PERMIT DOCUMENTS Itle t'SdrN,11Ot `l erA0V CCP-
UNIVERSAL COUNTY-WIDE/MUNICIPAL FOR OFNLEUSE ONLY
BUILDING PERMIT APPLICATION FORM FBC Version: PermhType:
January 2020 Edition Accepted By:_________ r r"Date
Approved for use throughout Palm Beach County and Munklpalkies Application* d 1
KIND of PERMIT(CHECK ONE): PROPERTY OWNER: ilk, re/Ne% gen i/4
OPRIMARY PERMIT TENANT:
❑SUB-PERMIT-If Fee&Value of a Sub-Permit ere ADDRESS: V) ,57V/el Age NC UNIT:
covered under a Primary Permit,complete boxes 1,1 4.1 6 $s CITY: vlyl I { CAC h ST TE 21P: nA/�
A only to apply.If not covered under a Primary Permit I
complete the entire application to apply. PHONE: 11'6 I-317 - 7H1 ;4 #�: S61 in-74 74
PRIVATE PROVIDER:QPLAN REVIEW❑INSPECTIONS EMAIL: Alex�otn;lkt1•-Zetohcorol
TRADE(CHECK ONE): PROJECT NAME: BO/]t> Cit
❑STRUCTURAL ❑ROOFING 0ELECTRICAL PCB: Q fc li3 ,1•i .1-L1-a 1-a Q it:Q a Q
❑MECHANICAL nOPLUMBING ❑FIRE ❑GAS LEGAL DESCRIPTION: D/IVPkXw
pr OTHER: AVL kat Ai/co f
PRIMARY PERMIT#: PROJECT ADDRESS: 12)
RS Ave At
CITY:FURTHER WORK DESCRIPTION: liki4) vi;# k kAy
Type of Work: °NNew ['Addition ❑Alteration ['Repair ❑Demo ['Temporary QOther
VALUE: # OM PERMIT FEE: NET S.F(for SFD's):
para SCHEDULE) R5APPWsl aaMnuw
I
1f OWNER BUILDER PER FL ST.489(AS NAMED ABOVE,FOR CONTACT INFORMATION SEE BOX 2)
Q CONTRACTOR(CERT.HOLDER): License 0:
DBA(COMPANY NAME): Contact Person:
ADDRESS: STE: CITY: STATE: ZIP:
PHONE: FAX: EMAIL:
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 •••ne In compliance
with all applicable Ipws re . ;ung construction and zoning.
•
osmassrit zzat Mdudeu cats) ry�/
Prim .Name: ( .. 4 Mu We ti 4 .a.o u., u 4 Print Name: C.. , int - r . n.i 6(ct
NOTARY REQ IRED IF$2,500 OR MORE,OR FOR ALL OWNER/ NOTARY REQUIRED IF$2,500 OR MORE,OR FOR ALL OWNER/
BUILDERS
BOUNTY REGARDLESS�4O $V E ST TE OF FLORIDA BUILDERS RE DLESS OF VALUE ST TE OF FLORIDA
COUNTY OF L-uc
Sworn to(o affirmed)end subscribed before me this 3 Sworn to(or affirmed)and subscribed before me this ;
day of A"-t- , 20 2.,( ,by day of 20 ii ,by
n „t (ekt- of IlLLc.a 1fleet«) lta- i'e•iCa.-a_r (J set 13<-14)1)L__,
Pre of .e ml
Notary alotarSIELMrAftXtrt" �F AFEKETE
(S re of Note Public. d isolor State of Florida gneture of Notary Publk-State • • y ,= Nobly PUWk,Stale of Fbdde
ComMasbn000664>61 ii.e_:' commission.Gummi
oriot NN comm.ewe Mer.3.202.4
rz4
(PrintType,or Sta m'' ± �
€,� . rl
• (Print,type,or Sta 'miss
Physical Presence ','," OR Online Notarization Physical Presence OR Online Notarization
Personally Known I _ OR Produced identification Personally Known OR Produced Identification
Type of Identification Produced Type of identification Produced
Pate 1 of 2
FEE SIMPLE TITLEHOLDER,BONDING COMPANY,AROIRECT/ENGINEER AND MORTGAGE WIDER INFO 6 REQUIRED WHEN THE
AGGREGATE VALUE(TOTAL COST OF ALL IMPROVEMENTS&NOT JUST WORK AUTHORIZED BY THE INDIVIDUAL PERMIT)6$2,500 OR
MORE(EXCEPT HVAC REPAIR/REPLACEMENT<$7500).PLEASE ADDRESS ALL RENTS.
a a
fee Simple Titleholders Name In other then owner: Bonding Company:
Fee Simple Titleholders Address Is other then owner): Banding Company Address:
City: State: 74,1 City: State:_Zlp:
()Same as Owner [Not Applicable
u a
Architect/Engineers Name: Mortgage Lenders Name:
Architect/Engineers Name Address: Mortgage Lender's Address:
City: State:_Op: City: State:_zip:
ONot Applicable ONot Applicable
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.
NOTICE TO CONTRACTOR: FOR A DIRECT CONTRACT GREATER THAN 52,500(EXCEPT FOR HVAC SYSTEM REPAIR
OR REPLACEMENT LESS THAN $7500), FLORIDA STATUTES REQUIRE THE APPUCANT TO FILE WITH THE ISSUING
AUTHORITY, PRIOR TO THE FIRST INSPECTION, EITHER A CERTIFIED COPY OF THE RECORDED (BY OWNER)
NOTICE OF COMMENCEMENT OR A NOTARIZED STATEMENT (BY OWNER) THAT THE NOTICE OF
COMMENCEMENT HAS BEEN FILED FOR RECORDING, ALONG WITH A COPY THEREOF. IN THE ABSENCE OF A
CERTIFIED COPY OF THE RECORDED NOTICE OF COMMENCEMENT, NO SUBSEQUENT INSPECTIONS CAN BE
PERFORMED UNTIL THE APPLICANT FILES SUCH CERTIFIED COPY WITH THE ISSUING AUTHORITY. THE CERTIFIED
COPY OF THE NOTICE OF COMMENCEMENT MUST CONTAIN THE NAME AND ADDRESS OF THE OWNER, THE
NAME AND ADDRESS OF THE CONTRACTOR, AND THE LOCATION OR ADDRESS OF THE PROPERTY BEING
IMPROVED.
IF YOU INTEND TO OBTAIN FINANCING,CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING
WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT.
FOR APPLICATIONS SUBMITTED UNDER THE PRIVATE PROVIDER PROVISIONS OF FS. SECTION 553.791, THIS
APPLICATION IS NOT CONSIDERED COMPLETE OR SUFFICIENT FOR PURPOSES OF SUBMISSION TO THE BUILDING
DEPARTMENT UNTIL THE APPLICANT SECURES AU. NECESSARY APPROVALS FROM OTHER DEPARTMENTS OR
AGENCIES INCLUDING, BUT NOT LIMITED TO, PLANNING, ZONING, ENGINEERING, FIRE RESCUE,
ENVIRONMENTAL,AND THE FLORIDA DEPARTMENT OF HEALTH.
OFFICE USE ONLY BELOW THIS UNE
a M
CODE EDmON/NOTES: pajama ONE):
01 A 2 FAMILY ❑TOWNHOUSE OCONDOMINIUM
❑MULTI-FAMILY 0 COMMERCIAL ❑INDUSTRIAL
❑AGRICULTURAL-BLDG CODE EXEMPT ❑OTHER:
OUSE CHANGE:
Page 2 of
r City of Boynton Beach
o`i , Planning and Zoning Division
LAND SURVEY AFFIDAVIT
BEFORE me,the undersigned authority, personally appeared, 44lac 1%l Ott name),
and states:
1. The affiant is over 18 years of age and makes this Affidavit upon his/her own personal knowledge.
2. The affiant is the qviner of the prom located at
2) 23' A* Nr 4i 4refil 1/ 33 vii ( ).
3. The attached survey depicts conditions as they currently exist on the Property as of the date of this
affidavit.The survey shall be clean,legible and dear In detail. Survey shall not bear any previous City
stamps.
4. The Affiant warrants to the City of Boynton Beach that there am no other structures existing on the
Property other than those Indicated on the attached survey.
5. The Affiant hereby releases and holds the City of Boynton Beach harmless from any liability, claim,
suits,and/or damages associated with the installation of any Improvements on the Property based
upon the submission of the attached survey.
8. The Affiant further warrants and chrome that in the event there am any errors in the survey,or the
conditions of the Property are not as indicated on the survey,end additional permits and/or costs am
required,that the Affiant shall assume the obligation to pay for and incur any of the expenses or costs
associated with obtaining a new survey or removing any of the structures on the Property. The Affiant
hereby releases the City of Boynton Beach from any responsibility or obligation for any of the costs and
expenses associated with the removal or construction of any structures that are located on the
Property which am not indicated on the attached survey or permit
FURTHEER .- J. `'NAUGHT.
STATE OF G
Ain-SIgnatuter//4 COUNTY OF �q//Y/ Aga
THE FOREGOING
_INSTRUMENT
�was acknowledged before me this qday of dt.4,ate ,3& , by hee.x0M�WN Oa is personally known to me or has producedTL AIL-
ILas .......---
as
Idenll(I �� MBJPDA FEKETE
My Commission Expires: its i Not,17 motet.sr °I, da
�-M^ urn romm4.:olli OM�7n.
NOT• • PUBLIC " - *cent agdn+el ita2124
3301 Quenhun Blvd,ante 101,Boynton Beach Fl.33426 Plans:(561)742.8350 Per(501)742.8357
& TMnpitbsed aand Suite nblIdnecloa
OWNER/BUILDER AFFIDAVIT (CONTINUED)
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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 Construction Industry Licensing Board by calling 561-233-S52S or visiting their
website,htt //www nbcaov.comh,7 gran n.c oc for more mon about licensed contractors.
11. I am aware of, and consent to,an owner-builder permit applied for in my name and understand that I am the party legally and
financially responsible for the proposed construction activity at the property address stated below.
12. I agree to notify the City of Boynton Beach Building Division immediately of any additions,deletions,or changes to any of the
information that 1 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 property licensed and the status of the contractor's workers'
compensation coverage.
To apply for an owner-builder permit, this form must be completed and submitted with the building
permit application package.
Property Address 9/ t� 4 ' /1/ 4nktI, VW
Property Owner
(Signature)
STATE OF FLORIDA
COUNTY OF PALM BEACH
The • • • ng Instrument was acknowledged before me this day of A.4 (month), 202( (sear),
by IL ? Si a G _ (printed name of signer). lJ
Notary's signature a�� (SEAL)
Notary's name,printed,typed or = :
Personally known OR produced Identification ✓ •. NICOLE JORDAT•JONNSON
►y� ..
Type of Identification produced I/ I ffNotary Public-Slate of Florida
g • Commxr GG 747871
My Comm.Expires Aug 12,2022 (
Bonded through National Notary Assn.
C
CITY OF BOYNTON BEACH
0
DEVELOPMENT DEPARTMENT BUILDING DIVISION
u 3301 Quantum Boulevard,Suite 101 •Boynton Beach,FL 33426•(561)742-6350•Fax 742-6357
OWNER/BUILDER AFFIDAVIT
•
To qualify for exemption from contractor licensing requirements, an owner must personally appear
and sign the building permit application and satisfy local permitting agency requirements proving
that the owner has a complete understanding of the owners obligations under the law as specified in
the disclosure statement below. If any person violates the requirements of the subsection cited below,
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.
OWNER/BUILDER DISCLOSURE STATEMENT
SECTION 489.103,FLORIDA STATUTES
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.witb 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 the contractor's name instead of my
own. 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 one (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.
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 owiier-builder permit which
erroneously implies that the property owner is providing his or her own labor and materials: I, as airowner-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.dAny person;worjmg on by building who is not licensed must work under my direct supervision and must
be employed by'me, which means that;l must comply with laws requiring the withholding of federal income tax and social
security conm'biitions imder:the,Federel:lnsuriince Contributions Act (FICA) and must provide workers' compensation for the
employee.IUnderstand that thy 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 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.
(CONTINUED ON OTHER SIDE)
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