RESIDENTIAL ADDITION/ALTERATION PERMIT APPLICATION

RESIDENTIAL ADDITION/ALTERATION PERMIT APPLICATION PERMIT APPLICATION CHECK LIST ***INCOMPLETE PERMIT APPLICATIONS WILL NOT BE ACCEPTED. PLEASE REVIEW PACKAGE CONTENTS WITH THIS CHECKLIST TO INSURE THAT ALL REQUIRED DOCUMENTATION IS INCLUDED WITH YOUR SUBMITTAL*** 1) PROPERTY CARD - OBTAINED FROM PROPERTY APPRAISER S OFFICE OR THEIR WEBSITE: WWW.DESOTOPA.COM. (WE CAN PROVIDE A COPY FOR $.15 A PAGE). 2) APPLICATION FULLY COMPLETED WITH NOTARIZED SIGNATURE(S). ALL SIGNATURES MUST BE NOTARIZED WHERE INDICATED-ORIGINAL SIGNATURES ONLY (NO COPIES OR FAXES ACCEPTED FOR PERMIT ISSUANCE). 3) OWNER/BUILDER DISCLOSURE STATEMENT IS REQUIRED IF THE OWNER IS ACTING AS THEIR OWN CONTRACTOR. CERTAIN RESTRICTIONS APPLY AND THESE ARE LISTED ON THE OWNER BUILDER DISCLOSURE SHEET. 4) NOTICE OF COMMENCEMENT IS REQUIRED ONLY IF CONTRACT COST EXCEEDS $2,500.00. THE ORIGINAL NOTICE OF COMMENCEMENT MUST BE FILED IN THE CLERK OF COURT S OFFICE AND THEN A CERTIFIED COPY MUST BE RETURNED TO THIS OFFICE WITH THE APPLICATION. A SECOND CERTIFIED COPY MUST BE POSTED AT THE JOB SITE. 5) ASBESTOS WARNING AND STATEMENT OF COMPLIANCE. 6) CONSTRUCTION AND DEMOLITION DEBRIS DISPOSAL METHOD FORM IF THE JOB ADDRESS IS LOCATED OUTSIDE THE CITY LIMITS. (PER COUNTY FRANCHISE AGREEMENT) 7) AN APPROVED ZONING REQUEST AND SITE PLAN FROM THE PLANNING DEPARTMENT. ANY LOCATION INSIDE THE CITY LIMITS MUST HAVE A COMPLETED AND APPROVED CITY APPLICATION FROM THE CITY BEFORE SUBMITTING THIS PERMIT. COUNTY ZONING #863-993-4806 CITY ZONING #863-494-4114 8) THREE (3) SETS OF ENGINEERED BUILDING PLANS (STAMPED BY A FLORIDA LICENSED ENGINEER WITH RAISED SEAL). 9) ONE (1) SET OF ENERGY CALCULATIONS. 10) SEPTIC PERMIT. (ENVIROMENTAL SERVICES AT 863-993-4601 EXT. 120) 11) COPY OF CONTRACT OR OTHER DOCUMENT WHICH CONFIRMS OR VALIDATES CONTRACT COST. 1

DESOTO COUNTY BUILDING DEPARTMENT PERMIT APPLICATION 126 N. Hillsborough Ave * Arcadia, Florida 34266 * Phone: (863) 993-4811 * Fax (863) 993-4815 * Lester Hornbake, Jr., Building Official Owner Phone Contractor Phone / /_ Mailing Address_ Address Parcel # Subdivision Lot Block Project Street Address Directions to Project Description of Project Intended UseContract Cost $ Fee Simple Titleholder s Name and Address (If other than the Owner) Bonding Company s Name and Address Architect/Engineer s Name and Address Mortgage Lender s Name and Address Warning to Owner: Your failure to record a notice of commencement may result in paying twice for improvements to your property. If you intend to obtain financing, consult with your lender or attorney before recording your notice of commencement. Owner & Contractor Must Read Before Signing: This application is hereby made for permit(s) for the project indicated above. To the best of our knowledge, the information contained herein and on all submitted documents is correct and complete. We declare that all work requiring a permit has not yet begun at the work location and understand that work may not begin until permits are issued. We understand that permits or approvals may be revoked if there has been any false statement or misrepresentation as to the facts made on this application or on any of the submitted documents. Owner s Affidavit: I have read the Warning To Owner statement. If I am an owner acting as my own contractor, I certify I am the property owner and I have read and signed the Owner-Builder Disclosure Statement and meet the exemption requirements for an owner-builder permit. Owner and Contractor must both sign below if the contract amount exceeds $2,500 unless the contract is for HVAC at a cost of $7,500 or less. If Notice of Commencement has been signed by owner and submitted prior to, or with, this application, owner s signature is not required on this application form. Owner Signature Date Contractor Signature Date Signed and sworn before me on this day of, 20 By.He/She is personally known to me or Has produced as identification. Signed and sworn before me on this day of, 20 by.he/she is personally known to me or Has produced as identification. Notary as to Owner_ Notary as to Contractor FOR OFFICE USE ONLY RECEIVED BY: DATE RECEIVED: Permit #: CIRCLE ITEMS RECEIVED: 1 2 3 4 5 6 7 8 9 10 11 2

DeSoto County Building Department Contractor Assignment and Authorization Form This form is to be submitted at the time of Permit Application and must be completed with all applicable original signatures. By signing this form, the contractor accepts responsibility for work performed by authorization of the permit issued for this project and agrees to comply with all applicable laws, codes, ordinances, and regulations that govern the work. An owner may sign only if eligible by law to perform such work. JOB SITE ADDRESS Permit Type Contractor s Company Name License Number Contractor s Signature Date Building Mobile Home Electrical Plumbing Mechanical Aluminum Gas Roofing Drywall Carpentry Masonry Concrete Demo Fire Alarm Fire Sprinkler Other 3

DESOTO COUNTY BUILDING DEPARTMENT OWNER-BUILDER DISCLOSURE STATEMENT Pursuant to Florida Statute 489.103.7 b BY SIGNING THIS STATEMENT, I ATTEST THAT: ( 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 responsible for the construction and is 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 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 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 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 worker s compensation for the employee. I understand that my failure to follow these laws may subject me to serious financial risk. 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 Code. 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 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 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 contractor s workers compensation coverage. Property Address: I,, do hereby state that I am qualified and capable of performing the requested construction involved with the permit application filed and agree to the conditions specified above. Signature of Owner-Builder Date Signed and sworn before me on this day of, 20 by.he/she is personally known to me or has produced as identification. Notary Public-State of Florida 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. 4

Construction and Demolition Debris Disposal Method Form Desoto County Ordinance number 2006-35 dictates that prior to a building permit being issued for the construction or renovation of any structure, the applicant shall provide for the collection and disposal of any construction and demolition debris. No permit will be issued until one of the two following methods is chosen. 1. The applicant may choose to enter into a contract with the franchisee of the county. (Womack Sanitation Inc.) 2. The applicant may self haul their own waste to an authorized landfill using the applicants equipment and bona fide staff personnel of the applicant. I choose to: 1. Use County Franchisee attach contract with Womack Sanitation Inc. 2. I will self haul I will dispose of all construction and demolition debris at a licensed disposal facility. You will be required to show evidence of proper disposal upon request of code enforcement or any other county department. Self Haulers Equipment List Make_ Model Color Tag Number(s) Serial Number(s) Attach additional numbers the reverse side of this form if needed. THIS IS TO CERTIFY THAT I AM THE OWNER, OR THE OWNER S DULY AUTHORIZED AGENT, OF THE PROPERTY IDENTIFIED HEREIN AND ALL INFORMATION FILED HEREWITH IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT FAILURE TO SUBMIT A COMPLETED APPLICATION WILL BE CAUSE FOR NOT ACCEPTING THE APPLICATION. (NOTE: THE ATTACHED AFFIDAVIT OF OWNERSHIP AND AGENT AUTHORIZATION MUST BE COMPLETED IF AN AGENT IS USED). (OWNER/APPLICANT SIGNATURE) (DATE) THE FOREGOING INSTRUMENT WAS ACKNOWLEDGED BEFORE ME THIS DAY OF, 20 BY WHO IS PERSONALLY KNOWN TO ME OR WHO HAS PRODUCED AS IDENTIFICATION AND WHO DID NOT TAKE AN OATH. _ NOTARY PUBLIC STATE OF FLORIDA MY COMMISSION EXPIRES EXHIBIT B AFFIDAVIT OF OWNERSHIP AND AGENT AUTHORIZATION (TO BE COMPLETED ONLY IF AN AGENT IS USED) (NAMES OF PROPERTY OWNER(S)) BEING FIRST DULY SWORN, DEPOSE(S) AND SAY(S) 1. THAT (I AM/WE ARE) THE OWNER(S) AND RECORD TITLE HOLDER(S) OF THE FOLLOWING DESCRIBED PROPERTY, TO WIT: The following is an excerpt from Desoto County Ordinance number 2006-35. Section 7. Construction and demolition debris. Section 7.1 Prior to the issuance of a building permit for the construction or renovation of any structure, the applicant shall provide for the collection and disposal of any construction and demolition debris which may result from the construction. In order to obtain a building permit for the construction of any structure, the applicant shall indicate in writing on forms provided by the county which of the following methods of collection and disposal shall be used: Section 7.1.1 The applicant will contract with the franchisee to collect and properly dispose of all construction and demolition debris generated; or Section 7.1.2 The applicant will self-haul, that is, provide for the collection, recycling, or disposal of construction and demolition debris at an authorized landfill using bona fide staff personnel of the applicant and equipment for such collection and disposal that is acceptable to the county. Section 7.2 No building permit shall be issued by the county until one of the above alternatives has been selected by the applicant. The billing and collection of fees for collection and disposal of construction and demolition debris shall be the sole responsibility of the franchisee collector. The county may by separate ordinance or resolution provide for standard rates and fees for collection of construction and demolition debris. All such collection and disposal shall be the responsibility of the applicant for the building permit. All construction and demolition debris collected shall be recycled or disposed of at an authorized landfill. ARTICLE IV. MISCELLANEOUS: PENALTIES; REMEDIES Section 1. Penalties. Any person found guilty of violating any provisions of this ordinance shall be punished by a fine not exceeding $500.00 or by imprisonment in the county jail for not more than 60 days, or by both such fine and imprisonment.. Remedies. In addition to the penalties as provided herein, the county may have recourse to such remedies as provided in law and equity to ensure compliance with the provisions of this ordinance, to include temporary and permanent injunctive relief and recovery of damages, or actions before the Special Master to achieve compliance by corrective orders and fines enforceable by liens upon the realty of the offender. Each day a violation of this ordinance continues unabated shall be deemed a separate violation of same for penalty purposes. Administrative fines, as provided in 381.0061, F.S., or in a franchise agreement, may be imposed by the health authority should conditions necessitate. 5

ASBESTOS WARNING AND STATEMENT OF COMPLIANCE Federal and state regulations strictly regulate the removal and disposal of asbestos and asbestos containing on or within buildings or structures. This includes any and all roof coverings, sidings, insulation or other building components which include asbestos. The following requirements are from Florida Statutes, Chapter 469. Removal, encapsulation, or enclosure of asbestos materials may only be performed by licensed asbestos abatement contractors (with limited exceptions for small-scale short activities). Preparation of plans for such work must be made by a licensed asbestos consultant. If alterations to a building s structural, electrical, mechanical, or other system or components are being made, then such plans shall be sealed by a registered architect or engineer. Certified roofing contractors who have met the requirements of Chapter 469.012, Florida Statutes, May remove asbestos containing bituminous resinous roofing materials. Typically, this refers to built up roof where asbestos containing felts were used in the roofing plies. Asbestos tile roofs are not included in this exception. Chapter 469 Florida Statutes requires the following notification statement to be read when projects involve the demolition or renovation of an existing structure. Owners or operators demolishing or renovating structures must comply with the provisions of Florida Statute 469 and notify the Department of Environmental Regulation of their intentions to remove asbestos, when applicable, in accordance with State and Federal law. STATEMENT OF COMPLIANCE The undersigned applicant for a permit for reproofing, demolition or renovation of a structure hereby states they have read the above information and shall comply with the laws and regulations applying to asbestos. Also the applicant understands that failure to comply with such regulations will subject them to the penalties prescribed by Federal and Stated laws and revocation of any permit(s) issued for this project. PROJECT: LOCATION: DATE: SIGNATURE: (ATTACH COMPLETED FORM TO PERMIT APPLICATION) 6

THIS SPACE RESERVED FOR RECORDING State of Florida County of DeSoto Notice of Commencement The undersigned hereby gives notice that improvement will be made to certain real property, and in accordance with Chapter 713, Florida Statues, the following information is provided in this Notice of Commencement. Permit Number: Description of work to be done: Address where work is to be done:_ Street Address _ City, State & Zip Code Legal Description of Property: Lot Block Section Subdivision _ Name of Property Owner:_ Address of Property Owner: Contractor Name:_ Contractor Address: Bonding Company Name: _Phone # Bond Amount_ Bonding Company Address: Lending Company Name: _Phone # Lending Company Address: Persons within the State of Florida designated by the Owner upon whom notices or other documents may be served as provided in Section 713.13(1)(b), Florida Statutes. Name: Phone # Address:_ Expiration Date of Notice of Commencement: (The expiration date is one year from the date of recording unless specified otherwise.) Signature of Owner: Printed Name of Owner: -------------------------------------------------------------------------------------------------------------------------------- State of Florida County of Subscribed and sworn (or affirmed) before me this day of _, 20 by who is personally known to me [ ] or showed identification[ ]. Type of Identification shown if applicable:. Public Notary-State of Florida 7