, I agree to,perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conform ty with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit i assume respo�sibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBI MECHANICAL,WINDOWS;DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify �t th�f regoing informatiop'is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhernpo.t,-�I u rize above-name'd contractor to do the work stated.
April 03, 2015
r
Authorized Signature: "dYner' / Applicant / Contractor / Agent Date
Building Depart` tit Copy
April 03, 2015 1
- 1
Miami Shores Village
Building Department NV x012
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 _ s
Tel: (305)795.2204 Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305)762.4949
FBC 2,0
BUILDING Permit No. '7,1 2_ "�;OSY/'�
PERMIT APPLICATION Master Permit No.
Permit Type: PLUMBING
JOB ADDRES9z <'7 N V VqD S4-
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER:Name Fee Simple Title lder): hone#:
Address:
City: m State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: TZ 1 �` Phone#:
Address:
City: a Zip:
f '
Qualifier Name: ..�`` Phone#:
State Certification or Registration#: Certific9e Competency#:
Contact Phone#: _Email Add s:
DESIGNER:Architect/Engineer: r ti { �. '� Phone#:
Value of Work for this Permit:-$ Square/LinearFo tage of Work:
Type of Work: ❑Address ❑Alteration ❑New 4.` l pai ce ❑Demolition
Description of Work Q r lAl MbAnC2
► �� �ei►
x***Fees************xx*x***x
Submittal Fee$ Permit Fee$ s CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
lyatar3 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 Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City 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."
1
Notice to Applicant: As a condition to the issuance of a buildin pe` P""th an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commenc an ruction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a cert ifgl co to re ed notice of commencement must be posted at the job site
for the first inspection which occurs seven (7).0s al��h ! 'ng p fti'it is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection'ye wa. ch
Signature " Signature
Owner or gent Contractor
The foregoing instrument was acknf wledged before me this The foregoing instrument was acknowledged before me this
day of /w\/ ,20��by �"�%/� /� day of 20_,by
who is personally known to me or who has produced who is personally known to me or x*ho has produced
As identification and w�gOW,(pke an oath. as identification and who did take an oath.
NOTARY PUBLIC: \\\�`��\�efa NOTARY PUBLIC:
Sign: _ Sign:
Print: ` Print:
My Commission Expires: �a My Commission Expires:
APPROVED BY W Plans Examiner Zoning
Structural Review Clerk
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
R Miami Shores Village
Building Department
Bull10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME: y1 r �-C DATE: r Zc) Z
` e"' G�Z f� /G/J1/.��/t�,�. : � � "
ADDRESS:
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.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.
Initial
2. 1 understand that building permits are not required to be signed by a property r 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 aPaaZJ;W
rstand that I may protect myself
from potential financial risk by hiring a licensed contractor and having the permr ame instead of my own
name. I also understand that the contractor is required by law to be licensed inhis or license numbers on
permits and contracts. Or2
4. 1 understand that I may build or improve a one family or two-family residence or a farm outbuil 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 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
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 c
7. 1 undetstand 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,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 acting as an
owner-builder and am aware of the limits of my insurance coverage for injuries to workers on my property.
Initial
8. 1 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
9. 1 agree that,as the party legally and financially responsible for this proposed Construction activity,I will abide by all applicable
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. FC
,,tial `
10. 1 understand that I may obtain more information regarding my obligations as an employer from the Intemd Revenue Service,the
United Stales 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 hfp://www.myforidalir@gseiom/dbDr/p[olcilb/index.html
a �
Initial �!
a
11. 1 am aware of,and consent to;an owner-builder building permit applied for in mg new and unterstands that I am the party
legally and financially responsible for the proposed construction activity at the following"e ress:
Initial
12. 1 agree to notify Miami Shores Village immediately of any additions,deletions,or changes to any of the information that I
have provided on this disclosure. 1
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 Constr4uction 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
understandthat,if an unlicensed contractor or employee of an individual or firm is injured while working on your property,you may
be held Iia le 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 responsib • suia pe copy property owner's driver license,the
notarized signature of the property owner,or of of v ati able local permitting agency is required when
the permit is issued. '*
IWas acknowledged before me this day of 20 2�
By 6i who was personally known to me or who has
Produced there License or as 1018ftv,,
OWNE
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'moi �' .... •'.`Q~,���
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ST TEWI E
SEPTIC CONNECTIONS, INC.
6032 SW 23 Street * Miramar, FL 33023
Phn: (954) 963-0082 * Fax: (954) 963-DOSS
LIC# SM0971262 & INSURED
TO: REGINA COOLEY DATE: 01/2312013
JOB: 254 NW 92 STREET PERMIT: APB1089426N
MIAMI SNORES, FL 33150 REF: MARIO, ENG.
WE APPRECIATE THE OPPORTUNITY TO SUBMIT THE FOLLOWING SPECIFICATIONS TO:
• PUMP AND ABANDON EXISTING SEPTIC TANK
• INSTALL 1050 BALLON TANK FOR 4000" SFR
• INSTALL 667 S@FT BLD DRAINFIELD FOR 4000PD SFR
• INSTALLIREPLACE UP TO 42"OF SUITABLE SAND UNDER SYSTEM
• HAUL AWAY EXCESS FILL INCLUDED
• LEAVE JOB CLEAN AND MACHINE LEVELLED
• NO PLUMBING LINE OR WATER LINE INSTALLATIONS, RE-ROUTING, OR SLEEVING
• NO RESODDING OR RESTORATION OF PROPERTY
• MIAMI SHORES PERMIT IS INCLUDED
TOTAL AMOUNT $6,500.00
DOWN PAYMENT $3,250.00 (UPON ACCEPTANCE OF CONTRACT)
BALANCE DUE $3,250.00 (UPON HEALTH DEPT CONSTRUCTION APPROVAL)
SSG IS MOT RESPONSIBLE FOR ANY UNDEROROUNDIOVERHEAD LINES,MIRES,&PIPES. SSC IS NOT RESPONSIBLE FOR DAMAGED CONCRETE AND ASPHALT.
SSC IS NOT RESPONSIBLE FOR ANY RESTORATION FROM STREET OR ALLEY TO AND INCLUDING WORK AREA. THE INSTALLATION HAS A PRORATED
WARRANTY OF S YEARS,HOWEVER,SEPTIC TANK MUST BE NIGFECTED(FOR AN ADDITIONAL CHARGE OF$100.00)AMMR FUMPED(ADDITIONAL CHARGE OF
5228.00)EVERY TWO(2)YEARS BY SSC OR ITS AUTHORIZED AGENT. SSC WARRANTY BECOMES VOID IF SYSTEM kF ALTERED,PUMPED,INSPECTED ANWOR
MAINTAINED BY ANOTHER U14AUIMRIZED INDIVIDUAL OR SEPTIC TANK COMPANY,DAMAGED BY GREASE,VEHIULAR TRAFFIC,SYSTEM OVERSATURATION,
ANY ACT OF GOD SUCH AS HURRICANES,ROOTS,ETC. OWNER WILL FOLLOW PAYMENT TERMS ABOVE. 10%LATE PEE AFTER S DAYS. OWNER OF PROPERTY
WILL.BE RESPONSIBLE FOR ALLIANY COLLECTION FEES. IF TOTAL AMOUNT IS NOT PAID IN FULL,SSC RESERVE THE RIGNT TO CANCEL WARRANTY
A6REEMIENT ABOVE THEN INK WILL BE HELD HARIM,ESS, FOR ANY FUTURE NANOLVEMENT.REPAIRS,ETC.IF WATER,GAS,ELECTRICAL,ETC OR ANY
OBSTRUCTIONS ARE UNDERGROUND OR OVERHEAD THAT MAY NEED TO BE RELOCATED OR REPLACED TO DO THE ABOVE MENTIONED INSTALLATION-OWNER
WILL BE REPSONSIBIA FOR ANY ADDITIONAL COSTSMEES. IF ANY ADDITIONAL MATERIAL IS NEEDED THAT Hi NOT STATED ON THIS PROPOSAWCOITTRACT,
OWNER HE RESPONSIBLE FOR ANY ADDITIONAL FEES,ANY PUMPS,FLOATS,ALARMS CARRY A 1 YEAR WARRANTY ON PARTS ONLY LABOR TO REINSTALL M
ADDITIONAL FEE DEPENDING ON PART REPLACED.
BELOW SIGNATURES ACKNOWLEDGE AND AGREE TO TERMS,SPECIFICATIONS&CONDITIONS LISTED ABOVE:
OWNER: SSC i
AUTHORIZED AGENT AU AGENT
PERMIT:APII4069426 6/2914
NEXT SVC DATE:--
REFERRED
ATE:REFERRED BY: THANKS FOR YOUR BUSINESSH