RC-13-2476 (3) Miami Shores Village v r
Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 .,
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(30S)762-4949
FBC 20 (0
BUILDING Master Permit No. �
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ®2HANGE OF ❑CANCELLATION ❑ SHOP
, CONTRACTOR DRAWINGS
/
JOB ADDRESS: ! G�
City: Miami Shores County Miami Dade Zip: ��3
Folio/Parcel#: is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: h� Flood Zone: BFE: 1 FFE:
OWNER:Name(Fee Simple Titleholder):,) �j/Yr� /!//�•[��, Aal/Phone#: O
Address:
City: &4(a gL4 e A /eS State: .G2. Zip: *3 3 (3
Tenant/Lessee Name: Phone#:
Email: s 0 Y_tl yk e VKCL� 1• Cb nn
CONTRACTOR:Company Name: n\A) Phone#:
Address:
City: —State: Zip:
Qualifier Name: Phone#:
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: �� C �r� �• �o)c Sy'1 t "1 Phone#:
Address: City: State: Zip:
Value of Work for this Permit: r Square/Linear Footage of Work: ` 76
4,1,41
Type of Work: ❑ Addition ❑ Alteration ❑ New [Wepair/Repla e ❑ Demoliti
D�Scriptlor of Warks _ � a s
Specify color of color thru tile:
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$ C�
(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.
Signatur, , Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
1 day of 10�e—20 11 ,by day of_ .20 by
�l. �10t:;M .who is personally known to who is personally known to
me or who has produced B--D9JVQ?— UZU me 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: =0-13IS2
State of Florida Seal:
ez
ion FF 15675012018
17
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
4
s
s Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel:(305)795.2204
Fax:(305)756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME: tA-., M4ATE:
ADDRESS:15 IV 1 �k
®
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida,KS 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 byyou,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. 1 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 1,as the owner of the property listed,may act as my own contractor with certain
restrictions even though 1 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 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 teased 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
7. I 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.
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. Initiagm
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 regulation/_ ,
'1/NI/,)
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 htta://www.mvfloridalicense.com/dbor/proNIbAndex.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:
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.
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 21 day of 20
By l— !� V� > who was personally known to me or who has
Produced there License or R as identification.
Notary°«otic StAte d Florida
Sindia AN araz
OWNER NOTARY MY rorr'"'sai^"F;:159'50
ABDULSAMAD MUKHTAR
15 NE 104 Street.
Miami Shores, Florida 33138
Ph. 786-718-0444
September 8, 2015
Deen Construction Co.
5881 NW 192 St
Miami Gardens, Florida 33015
Attn: Suraj Adebisi
RE: Change of contractor: Permit# 13-2476
15 NE 104 Street. Miami Shores, Florida 33138.
Dear Mr. Adebisi,
Please accept this letter as an official notification that your company, Deen
Construction Co. has been removed as the contractor on record for 15 NE 104
Street, Miami Shores, FL 33138 from the building department at Miami Shores
Village Hall.
The decision and/or reason(s) for your removal are based on the following:
1. Your failure to maintain the agreement between both parties.
2. Misappropriation of funds for the project; causing the delay of the project
as well as avoidable additional extra expenses.
3. All efforts to meet with you and resolve this matter have been
unsuccessful.
A change of contractor process with the appropriate municipality or jurisdiction
has been initiated and is expected to be completed in a matter of days. If you
have any questions or concerns, please do not hesitate to call me at 786-718-
0444. Thanks for your cooperation and understanding.
Sincerely,
Abdulsamad Mukhtar (Owner)
Cc. Miami Shores Village
UNITED STATES
POSTAL SERVICE.
Date: September 15, 2015
ABDULSAMAD MUKHTAR:
The following is in response to your September 15, 2015 request for delivery information
on your Certified MailTm item number 70142120000304392510. The delivery record
shows that this item was delivered on September 12, 2015 at 5:22 pm in HIALEAH, FL
33015. The scanned image of the recipient information is provided below.
Signature of Recipient :
Address of Recipient
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Thank you for selecting the Postal Service for your mailing needs.
If you require additional assistance, please contact your local Post Office or postal
representative.
Sincerely,
United States Postal Service
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