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THIS DOCUMENT MUST BE REVIEWED AND SIGNED BY (Village of Wellington)

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OWNER/BUILDER AFFIDAVIT
(Please Type or Print Clearly)
Owner/Builder Applicant Name:
1. Site address of the proposed building work
2. Name of legal title owner of the site address above
3. Describe the new construction or building work to be done at the site
4. How is the building or space going to be used?
6. Who will supervise the trade work to meet all the various adopted codes?
7. What provisions are there for Public Liability and Property Damage Insurance?
8. What provisions exist for withholding Social Security and Federal Income Taxes, as
required by Federal Law, from wages paid to people you hire who are not licensed?
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
OWNER/BUILDER AFFIDAVIT FORM
12300 Forest Hill Blvd. Wellington, FL 33414
Phone: 561-753-2430 Fax: 561-791-4045
www.wellingtonfl.gov
NOTICE: Florida Statute 489.103 requiring construction to be done only by licensed
contractors provides an exemption from licensing for property owners acting as their
contractor under specific conditions. Answers to the following questions are essential to
determine if those state qualifications are satisfied by an Owner/Builder applicant.
THIS DOCUMENT MUST BE REVIEWED AND SIGNED BY A REPRESENTATIVE
OF WELLINGTON
5. Who will do the actual labor in each major trade area? Owner Alone, Owner with Hired
Help or By Licensed Contractor (Name)
Trade Owner Alone or Owner with Hired Help or Licensed Contractor
•
OWNER/BUILDER AFFIDAVIT
9. How will Workers Compensation be provided for any people hired who are not licensed?
10. After improvements are done, who will use the space.
11. Do you plan to rent, lease or offer for sale and if so, when?
13. What Code books do you own for reference?
Building Electric HVAC Plumbing
14. Do you realize that as the permit holder you are liable for following all Local, County, State
and Federal codes, laws and requirements? You are also liable for any one injured on the
construction site.
15. Have you consulted with your Homeowner’s Insurance Agent or Attorney?
Owner/Builder Signature Date
Reviewed and Accepted by VOW Personnel Date
12300 Forest Hill Blvd. Wellington, FL 33414
Phone: 561-753-2430 Fax: 561-791-4045
www.wellingtonfl.gov
12. What previous Owner/Builder improvements have you done in Florida?(If “none”, state so)
Location Type of Work Done Year Done
I have read and understand all laws pertaining to Owner/Builder Construction and
agree to comply.
OWNER/BUILDER AFFIDAVIT
12300 Forest Hill Blvd. Wellington, FL 33414
Phone: 561-753-2430 Fax: 561-791-4045
www.wellingtonfl.gov
# OWNER BUILDER AFFIDAVIT & DISCLOSURE STATEMENT PERMIT
The provisions of Chapter 489.103, F.S. requires construction to be done by licensed contractors. You have applied for a
permit under an exemption to that law. The exemption allows you, as the owner of your property, to act as your own
contractor even though you do not have a license. You must perform or provide direct on-site supervision of the
construction yourself. You may build or improve a one-family or two-family residence or improve a commercial building at
a cost of $75,000 or less in value within any 12 month period, provided the residence or building is for your own use and
occupancy. It may not be built or substantially improved for sale or lease. If you sell or lease a building you have built or
substantially improved yourself within one year after the construction is complete, the law will presume that you built it for
sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as your contractor or to
supervise people working on your building. It is your responsibility to make sure that people employed by you have licenses
and insurance required by State law and by County licensing ordinances. Any person working on your building who is not
licensed must work under your direct supervision and must be employed by you, which means that you must deduct F.I.C.A
and withholding tax and provide workers’ compensation for that employee, all as prescribed by law. The construction
must be performed according to all Building Codes and Zoning Regulations, and it is your responsibility as the
Owner/Builder to make sure this is done and correct any code violations. A Village Building Permit does not assure
compliance with your Homeowners Association’s rules, regulations and/or deed restrictions. We advise you to obtain
approval from your Homeowners Association before improving your property.
Disclosure Statement:
Therefore, I understand and agree:
1. 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. 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. 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. 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. That, as the owner-builder, I must provide direct, onsite supervision of the construction.
6. 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. 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. 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.
~LINGToN
OWNER/BUILDER AFFIDAVIT
(address of
property )
12300 Forest Hill Blvd. Wellington, FL 33414
Phone: 561-753-2430 Fax: 561-791-4045
www.wellingtonfl.gov
OWNER (Print) DATE OWNER (SIGNATURE) DATE
(Name of Person Acknowledging)
(Type of I.D.)
(Signature of Person Taking Acknowledgement) (Name of Officer Taking Acknowledgement Typed, Printed orStamped)
9. 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. That 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:
.
11. To notify Village of Wellington 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.
I, the owner of property legally described as (attach copy of Warranty Deed):
do hereby certify that I have read the foregoing, and am aware of my responsibilities and liabilities for construction work on
the above-described property. I do hereby covenant and agree to abide by each of the aforesaid stipulations. I further
understand that any falsification of the above statements constitutes fraud and may result in revocation of this permit.
STATE OF FLORIDA COUNTY OF PALM BEACH
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/did not take an
oath. SEAL
Pursuant to Florida Law, Chapter 489 Part 1, property owners qualified to act as their own contractor must personally appear at the
Building Department and sign the permit application.
Address:
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THIS DOCUMENT MUST BE REVIEWED AND SIGNED BY (Village of Wellington)

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Completed 17 July 2020

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