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DOC-14-1455 Miami Shores Village C.P.JUL Building Department 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 k"' BUILDING Master Permit No.TcScillf-r`-t P I"s� PE IT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP' �]]�, CONTRACTOR DRAWINGS JOB ADDRESS: 12-S 5 City: Miami Shores County: Miami Dade Zip: — Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone:p��.yy�� ,��0 BFE: ,� nnFFE: OWNER: Name(Fee Simple Titleholder): (M 1 it" ftWone#: &5—�ft S "® Address: v� City: [ A M l .q` (�V.ES State: PLOP-( 1D A'- Zip: e5 ✓13? Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Phone#: Address: City: State: Zip: Qualifier Name: Phone#: State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip- Value igValue of Work for this Permit:$ 4 SO ©o Square/Linear Footage of Work: 2� Type of Work: ❑ Addition ❑ Alteration ❑ New [K Repair/Replace ❑ Demolition Description of Work: QE�L�t LQZC V ac VG L (V G- o Aj D©C V, w l T H C W 0©DUJ kk � rdLS . DFC L BOA-a-103 TD &C- SGV_G1v L-l� Mi PLP[z W MHtip— INCL 4 010V—f �)t0V_05I5DMT 5CgL_WS. Specify color of color thru tile: Submittal Fee$5 Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (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. i Signatu a Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of �� 0 � by day of 20 by r`' Trv-A 1 P- 5n who is pers nown t who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. o��n�iiiuiii,, identification and who did take an oath. VC/ ��'% NOTARY PUBLIC: d'Q NOTARY PUBLIC: Sign: (2 Sign Print: �'i ��o `�.� Print: CY Seal: r�'nioV��inni��``��`��\\ Seal: APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Miami Shores Village Building Department 10050 N.E.2nd Avenue ' Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 � II OWNER BUILDER DISCLOSURE STATEMENT NAME: &I S ( '-,Z MV C� DATE: .C'-O " ADDRESS: I Zan N L 0 4 S f � `( ( SlIZ, Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida,FS 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 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 licensp numbers on permits and contracts. 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 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 r substantially improved it for sale or lease,which violates the exemption. Initia 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 m building or residence.It is my responsibility to ensure that the persons whom I employ have the license required by law nd by county or municipal ordinance. Initia 7. 1 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,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. 6 Initi 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. Infi 9. 1 agree that,as the party legally and financially responsible for this proposed Construction activity,I will abide b 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. Initial �-' 10. 1 understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service,the United States Small Business Administration,and the Florida Department of Revenues.I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or h :/Aw Av.m floOdalicense.com/db r/ ro/Cilbfiin e) h Infi 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 informa n 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 he e 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 understand that,if 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 ofu�2 20 By � �` �� "', who was peonally known to me or ho has Produced there License or as identification. 0 ��i/// OWNER ♦51it,�,�s ... a�.� Miami shoresVillage Building Department lR 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.y2u MU be personally liable for the worker compensation Wuries of any person allowed to work under this permit Please check with your insurance carver 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 Contractor Print Name: I4(AJ °�/ �, Print Name: Signatur Signature: State of Florida) State of Florida) County of Miami-Dade) County of Miami-Dade) Sworn to and subscribed before me this Sworn to and subscribed before me this day of 1 201-:1* day of ,20 By By (SEAL) (SEAL) Type of Identification produced T e of Identification produced MIAMI SHORES VILLAGE 1%99A IN eo NWALm APPROVED BY DATE ZONING s` �, Lo �:a • (Z6 as .STRUCTURAL -v I tall ELECTRICAL �6to«�S C`�• � kip PLUMBING LAW s,�ECHAN.CAI SUUIECT TO; COMPLIANCE WITH ALL FEDERAL, STATE 1%0 CGUTITy RLkLES AND REuULAFtOfiS. ?M ' AU 0 8 014 h 2.t` l9" 2t9 ►®= 4 S' �I "AMOV DSfk KE " : X$ VT ROWN 120451461" �'�