Disclosure Statement (Page 3 of 4) in pdf

AFFIDAVIT

STATE OF FLORIDA AT LARGE

1. That I acknowledge that this Owner / Builder exemption does not waive any permit

conditions or requirements or waive any portion or portions of any applicable laws,

ordinances, building codes or zoning regulations.

2. That I have not received an Owner / Builder permit authorizing me to act as an

Owner / Builder for a period of at least twelve (12) months immediately prior to

executing this affidavit from any permitting agency within the State of Florida.

3. That I

am the owner of the property located

and

will

call

for

the

required

inspections of all construction, improvements, or repairs performed under this

permit.

4. That I, the Owner / Builder, intend to: (Initial all that apply)

Do all physical work without the use of hired labor or contractors; or

Use licensed contractors whose license numbers and names appear on the

permit application and the on-site permit card; or

Use unlicensed workers under my full-time direct supervision and deduct

F.I.C.A. and withholding tax and provide workers’ compensation for that employee.

5. That no licensed contractor shall supervise any work except that work for which he is

licensed to perform.

6. That I have not sold or leased, or offered for sale or lease, any structure on which

improvements were performed by me pursuant to a building permit obtained by me

as an Owner / Builder within one year after completion of such improvements.

7. By executing this affidavit, I acknowledge having received the disclosure statement

provided by Section 489.103(7), Florida Statutes.

8. That any residence or improvement thereto, contemplated shall be for my own use

and occupancy.

9. That I, as Owner / Builder, in consideration of the City issuing the Owner / Builder

permit, agree to Indemnify and Hold Harmless said City of Satellite Beach, Florida,

its elected and appointed officers, agenda and employees, from any and all liability,

claim, demand, expenses, causes of action or damages for injury or death arising

from the construction, improvements, or repairs accomplished in connection with this

building permit.

Page 3 of 4

SB-BZ Own Bdr 04-11

Disclosure Statement Page 3