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CITY OF SANFORD
BUILDING & FIRE PREVENTION
D FEB i 2016 ;
PERMIT APPLICATION
Application No: i
Documented Construction Value: $ y I
00
Job Address: 0X)Ut7 l U Historic District: Yes No 9—
Parcel ID: Residential Commercial
Type of Work: New Addition Alteration Repair Demo Change o e Move
t
Description of Work:-F 021
Inc a'!7'4' S
Plan Review Contact Person: Li n Title: mow C )Z yn .
Phone: 7- Fax: Email: C a qmo r'^ rL
Name
Street:
City, S
Name
Street:
City, State Zip:
Name:
Street:
City, St, Zip: _
Pronertv Owner Information
J
Phone: / `4 D 9 - L f3
G ?" W& /
Resident of property? :
mation
Phone:
Fax:
State License No.:
Architect/Engineer Information
Phone:
Fax:
E-mail:
Bonding Company: Mortgage Lender:
Address: Address:
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS, TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE
RECORDED AND POSTED ON THE JOB=SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
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 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.
FBC 105.3 Shall be inscribed with the date of application and the code in effect as of that date: 5'h Edition (2014) Florida Building Code
Revised: June 30, 2015 Permit Application
NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be
found in the public records of this county, and there may be additional permits required rom other governmental entities such as water
management districts, state agencies, or federal agencies. f. .
Acceptance of permit is verification that I will notify the owner of the property of the'requ irements of Florida Lien Law, FS 713.
The City of Sanford requires payment of a plan review fee at the time of permit submittal. A copy of the executed contract is required
in order to calculate a plan review charge and will be considered the estimated construction value of the job at the time of submittal.
The actual construction value will be figured based on the current ICC Valuation Table in effect at the time the permit is issued, in
accordance with local ordinance. Should calculated charges figured off the executed contract exceed the actual construction value,
credit will be applied to your permit fees when the permit is issued.
t'S AFFIDAVIT: I certify that all of the
in complianc ith all applicable laws re
Signature of Notary-Staldof
Owner/Agent is ersonally
Produced ID Type of ID
u
information is
nstruction and
Signature
and that all work will
Date
Print o
r L/
actor/Agent's Name
Date Signature
Y°vo• DEBBIEBLWON
MY COMMISSION 9 FF 17"
f a EXPIRES: February 25 2019
GF K, Bonded Thru Notary Public Underwriters
to Me or Contractor/Agent is Personall Known to Me or
Produced ID Type of ID L
0
BELOW IS FOR OFFICE USE ONLY
Permits Required: Building Electrical Mechanical Plumbing[] Gas Roof
Construction Type: Occupancy Use:
Total Sq Ft of Bldg:
New Construction: Electric - # of Am
Fire Sprinkler Permit: Yes No
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
Min. Occupancy Load:
Flood Zone:
of Stories:
Plumbing - # of Fixtures.
of Heads Fire Alarm Permit: Yes No
UTILITIES: WASTE WATER:
FIRE: BUILDING:
Revised: June 30, 2015 Permit Application
OWNER BUILDER STATEMENT/AFFIDAVIT
Altamonte Springs, Casselberry, Lake Mary, Longwood, Oviedo, Sanford,
Seminole County, Winter Springs
Florida Statutes are quoted here in part for your information to indicate the authority for exemptions for
homeowners from qualifying as contractors and to express any applicable restrictions and responsibilities.
OWNERS MUST PERSONALLY APPEAR AT THE BUILDING DIVISION TO SIGN THIS DOCUMENT
BY SIGNING THIS STATEMENT, I ATTEST THAT: (Initial to the left of each statement)
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.
I understand that building permits are not required to be signed by a property owner unless he or she is
c responsible for thej construction and is not hiring a licensed contractor to assume responsibility.
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 all permit and contracts.
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
in 1 year after the construction is complete, the law will presume that I built or substantially improved it
for sale or lease, which violates this exemption.
I understand that, as the owner -builder, I must provide direct, onsite supervision of the construction.
I understand that I may not hire an unlicensed individual person to act as my contractor or to supervise
ersons 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 city ordinance.
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.
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 workers' compensation
for the employee. I understand that my failure to follow these laws may subject me to serious financial
risk.
Rev. 9.14.2009
r
M
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 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.
I am of aware of construction practices and I have access to the Florida Building Codes.
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
onstruction Industry Licensing Board at 1-850-487-1395 or at www.myflorida.com/dbpr/pro/cilb/ for
more information about licensed contractors.
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 address
listed below.
I agree to notify the building department immediately of any additions, deletions, or changes to any of the
information that I have provided on this disclosure or in the permit application package.
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, the Department of Business and
Professional Regulation and the building department may be unable to assist you with any financial loss
at 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 property licensed and the status of the contractor's workers' compensation
coverage.
Property
I, 1 1 l t` o , do hereby state that I am qualified
and capable of perf ing the requested construction involved with the permit application filed and agree to the
conditions specified above.
Signature of Owner -Builder
Form of Identification S2 S 2 - 9 C7 ^ ` D
Must be Photo ID)
Date
A violation of this exemption is a misdemeanor of the first degree punishable by a term of imprisonment
not exceeding 1 year and a $1,000.00 fine in addition to any civil penalties. In addition, the local
permitting jurisdiction 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.
Rev. 9.14.2009
City of Sanford
Roof Permit Application Checklist
All permit application packages must be complete prior to acceptance. You must check each box to the
left or i dicate n/a on this submittal. A complete application package shall include the following:
Building Permit Application completed, signed and notarized. Application must include correct address
and complete parcel I.D. number.
Copy of applicable contractor's license issued by the State of Florida (if the contractor is the
applicant).
A site specific notarized power of attorney shall be required from the licensed contractor if
he/she appoints an employee of his/her company to sign the permit application as the contractor.
Certificate of insurance indicating worker's compensation insurance coverage and naming the City of
Sanford as certificate holder, or a copy of a worker's compensation exemption issued by the State of
Florida (must be submitted with each application if contractor is the applicant).
Completed and signed Owner Builder Statement / Affidavit (if the owner is the applicant).
These guidelines were compiled to assist the applicant in preparing a roof permit application and may not be
complete. The applicant is required to meet all City of Sanford, state, and federal code requirements.
CITY OF SANFORD BUILDING SERVICES
E Residential Re -Roof
Hurricane Mitigation Inspection Affidavit
Permit #: Ae ^ 3 q
C
S hereby acknowledge that I personally inspected
2400f deck nailing and/or ®'Secondary water barrier work
at and have determined that the work
was done according to the Hurricane Mitigation Retrofit Manual. (based on 553.844 F.S.)
I certify that my statements herein are true and accurate to the best of my belief and that I fully
u erstand that making any false statements in writing with the intent to mislead a public servant in the
p foI mance of his or he official duty shall constitute a misdemeanor of the second degree pursuant to
S ti 837.06 F.S.
Z
t re o C tractor Date
I . k, IN, n..Tod mw_
Printed Name o ontractor License #
License Type: General 0 Building Residential Roofing Contractor
or any individual certified in accordance with F.S. 468 to make such an inspection.
STATE OF FLORIDA COUNTY OF
worn to (or affirmed and subscribed before me is day of a U r , 20 , by
J , who is ersonally Known tome or has uced (type of
id tific i a r19 as identification.
SEAL)
Signature of N taryis te
of F tida QNotary Pubft state of FWW9 Print/
Type/Stamp Name ; Sarah Freeney My
Camedsaloo FF 932406 of
Notary Public iV 11/01/2019 3