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893 AMBERJACK DEMO24-0003 REV 3-3-25 �t Revision Request/Correction to Comments **ALL INFORMATION �. 3p HIGHLIGHTED IN ri) City of Atlantic Beach Building Department GRAY IS REQUIRED. 800 Seminole Rd, Atlantic Beach, FL 32233 ;� tt Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: 1-3EMO -O0c3 **ALL REVISION SUBMITTALS MUST BE EMAILED AS A PDF ATTACHMENT ONLY** ❑ Revision to Issued Permit OR Corrections to Comments Date:3 13115 Project Address: S`"1'S Contractor/Contact Name: `--V \ ar l'p.r\ Contact Phone: 04—9(0-1- 7 9 5 Email: ace_b('P @ ho-(incti- 1 ,Q-0 in - Description of Proposed Revision/Corrections: •re,e ©n s , I(V\c Ao.S Coq QWne1` e ot,tcPC— affirm the revision/correction to comments is inclusive of the proposed changes. (Printed name) • Will proposed revision/corrections add additional square footage to original submittal? —No 1 Yes (additional s.f.to be added: • Will proposed revision/corrections add additional increase in building value to original submittal? INo C*yes (additional increase in building value: $ ) (Contractor must sign if increase in valuation) *Signature of Contractor/Agent: (Office Use Only) — Approved ❑ Denied — Not Applicable to Department Permit Fee Due$ Revision/Plan Review Comments Department Review Required: Building Planning&Zoning Reviewed By Tree Administrator Public Works Public Utilities Public Safety Date Fire Services rj_:JJ), TREE & VEGETATION AFFIDAVIT FOR INTERNAL OFFICE USE ONLY 7 'f , City of Atlantic Beach PERMIT# ", ; Community Development Department � 800 Seminole Road Atlantic Beach, FL 32233 **Please submit form in person -01i>9%' (P)904-247-5800 or to buildng-dept@coab.us SITE INFORMATION ADDRESS ;737 , i4a %AL_ SUBDIVISION a/ `jy BLOCK ¢ LOT 2 RE# / 7// -7y/ -,mem IX RESIDENTIAL El COMMERCIAL D OTHER APPLICANT INFORMATION NAME (xir/e-f Ui-7�ref PHONE# 9, 7y6 29��s� V ADDRESS 0 93 dek Qc Zkif2. CELL# I' CITY /Iri je.„ r ' ,e. STATE ZIP CODE 372-73 EMAIL c e£6/1e e z_O d LAT,(/61,144 OWNER ❑ LEGAL AUTHORIZED AGENT I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation", of the Municipal Code of Ordinances for the City of Atlantic Beach Florida and/or I have participated in a pre- application meeting with the Administrator of those regulations. Subsequently, I affirm that no regulated trees and no regulated vegetation will be damaged, destroyed and/or removed from the above-described property and/or adjacent properties including right-of-way. "In lieu of signed, sworn and notarized signatures of the property owner, agent and/or contractor, and under penalties of perjury, I declare that I have read and examined the foregoing application and that the facts stated in it are true and correct." '1" /arI e A-- ��S Ph�r 3 3-2-d 25 -s( NE OF APPLI , T PRI OR PE NAME OF APPLICANT DATE TREE AND VEGETATION AFFIDAVIT 11.26.2024 0,10/V5ItU CTri ON 5 I-1 ilitg-IJA-66/vieN -i ?L/1-N 64'1_3 krik.be,ricce-- _ Lavie- (--„,:f) (-4D , 24 . . .• , . , , 44qiii-he- FeAct, 1-(-7 Pd 1 d-e- 1,0 a51.5-r- WI-I/LC CoAlce--0- 6--• 'U AA 17 -r12._ dr or '00F % 5 C L3 0- LOT 24 ./ 1-3 a .- Z • 4 t .^. ...1 ,R.... /IF .•••• "' It I I k, i 44i , ....-• . i .:; NI l? ,ckcS i , % , 4-.•i \ ' -\' ck`t — , \ LOT 24 (- ,,pt\,.._„----; ,,-- 10.- ' i Ittl i 1 : 44, .. , ,,,':"! : 14..,N ..\, \ • , ...,.../(X\ \ 1 • 1 i \ / , .., N . ..- ‘,..* watereststvc.us.e ••-•.A\''C .----- •\T--t.s\v- ID i /K\ cf$,,, , tINS0?zitotto4, CP. 4.173 7.9•7t MC 2949 •••9C V•4997 9.919:314•9 :1•9 '22 - - =TVA CV 1•.+994,,, ., ' \ ,;:....'T'.......... 0 \ • .90 •••••^ 9, .., 11 \,•,, 1 ..o.. CV 394.• 5:9. .2,179 alai .. •F , .k. '4,0k.. '', -''''<:\L\%._ •cOv— „,, ,--, -179179•VIC,97...9 ,...4k,49,.... 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L- elle 01 Ica/ 7-(3/ (e t ,;---.7."-- •V,.9•40,;19 / - po01195r-c-7z 7.'"T.:4;:47 a, - p/ligov - 4-4ell • - _ 111 (", - cep5-92-vcri oi.i -rie..q/ L=0/2-5 to Pr9ir 4 0.-/V N -6,1).-P./A16-ill_ell 0!.. .Ir,,, OWNER BUILDER AFFIDAVIT res ," City of Atlantic Beach Building Department JOB ADDRESS: 800 Seminole Road, Atlantic Beach, FL 32233 " f,93 �mie�/Q /� An& "-.0109'? v Phone: (904) 247-5826 Email: Building-Dept@coab.us `/ cl **OWNERS MUST PERSONALLY APPEAR AT THE BUILDING DEPARTMENT TO SIGN THIS DOCUMENT** 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. 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. R 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. 5. 4Z_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 ermit 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. LO 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. Owner Builder Affidavit 11.12.2024 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) 4 7-1395 or the DBPR 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 job address listed on this document. 12. I agree to notify the Atlantic Beach Building Department immediately of any additions, deletions, or changes to any of the 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 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: e(3 //,44.71y, LI1G RE# I2ES 2 02,6U— Owner Name: ��(e f (/1 /y�� Phone Number: y)01 95-75- Mailing Address: 0/3 , 1 ejptc rl� City: exy G gede..64 State: ft— Zip: 7 7.2-3Y I GINDLESPERGER � J MY COMMISSION#HH 407122 ignature o 0, -r or ent) (Date) / EXPIRES:October 6,2027 Signed before me this day of Vat 2.0 25 in the County of Duval,State of Florida, has personally appeared (),Ad/4: /C(f n Personally Known OR [ ] Produced Identification n My commission expire • Owner Builder Affidavit 11.12.2024 Notary Signature: 0 / OF