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Contact Person:
Company Nam
Business Address
city
City of Parkland
Building Permit Application
www.cityofoa rk la nd. org
Phone 0:
E-mail:
ALL OF THE FOLLOWING MUST BE FILLED IN BY APPLICANT, ACCORDING TO F.S. 713.135
64.-/ (e• eepe-
State Zip Phone it
propeety PUNA NM'S j'/1
Owner's Street Address 0 a
ea/{ K4RA ce State Ft— Zia -3-ao kh,Phtley q -C11 -32r— 0 7
Job Site AddreSS g(9,00
Work Description: 044_,‘
Pennit Number //?
License
Nene
License 0
Application is hereby made to obtain a permit to do the work and installation as indicated. I certify that no work or Installation has commenced prior to the issuance of permit
and that all work Mil be performed to meet the standards of all laws regulating construction in the aty of Paridand, Florida. I understand that a separate permit -maybe
secured for ELECTRICAL, PLUMBING, SIGNS, WELLS, POOLS, BOILERS, TANKS, AIR CONDITIONERS, ROOFING, SHUTTERS, ETC.
WARNING TOOWNER: YOUR FAILURE TO RE03110 A Nana OF commEwpaEra MAY emu IN youR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU
INTEND TO OBTPJN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING -YOUR NOTICE OF COMMENCEMENT
Contractor
Notification E-mail:
Print Name of Qualifier/Builder:
License number:
Signature of Qualifier:
MEIN
Notification E -mall:
Property Owner/6a /e4
Print Nameof Property Owner:
Owners Address:
On this day of ,20 , before me, the undersigned
Notary Publk of the State of Florida, personally appeared
and whose name Is subscribed to and within
the Instrument, and he/she acknowledges that he/she executed it.
NOTARY PUEIUC, STATE OF FLORIDA
PRINTED NAME OF NOTARY PUBLIC
0 Personally known to me
0 Oath taken
NOTARY PUBLIC SEAL OF
OFFICE:
Application Approved By:
Permit Officer
0 Produced identification
0 Oath not taken
• *1 (- LL - Lat
Sigmt(tre
• 1
this_ / daY of UN-& , 201.,4L_, before me, the undersigned
otary Publk of the Stated Vida, personally appeared
z --Th AA.) rid r e'• and whose name Is subscribed to and within the
instrument, and he/she admoy. ledges that he/she executed It.
Cfn dj,(.1,,..- eat -41'.4414(
1 NOTARY PUBUC, STATE& FLORIDA
/ka--riVir - &(414
PRINTED NAME OP NvTARY PUBLIC
0 Personally known to medtr--:-.---ced identification
0 Oath taken
0 Oath not taken
MARILYN BLANCETT
Notary Public - State of Florida
NOTARY PUBLIC S
• My Comm. Expires Oct 30, 2015
OF OFFICE: Commission # EE 132703
Bonded Through National Notary Assn.
,mp•mwmpmwasp...----
Date:
•
Electrical Contractor:
Business Address:
License #:
phone #:
Qualifier Signature:
Estimated Construction Value:
Notification E-mail:
Print Name:
The foregoing instrument was acknowledged before me thus day of
who is personally known to me or who produced
Notary Publk: My Commission Expires:
,20 ,by the above named person
as identification who did/did not take an oath
Plumbing Contractor
Business Address:
License #:
Phone #:
Qualifier Signature:
Estimated Construction Value:
Notification E-mail:
Print Name:
The foregoing instrument was acknowledged before me thus day of ,20 ,by the above named person
who is personally known to me or who produced as identification who did/did not take an oath
Notary Publk: My Commission Expires:
Mechanical Contractor:
Business Address:
License #:
Phone
Qualifier Signature:
Estimated Construction Value:
Notifkation E-mail:
Print Name:
The foregoing instrument was acknowledged before me thus day of ,20 ,by the above named person
who is personally known to me or who produced as identification who did/did not take an oath
Notary Public: My Commission Expires:
:Landscaping Contractor:
Business Address:
License #:
Phone it
Qualifier Signature:
The foregoing instrument was acknowledged before me thus day of
who Is personally known to me or who produced
Notary Public: My Commission Expires:
Estimated Construction Value:
Notification E-mail;
Print Name:
Other Contractor:
Business Address:
License
Phone #:
Qualifier Signature:
,20 ,by the above named person
as identification who did/did not take an oath
Estimated Construction Value:
Notification E-mail:
Print Name:
The foregoing instrument was acknowledged before me thus day of ,20 ,by the above named person
who is personally known to me or who produced as identification who did/did not take an oath
Notary Public: My Commission Expires:
PERMIT NO
SUB -PERMIT
SUB -PERMIT
SUB -PERMIT
BLDG1405-0182
PERMIT TYPE
STATUS
FEES CHARGED
JOBVALUE
PAVERS
APPROVED
$301.70
$800.00
DESCRIPTION
APPLIED ISSUED
FEES PAID BALANCE DUE
OWNER
ADDED 6'X24'X31' PAVERS TO EXISTING PAVERS
OS/21/2014
$94.00
$207.70
FLORA,JOHN A & IRENE D
Printed • Wprinecrlav (19 hilv 7n14 1 nf 1
imam/
FS 489.103 Owner / Builder Exemption
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.
5. I understand that, as the owner -builder, I must provide direct, onsite supervision of the construction.
6. I 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 licenses required by law and by county or municipal ordinance.
7. I understand that it is a frequent practice 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 her 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.
8. I understand that I may not delegate the responsibility for supervising work to a licensed contractor
who is not licensed 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 workerscompensation for the employee.
I understand that my failure to follow these laws may subject me to serious financial risk.
9. I agree that, as the party legally and financially responsible for this proposed construction activity, I
will abide by all applicable laws and requirements that govem owner -builders as well as employers. I also
understand that the construction must comply with all applicable laws, ordinances, building codes, and
zoning regulations.
10. I understand that I may obtain more information regarding my obligations as an employer from the
Internal Revenue Service, the United States Small Business Administration, the Florida Department of
Financial Services, and the Florida Department of Revenue. I also understand that I may contact the
Florida Construction Industry Licensing Board at 850-487-1395 or
htto://www.mvflorida.com/dbor/consumers.html for more information about licensed contractors.
11. I am aware of, and consent to, an owner -builder building permit applied for in my name and
understand that I am the party legally and financially responsible for the proposed construction activity at
the following address: ,?(9 0 0 F-1-6J—
Address of property
12. I agree to notify The Citv of Parkland Building Division immediately of any additions, deletions, or
changes to any of the information that I have provided on this disclosure.
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not
have a license, the Construction 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 a complaint. Your only remedy against an
unlicensed 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 contractors workers' compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property
owner and ret ed to local mitt' g agency responsible for issuing the permit. A copy of the property owner's
driver liced s re f the property owner, or other type of verification acceptable to the local
permitt is issued.
Sign
Si-ture of property owner
Date:
7/7 /1 (,/
Rev. Au 009 Page 2 of 2
FS 489.103 Owner / Builder Exemption
City of Parkland
Development Services Department
Building Division
6600 University Drive, Parkland, FL 33067
Building Permits ft Inspections for your Safety!
Phone: 954 753-5447 Fax: 954 753-8838
Website: www.citvofoarkland.org
The following Disclosure Statement is required to be read and signed by a property owner who is applying for a permit for
construction on their own property, and intends to act as their own contractor under the Owner / Builder Exemption provided by
Florida Law, as described in the following excerpt. Please sign two copies.
489.103 Exemptions. --This part (regarding licensed contractors) does not apply to:
(7) Owners of property when acting as their own contractor and providing direct, onsite supervision themselves of all
work not performed by licensed contractors:
(a) When building or improving farm outbuildings or one -family or two-family residences on such property for the
occupancy or use of such owners and not offered for sate or tease, or building or improving commercial buildings, at a
cost not to exceed $75,000, on such property for the occupancy or use of such owners and not offered for sale or
lease. In an action brought under this part, proof of the sale or lease, or offering for sale or lease, of any such
structure by the owner -builder within 1 year after completion of same creates a presumption that the construction
was undertaken for purposes of sale or lease.
(b) When repairing or replacing wood shakes or asphalt or fiberglass shingles on one -family, two-family,, or three-
family residences for the occupancy or use of such owner or tenant of the owner and not offered for sale within 1 year
after completion of the work and when the property has been damaged by natural causes from an event recognized as
an emergency situation designated by executive order issued by the Governor declaring the existence of a state of
emergency as a result and consequence of a serious threat posed to the public health, safety, and property in this
state.
This subsection does not exempt any person who is employed by or has a contract with such owner and who acts in the
capacity of a contractor. The owner may not delegate the owner's responsibility to directly supervise all work to any
other person unless that person is registered or certified under this part and the work being performed is within the
scope of that person's license. For the purposes of this subsection, the term "owners of property" includes the owner
of a mobile home situated on a leased lot. To qualify for exemption under this subsection, an owner must personally
appear and sign the building permit application and must satisfy local permitting agency requirements, if any, proving
that the owner has a complete understanding of the owner's obligations under the law as specified in the disclosure
statement in this section. If any person violates the requirements of this subsection, the local permitting agency shall
withhold final approval, revoke the permit, or pursue any action or remedy for unlicensed activity against the owner
and any person performing work that requires licensure under the permit issued. The local permitting agency shall
provide the person with a disclosure statement in substantially the following form:
DISCLOSURE STATEMENT
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.
2. I 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.
3. I 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 a contractor is required by
law to be licensed in Florida and to list his or her license numbers on permits and contracts.
4. I 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 own 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
Rev. Aug 2009
Page 1 of 2