474 AQUATIC DR RFNC25-0055 :�"8 BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
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`' City of Atlantic Beach Building Department PERMIT# RP-Ivc2J- UU55
800 Seminole Road, Atlantic Beach, FL 32233 **ALL information required to process
_'.n° Phone: (904) 247-5826 Email: Building-Dept@coab.us Q
Job Address 1/ 1 hl U Itkc '�(,UG RE# 17 I S l s S 15 O
Legal Description bU Q , (0 A S p.4 - a
Valuation of Work(Replacement Cost) O Heated/Cooled SF Non-Heated/Cooled SF
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•Class of Work: p New ❑Addition ❑Alteration Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Residential • If existing structure, is a fire sprinkler system installed?:❑Yes❑No
•Will tree(s)be removed in association with proposed project? ❑Yes (Must submit separate Tree Removal Permit)p•No
Describe in detail the type of work to be performed:
•
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Florida Product Approval# (For multiple products use Product Approval Information Sheet)
PROPERTY OWNER Name '�j�l 414 CS,trOeat I Phone 7 yip- .61q-
Address 1-'1T'di .3- u c fi.G 1).( , City l State Zip 322-3 3
Email �.c . M Owner or Agent VW Ilei
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CONTRACTOR Name of Company -a1/,ea1.Ge ,c-pic g Cana ��� T,OleiPhone %� pis.
Address City ja State PLZip j- 22.-/p
CWalifying Agent State Certification/Registration#
Email Job Site Contact Number
Worker's Compensation Insurer OR Exempt ❑ Expiration Date
Engineer of Record Architect of Record
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 city/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 YOU PAYING
TWICE FOR IMPROVEMENTS TO YOUR PROPERTY.A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE
SITE OF THE IMPROVEMENT BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING,CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
"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."
SIGN TURF OF CONTRACTOR PRINT OR TYPE NAME
E OF CONTRACTOR DATE /
....... cy
„ J — � Uv1lc _ y / S ZS
SI TURE F OWNER OR AGENT PRINT OR TYPEAME OF OWNER OR AGENT DATE c(c /
Building Permit Application 11.05.2024
01...Aft OWNER BUILDER AFFIDAVIT
'S'I*41 City of Atlantic Beach Building Department JOB ADDRESS:
r800 Seminole Road, Atlantic Beach, FL 32233 I
risi'r V Phone: (904) 247-5826 Email: Building-Dept@coab.us pLN 1w,, 1
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.
2. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for
t e construction and is not hiring a licensed contractor to assume responsibility.
3.t-2-71) 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. -1276 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.
0 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. 0 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. 0 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. Pp 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 the DBPR for more information about licensed contractors.
11.-- DI am aware of, and consent to, an owner-builder building permit applied for in my name and understand that I am the party
egally and financially responsible for the proposed construction activity at job address listed on this document.
r
1213± 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. ?our 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[a 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. + (� ff
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Job Address: / (� d G �i V Q RE# I l 5 L C>— l E-Owner Name: [ d -( o,, - Phone Number:
Mailing Address: ill Al �( ve City: State: - Zip: 32 Z .?3
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p.';�``.*. TONI GiNGLESPERGER (Si ature of Ow er or Agent) 'ate)
,;-,•. MY COMh11S5:0N#HH 407122
^:F �F"' EXPIRES October 6,2027 Signed before me this_i__ __day of 0,(i)( ( 2c) 7,....5
�---..........., in the County of Duval,State of Florida, has personally appeared
(- r LAT _--(-- UV- C) .-i---1-0IN, cr
[ ] Persbf all known OR (Poduced Identification �
My commission expi es: I i
Owner Builder Affidavit 11.12.2024 Notary Signature:
2„,'-,,,,,,;r Fence Addendum Updated 03/07/2024
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City of Atlantic Beach Building Department
15 `�,; i800 Seminole Road, Atlantic Beach, FL 32233 PERMIT #
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: Date: / C1/25
i-{1--( A, tA cch 6—i. i .
Property Type: Lot Type/ Features:
pesidential (DOne Street frontage (interior lot)
❑ Commercial ❑ More than one street frontage (corner lot,through lot,
etc.)
El Swimming Pool
Fence Material: Fence Height (select all that apply):
eNood ❑ Four Foot(4ft)
❑ Chain LinkSix Foot (6ft)
CI Vinyl ❑ Other
❑ Block/Stone (Plan details required for footings and/or
retaining walls)
❑ Other
Fence Location:
Please submit an accurate and current boundary survey showing all existing improvements(including building footprint,
driveway, swimming pool, etc.) and location of fence/wall and any gates. Plan details required for block wall footings and/or
retaining walls and any portion or fencing above 6ft in height.
Will the fence be built in an easement?
❑ Yes (must submit separate Revocable Encroachment Agreement)
No
Will tree(s) be removed in association with proposed project?
❑ Yes (must submit separate Tree Removal Permit)
i7No
. (Conditions of Approval:
• All old fencing and debris must be removed from job site by contractor or homeowner.
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
RECORDING YOUR NOTICE OF COMMENCEMENT.
Kat 10 111116 . r' C i'L ji •
MAP SHOWING. BOUNDARY SURVEY OF 4,1 JUL 6 1992
LOT 8.4 BLOCK AS SHOWN ON MAP OF
,44-a.47-7 ' &.4R.0E4/5. Building and Zc
AS RECORDED IN PLAT BOOK 38 PAGES 7/0A OF THE CURRENT PUBLIC RECORDS OF *DUVAL CO.. FLA.
FOR, Mh/Arie 611fDEA/6, 1o,vr ✓Euro.PE
NOTE ..BEAR^p4G DATUM SHOWN HEREON ALE,, A EO 0 THE ABOVE MEN-TIONEO LAT,
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