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PL-10-643 >l Inspection Worksheet Miami Shores Village 10060 N.E.2nd Avenue Miami Shores, FL D Phone: (305)796-2204 Fax: (306)756-8972 Inspection Number: INSP-154996 Permit Number: PL-4-10-643 Scheduled Inspection Date:January 19,2011 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: CLAY, MICHAEL &GENEVIEVE Work Classification: Addition/Alteration Job Address: 141 NE 109 Street Miami Shores,FL 33161- Phone Number 306-766-9832 Parcel Number 1121360040620 Project: <NONE> Contractor: HOME OWNER Building Department artment Comments PLUMBING WORK FOR BATHROOM REMODEL Inspector Comments Passed Failed Correction a Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. January 18,2011 For Inspections please call: (306)762-4949 Page 11 of 15 1 Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL 33138-0000 �it £ 9'• Phone: (305)795-2204 i #E� Expiration: 1012412010 Project Address Parcel Number Applicant 141 NE 109 Street 1121360040520 MICHAEL &GENEVIEVE CLAY Miami Shores, FL 33161- Block: Lot: Owner Information Address Phone Cell MICHAEL &GENEVIEVE CLAY 141 NE 109 Street 305-756-9832 MIAMI SHORES FL 33161 Contractor(s) Phone Cell Phone Valuation: $ 2,000.00 HOME OWNER Total Sq Feet: 200 Type of Work:PLUMBING Available Inspections: Type of Piping:BATHROOM REMODEL Inspection Type: Additional Info: Top Out Bond Return: Re Pipe Classification:Residential Main Drain Heater Water Service Final Water Main Lavatory Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# PL-4-10-37603 DBPR Surcharge $1.00 06/24/2010 Credit Card $163.20 $0.00 Education Surcharge $0.40 Notary Fee $5.00 Permit Fee-Additions/Alterations $150.00 Radon Surcharge $1.00 Scanning Fee $3,00 Technology Fee $1.60 Total: $163.20 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT. I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated June 24,2010 Authorized Signature.Owner / Applicant / Contractor / Agent Date Building Department Copy June 24,2010 1 Miami Shores Village .6 g a. r Building Department APR 16 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795.2204 Fax: (305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 BUILDING Permit No. Ito " (9A02, PERMIT APPLICATION Master Permit No. fgc/ in 5�n FBC 20 Permit Type: PLUMBING Owner's Name(Fee Simple Titleholder) / +(411, (i� Phone# ,?Oji 7� Owner's Address 10 Cr A L State G- . zip "33 A6 / Tenant/Lessee Name Phone# Email t CSU l� G�G� �i-C C �! M C41 t-Uv'� Job Address(where the work is being done) "I l /,j , 16 q City Miami Shores Village County Miami-Da Zip 331,61 FOLIO/PARCEL# Is Building Historically Designated YES NQ ��_ Flood Zone Contractor's Company Name Phone# Contractor's Address City State Zip Qualifier Name Phone# State Certificate or Registration No. Certificate of Competency No. Contact Phone E-mail Architect/Engineer's Name(if applicable) Phone# Value of Work For this Permit$ �'�00 Square/Linear Footage Of Work: Type of Work: ElAdditiionq DAlterattio��n ONew 2--Repair/Replace El Demolition Describe Work: � �uiw 1�[ �I fyl Inca hro0►A,.. t`e(Mod�v, Submittal Fee$ Permit Fee$ Z- � CCF$ CO/CC$ Notary$ Training/Education Fee$ -'� Technology Fee$ f-(nn Scanning Raioi S 1)?sR S . Bond$ Double Fee$ Violation date: Structural Review.$ Total Fee Now Duey -- See Reverse side—> Bonding Company's Name(if applicable) Bonding Company's Address City State zip Mortgage Lender's Name,(if applicable) Nb Wage Leader'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 EM PROVEMENTS 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 5onstruction lien davV•�brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy pf 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 reinspe ion fee will be charged. SignaturZL_ Signature Owner or Agent Contractor The fo oin instrument was ac ged b ore s The foregoing instrument was acknowledged before me this day of 20 ,b day of .20_,by -who is rsonall k=tification or who has produced vdho is personally known tome or who has produced l b and who did take an oath. as identification and who did take an oath. NOT • Y UBLIC:. e emAo NOTARY PUBLIC: Coo- Sign: � ' 'b ' V`�7 Sign: Print: °y" �' o� Print: My Commission Expires: a ` : '�i. My Commission Expires: APPROVED BY Z` Plans Examiner Zoning Engineer Clerk checked (Revised 07/10/07XRevised 06/10!2009) •° Miami! Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 r/ OWNER BUILDER DISCLOSURE STATEMENT NAME: A'dt DATE: bth ADDRESS: i dAore5 f�- 33X( 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 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 75,004).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.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 inhial 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 properly owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. InrdaL 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 taw to be licensed in Florida and to list his or license numbers on permits and contrails. 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 sate 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 ubstantially 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 ! 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.1,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. Infia��G�� 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 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 employee.I understand that my failure to follow these may subject to serious financial risk. In 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 Corstruction must comply with all applicable laws,ordinances,building codes, and zoning regulations. Inffia�����sCC� 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.l also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or httpJhNww.myfloridalicense.com/dbpdpro/cilbfindex.html 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: c)q � ' Initial 4�L 12. 1 agree to notify Miami Shores Village immediately of any additions,deletions,or changes to any of the informs W' n that 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 Busing 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 of 20in B 1 . O CIL A who was personally known to me or who has Produced there License or ' en ' cation. a { OWNEIT NOTARY f •"�� �ry tit • sRa 0* �Q�