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725 Amberjack Ln RESA22-0015 convert porch to bedrrom, bathroom submittal_2Building Permit Applicationk Updated 10/9/18 City of Atlantic Beach Building Department ALL INFORMATION 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED. Job Address: 7 a 5 M brr a,/ L 4-(-!0,-j, „ 1 i3. 2,,;. Permit Number: Legal Description Lu% it) 6Ictk 5 auuri,„,) -]h 'I — ?Li cA. Rol./ PAIA5 L' 1 RE# I-1 i l 15 v” Valuation of Work(Replacement Cost)$ 3o,a 0 0 Heated/Cooled SF Non-Heated/Cooled Class of Work: New Addition Alteration RepairMove Demo Pool Window/Door Use of existing/proposed structure(s): Commercial ©Residential If an existing structure,is a fire sprinkler system installed?: Yes I21Vo Will tree(s)be removed in association with proposed project? Yes(must submit separate Tree Removal Permit) L o Describe in detail the type of work to be performed: .-„1,),,,4_ o.i- frc-'cx,54,, j.rel-. -Ev c,•tri, 4- to ta H batty'0/11 4 kA.-4%,•••••v-‘)r"• We w,U a(sd 0.)J ti Florida Product Approval#for multiple products use product approval form Property Owner Information Name IC-- $. Kt ill ro_ , ) Address `7a 5 Ar,,^04 1./Nt (454-2 - City 4-FLtor« vfe,;... nt. . +° asy'' State FL Zip 3->a33 Phone Ru4- 'i o3--1.x .6`7E-Mail )brwl do `,,,n:n77 E) ',h, I • C., , Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Contractor Information Name of Company Qualifying Agent Address City State Zip Office Phone Job Site Contact Number State Certification/Registration# E-Mail Architect Name& Phone# Engineer's Name&Phone# Workers Compensation Insurer OR Exempt o Expiration Date 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 the 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. NOTICE: In addition to the requirements of this permit,there may be additional restrictions applicable to this property that may be found in the public records of this county,and there may be additional permits required from other governmental entities such as water management districts,state agencies,or federal agencies. 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. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDI .,-UR NOTICE OF COMMENCEMENT. two Signature of O Agent) / trO Signature of Contractor) Signed and sworn to(or affirmed)before me this I`I day of Signed and sworn to(or affirmed)before me this___day of7u \ -,6-02r - ,by 70_(\ R an(.Ona F4M.n by r e^— JENNIFER JOHNSTON (5i t Notary) Signature of Notary) 1,1 MY COMMISSION#HH 057579 o;' EXPIRES:October 27,2024 I•`•1`kr •• •NotrriFbbc Uotlenotars Personally Known OR j•oc)uce. ItleilralC IT" Produced Identification Type of Identification: Q L- Type of Identification: rs-1,;Owner Builder Affidavit S t,City of Atlantic Beach Building Department 800 Seminole Rd, Atlantic Beach, FL 32233 r Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: I. FLORIDA STATUTES;CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW: To qualify for exemption under this subsection, an owner must personally appear and sign the building permit application and must satisfy local permitting agency requirements, if any, proving that the owner has a complete understanding of the owner's obligations under the law as specified in the disclosure statement in this section. However, for purposes of implementing a "United States Department of Energy SunShot Initiative: Rooftop Solar Challenge" grant and the participation of county and municipal governments, including local permitting agencies under the jurisdiction of such county and municipal governments, an owner's notarized signature or personal appearance to sign the permit application is not required for a solar project, as described in subparagraph (a)3., if the building permit application is submitted electronically to the permitting agency and the owner certifies the application and disclosure statement using the permitting agency's electronic confirmation system. 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. The local permitting agency shall provide the person with a disclosure statement in substantially the following form: DISCLOSURE STATEMENT Please initial Items 1 - 13. 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. 2I 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 Florid and to list his or her license numbers on permits 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, unless I am completing the requirements of a building permit where the contractor listed on the permit substantially completed the project. 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. 2('--5. I understand that, as the owner-builder, I must provide direct, onsite supervision of the construction. i 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. 1 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. 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. i4 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. 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.myfloridalicense.com/DBPR/construction- industry/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 following address: 1 agree to notify the Atlantic Beach Building Department immediately of any additions, deletions, or changes to any of th information that I have provided on this disclosure. 13 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 2 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. II. INJURY LIABILITY;SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED. III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY EMPLOY ON THEIR IMPROVEMENT TRADES. IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY CIRCUMSTANCES.OWNERS BEING SUBJECT TO$5,000 PENALTY UNDER FLORIDA STATUTE NO.455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY SEE THE COUNTY"CERTIFICATE OF COMPETENCY"OR THE FLORIDA"CONTRACTORS CERTIFICATE"TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904- 247-5826 OR BUILDING-DEPT@COAB.US) IF IN DOUBT. V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT. Job Address: -7a5 24, ,heti G 1 L., i A-I 1.1/14 I t-. Le,4k fL 3›,-33 Owner Name:w3o ,n^•^_) Phone Number: w‘f -3c)3-7 7 6 7 Mailing Address: '7).S ,,_ber u 4 LOAL City: Atte%1-c-t,State: 'L Zip: -3 -3 3 Notarized Signature of Owner .// Age The foregoing instrument was acknowledged before me this t‘( day of li'tLk , 20 be),-in the State of Florida, County of N'1/4-v "t. \ joHNeaON ` Signature of Notary Public L 0*, IAY COQ II HH 5757 V p October 27.ZO24 Personally Known OR [ y,Ptoduced Identification meq. ,° i;: gq edThr„mayPO*Unda"'ll0f \ Type of Identification: t'L- Updated 7/12/22 3 NOTICE OF COMMENCEMENT State of FL7rtA- Tax Folio No. County of Dv`^' To Whom It May Concern: The undersigned hereby informs you that improvements will be made to certain real property, and in accordance with Section 713 of the Florida Statutes,the following information is stated in his NOTICE OF COMMENCEMENT.y Legal Description of property being improved: Lo+ 10 6 t cI . S Au,,-„1.14v It-, ( 4 4 got., A t+s von 4- or\Q, as c car PL.', L,i cA PPL.', uk 3(l Py ft, A A- 4- (,u.N'&n} Ppb 1'4- RE(nrr4 u4- pv..a.1 C-vn Address of property being improved: —Ns rTm6r ja,k Lw.s. , ik+1,A-4l, 6-e—k. 1-L 3 3J General description of improvements: Enc.lJJvfY A parc-k Owner: 7o1•n 6rav‘J,,n Fartnol g IGAp ..frc Lj rcret —1)-5 Arh ec ...11 l•.. , 1,6 , )=t. .P.- -33 Owner's interest in site of the improvement: Ir,,,nw-7 RCS%icnc, Fee Simple Titleholder(if other than owner): NPr I Name: Contractor: Address: Telephone No.: Fax No: Surety(if any) Address: Amount of Bond$ Telephone No: Fax No: Name and address of any person making a loan for the construction of the improvements Name: Address: Phone No:Fax No: Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may be served:Name: A9 Kc l ly -•,.t AA sn9 Address: J7)-5 APAitr;„,..k UAL , R+ISA4« 6t.,, r Ft 1):)-33 Telephone No: 'O't- 05-01 \-1 Fax No: In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 713.06(2)(b),Florida Statues. (Fill in at Owner's option) Name: Address: Telephone No: Fax No: Expiration date of Notice of Commencement(the expiration date is one (1)year from the date of recording unless a different date is specified): THIS SPACE FOR RECORDER'S USE ONLY OWNER X......._____-Signed: Date: Befo me this 14 day of ' ill -1 , in the County of Duval,State Of Florida,has personally appeared VA. •.f0.(l•fQnn..n5 Notary Public at Large,$tate Florida,County of Duval. My commission expires. Personally Known:7=';.7=';' : , ..• 4rt. Produced Identification: '"L 0 Lr- NW'' 42 MYCOM4111 pM ap•t EXPIRE&Ocbber27,20 BondedilruNodypbklbdwebts i