Owner/Builder Permit Affidavit Rev. 08/21/09
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.
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 http://www.myflorida.com/dbpr/pro/cilb 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:
___________________________________________________________________________________________.
12. I agree to notify the City of Dania Beach Building Department 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.
_______________________________________________ ______________________________
Property Owner Date
The foregoing instrument was acknowledged before me this ________ day of _____________________, 20______
by __________________________________________ who is personally known to me or has produced
_____________________________________________ as identification and did (or did not) take an oath.
___________________________________________ My Commission Expires: _____________________
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