DS-15-1014 Miami Shores Village
10050 N.E.2nd Avenue NE
Miami Shores,FL 33138-0000
Ka 3
Phone: (305)795-2204
Expiration: 02M612016
Project Address Parcel Number Applicant
59 NE 101 Street 1132060131540
CHARLES KILLINGSWORTH
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
CHARLES KILLINGSWORTH 59 NE 101 Street
MIAMI SHORES FL 33138-
59 NE 101 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 2,500.00
HOME OWNER
Total Sq Feet: 1090
Approved:In Review Available Inspections:
Comments: Inspection Type:
Date Approved::In Review Final
Date Denied: Foundation
Type of Work:NEW DRIVEWAY WITH BRICK PAVERS O Additional Info: Review Building
Bond Return: Classification:Residential Review Building
Scanning:3 Review Planning
Review Planning
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Owners Bond $500.00 Invoice# DS-4-15-55367
CCF $1.80 04/29/2015 Credit Card $50.00 $618.30
DBPR Fee $2.25
DCA Fee $2.25 08/20/2015 Check#:1550 $618.30 $0.00
Education Surcharge $0.60 Bond#:2812
Permit Fee $150.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $668.30
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constructio d zoning. Futhermore,I authorize the above-named contractor to do the work stated.
August 20,2015
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
August 20,2015 1
Miami Shores Village
Building Department APR 2 201
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY
INSPECTION UNE PHONE NUMBER:(305)762-4949
FBC 200
BUILDING Master Permit No. (0
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ROOFING ❑ REVISION EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 5TC-1 �V tc�l S -T
City Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: jFlood Zone: BFE: FFE:
OWNER:Name(Fee Simple
//Titleholder): vUS �a.�� ILl`��i SwJ hone#: �`i�
Address: Ss M-C. lz) ` _19"
City: 'SV State: EL Zip: 121�
Tenant/Lessee Name: Phone#:
Email: 0w C"'k. y"11'.%
CONTRACTOR:Company Name: M [GAJ Vl. Phone#:
Address:
City: -State* Zip:
Qualifier Name: Phone#:
State Certification or Registration#: Certificate of.Competency#:
DESIGNER:Architect/Engineer: Phone#: .
Address: City: State: Zip:
o,
Value of Work for this Permit: 53;z. • Square/Unear Footage of Work:b .0
Type of Work: ❑ Addition ❑ Alteration ew ❑ Repair/Replace ❑ Demolition
Description of Work: N eW Dylizg&t j 1&-141 BaiGt— PA1445 DA..- SA&D
Specify color of color thru tile:
Submittal Fee$Y-50.CL,,j Permit Fee$ CCF$ CO/CC
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ TrainipgjEducation Fee$ Double Fee` � o0
$ , n,1
Structural Reviews$ Bond$ s`! • 3
'S TOTAL FEE NOW DUE$ 1 9—Y
(Revised02/24/2014) p i G�. ,3a
T
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.
SignatureSignature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
SPY day of .W2I�- 20 1 OF by day of ,20 .by
6 1<11U-1 N4 dml
aiho�e- rg6hally known to who is personally known to
me or who has produced PL tyJMu woome or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign• Sign
Print: Print:
Seal: 00 Notary Pubft stata of Florida Seal:
y CO Alvarez
M
My Canmiasion FF 158750
q pd Expires 0910=018
************ * * * * *****************************************************************************
APPROVED BY Plans Examiner ` Zoning
Structural Review Clerk
(Revised02/24/2014)
g► .s Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
�oR> Tel: (305) 795.2204
Fax: (305)756.8972
11 OWNER BUILDER DISCLOSURE STATEMEN
NAME: C,64 1 6 W DATE: �
ADDRESS: S 1 S
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 entities 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 bulk 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 Ck
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.
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 pr jubstantially
improved it for sale or lease,which violates the exemption. Cil.
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 cxwnty or
munidpatordinance.
q` Initial
a,.
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 homeowners 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. 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 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. V V
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 odes, 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 htto:/Avww.mvfloddalicense.com/dbDr/Dro/cilbfind .htm
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 informatio at i
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 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 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 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 04 day of Al-LV\ ,20231�-_
By Ctkil"�5 L1''11,Lln kn who was personally known to me or who has
Produced there License or fl, as identification.
OWNER 'S
Notary Public State of Florida
My diaCo Alvarez
+� mmission FF 158950
� My Co
�" F_VIM 09103/2018
Miami Shores Village
.�� Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) �a'Uca'6'4k '��i �� rein er ref ed to as the
owner of the following described property(address •) Sq Nt
Legal Description Lot Block Subdivision
Folio #
Requests permission to install (describe work):
Within the public right of way of(address)
IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows:
1. To maintain and repair, when necessary, the above-mentioned item(s) installed within the
dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County
to make repairs or maintain said items within public right of way including restoration of
street by reason of the Owner's failure to do so, such expense shall be paid by the Owner
or shall constitute a lien against the above described property until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade
County harmless from any and all liability, which may rise by virtue of permitting the
installation of these items within the public right of way.
3. The Owner does hereby agree to remove or relocate their facilities at their own expense,
within 60 days notice by the Village to do so. Failure to comply with this notice will result
in the Village causing the item(s) to be removed and a lien being placed on the property
and/or assessed against the Owner for all costs incurred in the removal and disposal of
the item(s).
4. The undersigned further agrees that these conditions shall be deemed a covenant
running with the land and shall remain in full force and effect and be. binding on the
undersigned, their heirs and assigns, until such time as this obligations has been
canceled by an affidavit filed in the Public Records of Dade County, Florida by the
Villa a anager of Miami Shores Village (or his fully authorized representative).
Signature
Owner or Agent
The foregoing instrumentacknowledged before me this L-�'` day of t_ , 20 �$, by
C, "-LAW K.lt..t,INs personally known tome or who has produced �R, -v tMEO tJlPl4e
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: n1blA .P�_Vd'Tt.0
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SUFFD(:L FLORIDA BOARD OF LAND SURVEYORSINCHAPTER
DATE OF FIRM: 9-11-09 MIAMI SNORES,FLORIDA 33138 61617-4 FLORIDA ADMM)VAMEOODB • •• -C• • # 098
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