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City of Miramar | Building Division (The City of Miramar)

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2200 Civic Center Place | Miramar, Florida 33025
One (1) set of the Roofing Uniform Application Package: Follow the instructions and provide only applicable
forms of the Roofing Uniform Application Package (i.e. Shingles→ section A, B & D).
City of Miramar | Building Division
Community & Economic Development Department
Tel: 954.602.3200 | Fax: 954.602.3635
www.miramarfl.gov
Roofing Application
Package
WHO CAN APPLY (A or
B)
A. Licensed Contractors for Residential Permit can be issued to Licensed Contractors properly registered in
the Community Development - Building Division. Contractors shall provide all required applications properly
signed and notarized. Also, Contract signed by both parties (Contractor & Homeowner) shall be provided
indicating contract value per every applicable discipline.
ATTENTION HOMEOWNER – READ CAREFULLY
B. Homeowner/Builder f
or R
e
si
d
ential Only. Permit can be issued to homeowner/builder if the address
where he/she intent to do the work matches the address on picture ID (Driver License, ID card) and matches
the Proof of ownership (Recorded w arranty deed, tax statement, settlement statement).
• If a contractor i s hired, then the contractor must pull the permit.
REQUIRED DOCUMENTS – CHECK LIST
Permit application, describing type of roof & square footage. For homeowner see the note (B) indicated above.
Job contract signed by both parties (Contractor & Homeowner). Contract Value shall include labor & materials
Affidavit of Awareness of Homeowner’s Association (Included in this package). This Affidavit is required even if
the property is not located in a Community Homeowner’s Association.
Owner-Builder Disclosure Statement (Only if application is by homeowner/Builder).
One (1) set of Product Approval or Notice of Acceptance for the roof system (Shingles, Roof Tiles, Flat roof
system, etc.).
Job Contract signed by both parties (Contractor & Homeowner).
Attention Applicant: As per Florida Statutes 713.13, a Recorded Notice of Commencement is required when
construction, renovation, alterations values exceed $2,500. This subsection does not apply to a direct
contract to repair or replace an existing heating or air-conditioning system in an amount less than $7,500.
Construction cost (Including labor & material) will be based on contract signed by both parties (owner &
contractor) and/or as determined by the Building Official (FBC 109.3). Notice of commencement can be
recorded at the office of Broward County Government Center / Records Division 115 S. Andrews Ave.
Fort Lauderdale, FL 33301.
REQUIRED INSPECTIONS
For Roof Shingles
For Roof Tiles
For Flat Roof
B163 – Tin Cap.
B165 – Roof in Progress.
B999 – Final Inspection.
B163 – Tin Cap.
B165 – Roof in Progress
B161 – Hot Mop or
B16
7
− Self-Adhesive Underlayment
B999 – Final Inspection
B163 – Tin Cap.
B1
61 – Hot Mop (
Hot Process)
B165 – Roof in Progress (Hot process)
B167
−Self-Adhesive Underlayment (Cold Process)
B999 – Final Inspection.
Attention Applicants → Based on the type of roof, some roofing applications may require Zoning approval.
REV 01/2019
Broward County Board of Rules and Appeals
Effective June 30, 2015
Application Date:
Permit Officer
5
th
Edition (2014) FBC Building
Broward County Administrative Provisions
X
APPENDIX A
BROWARD COUNTY UNIFORM BUILDING PERMIT APPLICATION
Select Trade: Building Electrical Plumbing Mechanical Other __
Application Number:
Job Address: Unit: Cit
y:
1
Present Use: Proposed Used:
Description of Work:
Tax Folio No.: Flood Zone: BFE: Floor Area: Job Value:
Building Use:
Construction Type: Occupancy Group:
New Addition Repair Alteration Demolition Revision Other:
Legal Description:
Attachment
Property Owner: Phone: Email:
2
Owner’s Address: City: State: Zip:
Contracting Co.: Phone:
Email:
3
Company Address: City: State: Zip:
Qualifier’s Name: Owner-Builder:
License Number:
Architect/Engineer’s Name: Phone:
Email:
Architect/Engineer’s Address:
City: State: Zip:
Bonding Company:
4
Bonding Company Address: City: State: Zip:
Fee Simple Titleholder’s name (if other than owner):
Fee Simple Titleholder’s Address (If other than owner):
City: State: Zip:
Mortgage Lender’s Name:
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 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 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. 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 COMMENCING WORK OR RECORDING YOUR NOTICE OF
COMMENCEMENT.
X
Signature of Property Owner or Agent
Signature of Qualifier
STATE OF FLORIDA
COUNTY OF
STATE OF FLORID
A
COUNTY OF
Sworn to (or affirmed) and subscribed before me this day of
Sworn to (or affirmed)
and subscribed before me this day of
, 20
_ by
, 20_ by
(Type / Print Property Owner or Agent Name)
(Type / Print Qualifier’s Name)
NOTARY’S SIGNATURE as to Owner or Agent’s Signature
NOTARY’S SIGNATURE as to Qualifier’s Signature
Notary Name
Notary Name
(Print, Type or Stamp Notary’s Name)
(Print, Type or Stamp Notary’s Name)
Personally Known or Produced Identification
Personally Known
or Produced Identification
Type of Identification Produced
Type of Identification Produced
Code in Effect:
APPROVED BY: Issue Date:
A jurisdiction may use a supplemental page requesting additional information and citing other conditions, please inquire.
Note: If any development work as described in FS 380.04 Sec. 2 a-g is to be performed, a development permit must be obtained prior to the issuance
of a
building permit.
—
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City of
Miramar | Building Division
Community & Economic Development Department
2200 Civic Center Place | Miramar, Florida 33025
Tel: 954.602.3200 | Fax: 954.602.3635
www.miramarfl.gov
Affidavit
of
Aw
a
reness
of
H
o
me
o
wner’s
Association
Reg
ulation
s
The following “Affidavit” is required as per City’s ordinance. This is a mandatory affidavit which is required
even if your property is not located in a Homeowner’s Association.
ATTENTION APPLICANT. READ CAREFULLY
•
For homeowner/Builder applicants, this affidavit can be notarized by Permit Clerk at the Building
Division. Homeowner should appear in person with required picture I.D. (i.e. Driver License)
and proof of ownership (i.e. Recorded Warranty, County Tax Statement). The physical address on
I.D. shall match the address on the proof of ownership (i.e. Recorded Warranty Deed).
•
For Licensed Contractor applicants, this affidavit can be notarized outside the Building Division by any
Notary Public.
Homeowner or Condominium Association Affidavit requirement. Miramar - City Code Sec. 22-29.(c)(1) As
part of the application process for a building permit in accordance with this chapter and with Section 713.20
of the Land Development Code, each applicant shall sign an affidavit (the "affidavit of awareness")
indicating that the applicant is aware that, if the subject property is located in a Homeowners'
Association or Condominium Association, as defined in this section, the applicant's property may be
subject to additional regulations despite the issuance of a building permit by the city.
This serves to notify such homeowner that the issuance of a Building, Landscaping, or other permits by the
City of Miramar, Florida does not exempt he/she from any and all other regulations imposed by the
Homeowner’s Association (HOA) in which his/her property is located. Be aware that despite the issuance
of a building permit by the city, the applicant’s property may result in additional regulations or denial
to perform the work in your property located at HOA community.
Read and Initial to the left of the applicable statement
I acknowledge that I am the owner of property located in the following Homeowner’s Association:
Print Name of Homeowner’s Association
I acknowledge that my property is not located in a Homeowners’ Association.
Name:
Homeowner - Print
N
a
me
J
ob
A
ddr
ess:
Miramar, Flo
r
ida Zip Cod
e :
Signa
ture:
Homeowner - Signature
STATE OF FLORIDA. Sworn to and subscribed before me this day of , 20
Notary Public
REV 1/2019
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Miramar, FL, Zip Code:
City of Miramar | Building Division
Owner/Builder
Disclosure
Statement
Community & Economic Development Department
2200 Civic Center Place | Miramar, Florida 33025
Tel: 954.602.3200 | Fax: 954.602.3635
www.miramarfl.gov
Owner Name: ____________________________________________________________________________________
Address: ______________________
LOT: BLOCK: SUBDIVISION: ___________________________________________
I am submitting an application for a Building Permit as an Owner-Builder in accordance with the exemption set forth in
Florida Statute 489.103. Florida law requires construction to be done by a licensed contractor. It’s a requirement by law
you read and sign the following statements, and hence you can understand your responsibilities as an owner-builder. By
signing the following statements, you attest that:
DISCLOSURE STATEMENT
(Read and Initial to the left of each 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 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 workers’ compensation 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 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.
Date Signed
___________________________________________ _____________________________
City of Miramar | Building Division
Owner/Builder
Community & Economic Development Department
Disclosure
2200 Civic Center Place | Miramar, Florida 33025
Tel: 954.602.3200 | Fax: 954.602.3635
Statement
(Continuation)
www.miramarfl.gov
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 (telephone number) or (Internet website address) 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 address listed above.
12. I agree to notify (issuer of disclosure statements) 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 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.
I have read the foregoing instructions and I am aware of my responsibilities.
Owner Signature
STATE OF FLORIDA, COUNTY OF BROWARD. Sworn to and subscribed before me this _day of _, 20 .
Notary Public
F.S 489.103. 3(c). 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.
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HIGH VELOCITY HURRICANE ZONES — UNIFORM PERMIT APPLICATION
2017 Florida Building Code Edition
2020
High Velocity Hurricane Zone Uniform Permit Application Form
INSTRUCTION
PAGE
COMPLETE THE NECESSARY SECTIONS OF THEUNIFORM
ROOFING PERMIT APPLICATION FORM AND ATTACH
THE REQUIRED DOCUMENTS AS NOTED BELOW:
Roof System
Required Sections of the
Permit Application Form
Attachments Required
See List Below
Low Slope Application
A,B,C
1,2,3,4,5,6,7
Prescriptive BUR-RAS 150
A,B,C
4,5,6,7
Asphaltic Shingles
A,B,D
1,2,4,5,6,7
Concrete or Clay Tile
A,B,D,E
1.2.3.4.5,6,7
Metal Roofs
A,B,D
1,2,3,4,5,6,7
Wood Shingles and
Shakes
A,B,D
1,2,4,5,6,7
Other
As Applicable
1,2,3,4,5,6,7
ATTACHMENTS REQUIRED:
1.
Fire Directory Listing Page
2.
From Notice Of Acceptance:
Front Page
Specific System Description
Specific System Limitations
General Limitations
Applicable Detail Drawings
3.
Design Calculations per Section R4403, or If Applicable, RAS 127 or
RAS 128
4.
Other Component Notice of Acceptances
5.
Municipal Permit Application
6.
Owners Notification for Roofing Considerations (Re-Roofing Only)
7.
Any Required Roof Testing Calculation Documentation
2017
High Velocity Hurricane Zone Uniform Roofing Application
Fo
rm
Yes
No
Gas Ventilation
ROOF SYSTEM INFORMATION
2017 Florida Building Code Edition
2020
Section A (General Information)
Master Permit No. _
Process
No.
Contractor’s
Name: _
Job Address : _
ROOF CATEGORY
Low Slope
Mechanically
Fas
tened Tile
Mortar / Adhesive Set Tile
Asphaltic Shingles Metal Panel / Shingles
Wood Shingles / Shakes
Prescriptive
BUR-RAS 150
ROOF TYPE
New Roof Reroofing Recovering Repair Maintenance
Low Slope Area (SF)
Total Area (SF)
_
Section B (Roof Plan)
Sketch Roof Plan: Illustrate all levels and sections, roof drains, scuppers, overflow scuppers and overflow drains.
Include dimensions of sections and levels, clearly identify dimensions of elevated pressures zones and location of
parapets.
Steep Sloped Roof Area (SF)
Florida Building Code Edition
High Velocity Hurricane Zone Uniform Roofing Application
Fo
rm
FT.
Parapet
Height
FT
Mean
Roof
Section C (Low Sloped Roof System)
Fill in Specific Roof Assembly Components
and Identify Manufacturer
(If a component is not used, identify as “NA”)
System Manufacturer:
NOA No.:
Pages (Indicate applicable NOA pages) :
Design Wind Pressures, From RAS 128 or Calculations:
Pmax1: Pmax2: Pmax3:
Max. Design Pressure, From the Specific NOA
System: _____________________________________
Deck:
Type:
Gauge/Thickness:
Slope:
Anchor/Base Sheet & No. of Ply(s):
Anchor/Base Sheet Fastener/Bonding Material:
Insulation Base Layer:
Base Insulation Size and Thickness:
Base Insulation Fastener/Bonding Material:
Top Insulation Layer:
Top Insulation Size and Thickness:
Top Insulation Fastener/Bonding Material:
Base Sheet(s) & No. of Ply(s):
Base Sheet Fastener/Bonding Material:
Ply Sheet(s) & No. of Ply(s):
Ply Sheet Fastener/Bonding Material:
Top Ply:
Top Ply Fastener/Bonding Material:
Surfacing:
Fastener Spacing for Anchor/Base Sheet
Attachment
Field: ” oc @ Lap, # Rows @ ” oc
Perimeter: ” oc @ Lap, # Rows @ ” oc
Corner: ” oc @ Lap, # Rows @ ” oc
Number of Fasteners Per Insulation Board
Field: Perimeter Corner
Illustrate Components Noted and Details as
Applicable:
Wood blocking , Gutter, Edge Termination, Stripping Flashing,
Continuous Cleat, Cant Strip, Base Flashing, Counter-Flashing,
Coping, Etc.
Indicate: Mean Roof Height, Parapet Height, Height of
Base Flashing, Component Material, Material Thickness,
Fastener Type , Fastener Spacing or Submit Manufacturer’s
Details that Comply with RAS 111 and Chapter 16.
2017
Fire Barrier:
Mean
Roof
Height:
Section D (Steep Sloped Roof System)
Roof System Manufacturer:
Product Approval Number:
Minimum Design Wind Pressures, If Applicable (From RAS 127 or Calculations):
P1:
P2:
P3:
Maximum Design Pressure
Product Approval Specific System:
Method of Tile Attachment:
Steep Sloped System Description
Deck Type:
Type Underlayment:
Roof Slope:
______: 12
Insulation:
Fastener Type & Spacing:
Ridge Ventilation?
Adhesive Type:
Type Cap
Sheet:
Roof
Covering:
Type & Size Drips
Edge:
Florida Building Code Edition
High Ve locity Hurricane Zone Uniform Roofing Application Form
Section D (Steep Sloped Roof System)
2020
Method 1 “Moment Based Tile Calculations Per RAS 127”
)
-
Mg:
)
=M
r3
Product
Approval
M
f
=
x w:=
)
W:
x cos Q:
x w:=
)
W:
x cos Q:
=
x w:=
)
W:
x cos Q:
Florida Building Code Edition 20 71
2020
High Velocity Hurricane Zone Uniform Permit Application Form
Section E (Tile Calculations)
For Moment based tile systems, choose either Method 1 or 2. Compare the values for M
r
with the values from M
f
. If the M
r
values are greater than or equal to the M
r
values, for each area of the roof, then the tile attachment method is acceptable.
(P
1
: ______
x λ
=
)
-
Mg: )
=M
r1
________
Product Approval M
r
_______
(P
2
:
______
x λ
=
)
=M
r2
________
Product Approval M
r
_______
(P
3
:
______
x λ )
-
Mg:
=
________
Product Approval M
r
_______
Method 2 “Simplified Tile Calculation Per Table
Below”
Required
Moment
of
Resistance
(M
r
)
From
Table
Below
____________
M
f
Required Moment Resistance
*
Mean Roof Height
Roof Slope
15'
20'
25'
30'
40'
2:12
34.4
36.5
38.2
39.7
42.2
3:12
32.2
34.4
36.0
37.4
39.8
4:12
30.4
32.2
33.8
35.1
37.3
5:12
28.4
30.1
31.6
32.8
34.9
6:12
26.4
28.0
29.4
30.5
32.4
7:12
24.4
25.9
27.1
28.2
30.0
*Must be used in conjunction with a list of moment based tile systems endorsed by the Broward County Board of Rules and
Appeals.
For Uplift based tile systems use Method 3. Compare the values for F' with the values for F
r
. If the F' values are greater than or
equal to the F
r
values, for each area of the roof, then the tile attachment method is acceptable.
Method 3 “Moment Based Tile Calculations Per RAS 127”
(P
1
:
____
x 1:
_ _
=F
r1
______
Product Approval M
r
_______
(P
2
:
____
x 1:
=
___
=F
r2
______
Product Approval M
r
_______
(P
3
:
____
x 1:
__
=F
r3
_
______
Product Approval M
r
_______
Where to Obtain
Information
Description
Symbol
Where to
find
Design Pressure
P1 or P2 or P3
RAS 127 Table 1 or by an engineering analysis prepared by PE based on ASCE 7
Mean Roof Height
H
Job Site
Roof Slope
Q
Job Site
Aerodynamic Multiplier
λ
Product Approval
Restoring Moment due to Gravity
M
g
Product Approval
Attachment Resistance
M
f
Product Approval
Required Moment Resistance
M
r
Calculated
Minimum Attachment Resistance
F'
Product Approval
Required Uplift Resistance
F
r
Calculated
Average Tile Weight
W
Product Approval
Tile Dimensions
l = length
w = width
Product Approval
All calculations must be submitted to the Building Official at the time of permit application.
2. Renailing Wood Decks: When replacing roofing, the existing wood roof deck may have to be
renailed in
accordance
with the current provisions of Chapter 16 (High-Velocity Hurricane Zones) of this
code. (The roof deck is
usually concealed
prior to
removing
the
existing
roof
system
).
6. Overflow scuppers (wall outlets): It is required that rainwater flow off so that the roof is
not overloaded from a buildup of water. Perimeter/edge walls or other roof extensions m ay block this
discharge if overflow scuppers (wall outlets) are not provided. It m ay be necessary to install overflow
scuppers in accordance with the requirements of Chapter 15 and 16 herein and the
Florida Building Code,
Plumbing.
SECTION
1524
FBC 2017
FBC 2020
HIGH VELOCITY HURRICANE ZONES REQUIRED OWNERS
NOTIFICATION FOR ROOFING CONSIDERATIONS
1524.1 Scope. As it pertains to this section, it is the
responsibility
of the roofing contractor to provide the
owner with the
required
roofing permit, and to explain to the owner the content of this
section.
The
provisions
of this chapter govern the minimum requirements and standards of the industry for roofing system
installations. Additionally, the following items should be addressed as part of the
agreem
ent between the
owner and the
contractor.
The
owner’s initial
in the
designated space indicates
that the item has
been
explained.
1.
Aesthetics-Workmanship:
Reserved
____ 3.
Common
Roofs: Reserved
4. Exposed Ceilin
gs: Exposed, open beam ceilings are where the underside of the roof decking can
be viewed from below. The owner may wish to m maintain the architectural appearance; therefore, roofing
nail penetrations of the underside of the decking may not be acceptable. This provides the option of
maintaining this appearance.
5. Ponding W
ater: Reserved
7.Ventilation:
Reserved
Property Address: Miramar, FL
/ /
20
Owner’s/Agent’s
Signature
Date
Contract
or’s Signature

(name of person)
(name of party on behalf of whom instrument was executed)
(Signature of Notary Public)
Print Name and Provide Signatory’s Title/Office
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
AFTER RECORDING – RETURN TO:
PERMIT NUMBER:
NOTICE OF COMMENCEMENT
The undersigned hereby given notice that improvement will be made to certain real property, and in accordance with Chapter 713,
Florida Statues the following information is provided in the Notice of Commencement.
1.
DESCRIPTION OF PROPERTY (Legal description & street address, if available) TAX FOLIO NO.: _______________________________
SUBDIVISION
_______________________________BLOCK_________TRACT_________LOT________BLDG_______UNIT_______
__________________________________________________________________________________________________________
2. GENERAL DESCRIPTION OF IMPROVEMENT:
__________________________________________________________________________________________________________
3.
OWNER INFORMATION: a. Name________________________________________________________________________________________________
b. Address________________________________________________________________________________ c. Interest in property_________________________
d. Name and address of fee simple titleholder (if other than Owner) ______________________________________________________________________________
4. CONTRACTOR’S NAME, ADDRESS AND PHONE NUMBER:
5. SURETY’S NAME, ADDRESS AND PHONE NUMBER AND BOND AMOUNT:
6. LENDER’S NAME, ADDRESS AND PHONE NUMBER:
7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by
Section 713.13 (1) (a) 7., Florida Statutes:
NAME, ADDRESS AND PHONE NUMBER:
8. In addit
ion to himself or herself, Owner designates the following to receive a copy of the Lienor’s Notice as provided in Section
713.13 (1) (b), Florida Statutes
:
NAME, ADDRESS AND PHONE NUMBER
:
9. Expiration date of no
tice of commencement (the expiration date is 1 year from the date of recording unless a different date is
specified):
_____________
___ ______
, 20____
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT
ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13, FLORIDA STATUTES, AND CAN
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 COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT.
________________________________________________ ____________________________________________________
Signature of Owner or
Owner’s Authorized Officer/Director/Partner/Manager
State of Florida
County of Broward
The foregoing instrume
nt was acknowledged before me this __________ day of _______________, 20________
By ________________
___________________________________
, as ________________________________________________
(type of authority,…e.g. officer, trustee, attorney in fact)
For ________________
__________________________________.
_____
Personally known o r _____ produced the following type of identification: __________________________________________
Notary ___________________________________________
Unde
r Pe
nalties of perjury, I declare that
I have read the foregoing and that the facts in it are true to the best of my knowledge and
belief (Section 92.525, Florida Statutes).
Signature(s) of Owner(s) or Owner(s)’ Authorized Officer/ Director / Partner/Manager who signed above:
By __________________________________________________ By _______________________________________________
Rev .08-09-07 (S.Recording)
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City of Miramar Building Division (The City of Miramar)

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Completed 19 January 2021

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