14 N SARATOGA CIR RES21-0304 , , -, '., Building Permit Application Updated l0/9/18
J
..,,-: City of Atlantic Beach Building Department **ALL INFORMATION
./`,/ 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
• �j:�� IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us [[��
Job Address: /'1 14/111-TO60 czac,LE Nef't}f' Permit Number:R L i - O 3 04_
Legal Description 3113 /1-Z5 -zqe IfWAXe' evaiVA RE# /7( 1 S -0000
linj- 1,4"c 134i'
Valuation of Work(Replacement Cost)$ 3 Jt•-
0 C ' Heated/Cooled-SF No Heated/Cooled
• Class of Work: ❑New DAddition :Alteration ❑Repair ❑Move ❑Demo :Wool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial ❑Residential
• If an 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) EINo
Describe in detail the type of work to be performed:
A2P1 41 4(
Florida Product Approval# for multiple products use product approval form
Property Owner Infor ation
Name ` i/ i'' "1 D-r Address —,Ari.. C/✓L ' f/_
City `.T.TI SIZE State sr-(- Zip_71-3 Phone tJ % : '
E-Mail ua 6.r., 7 '/Tr ,v€/ Kt,kCd'r'\ . 6' t2 . (1e.-
Owner or Agent(If Agent, Power.of Attorney or Agency Letter Required)
Contractor Information
Name of Company ()6avt` / 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❑ Expiration Date
Application is hereby made to obtain a permit to do the irk and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that . I work will be performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a -parate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,T, 'KS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirements of this
permit,there may be additional restrictions ap- icable to this property that may be found in the public records of this county,and
there may be additional permits required fri 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
RECOR I • '•N'TICE OF COMMENCEMENT.
4 " iv
( ignature of Owner or Agent) (Signature of Contractor)
igned nd sworn too`a ed)before me this 2 ay of Signed and sworn to(or affirmed)before me this day of
• _ ,zc21 , .'�/47,i;a / Jr , by
:na . e o .tart') (Signature o otary)
[ ]Personally Known OR ;, : Ytt' o..i TONT GINDLESt�F FPnally ;nown OR
[ ]Produced Identification ,r 1•+ :,,, MY COMMISSION 4 d/pod x d .lentification
Type of Identification: . .e:: 1111 % EXPIRES:OctobIY®,QOBdent cation:
of c`,b, Bonded Thru Notary Public Underwriters
MINN
**ALL INFORMATION
r-
"fer
L-Ai Owner Builder Affidavit HIGHLIGHTED IN
"' City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
l `` Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:1 E' i -o3o4
I. FLORIDA STATUTES;CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION CONTRACTING" REQUIRES
OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.103(7), FLORIDA STATUTES:
STATE LAW 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 SUPERVISE THE CONSTRUCTION YOURSELF.
YOU MAY BUILD OR IMPROVE A ONE OR TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY
ALSO BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS.
THE BUILDING MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE.
IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR AFTER THE
CONSTRUCTION IS COMPLETE,THE LAW WILL PRESUME THAT YOU BUILT IT FOR SALE OR LEASE, WHICH
IS IN VIOLATION OF THIS EXEMPTION.
YOU MAY NOT HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS.
IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE LICENSES
REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING ORDINANCES. ,
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: /'f Siaro 611 (--acLE No/(1 / M1/4,04-e: , ' TG 32233
Owner Name: �j/j//(-4i,,y c2,Af Phone Number: efQ -301-dzi 1
Mailing Address: 3020 ,�, .J 61-1.5 F31,4 City: :IAA' Ii State: FL- Zip: 3 ZZs-0
Notarized Signature of Owner ,i
Th regoing in trument was acknowledged before me this?etlay o4 , 202 ,(n the State of Florida, County
of 1. ` V-a b
O
Signature of Notary Public ��.L.—Ak.
[ ] Personally Known OR [ ] Produced Identification IP
Type of Identification: _ _
.,:,'4,. 6'', TONI GINDLESPERGER
••
COMMISSIONUpdated 10/24/18
• �•� •,: MY #GG 353178
is Tiff -
=,.��.;o EXPIRES:October 6,2023
''' f;1,°:' Bonded Thru Notary Public Underwriters
NOTICE OF COMMENCEMENT
I -
State of F(pn Tax Folio No. 171EI � 0000
County of 6w/41
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 this NOTICE OF COMMENCEMENT.
Legal Description of property being improved: (� I gr�' 6600
31 - I3 1-3--2.5 -Z 1e fi-4-14Hfie a cc& v,ll4 Laf (4 - AL/C `f
Address of property being improved: (41 t� 71014 C r C./te N�-f& *C- FG 3zz33
General description of improvements: /, *i C rc. 't' c K Ll ( 7d‘'7/6 tai^CJ 0(JS J .1d plt/✓4/7
Pte' �
Owner: /,{) 74^1(/ 74^1fK G,/� /7WuV Address: (J /1S /� r�
J G•r 4 �L 5125-0
Owner's interest in site of the improvement:
Fee Simple Titleholder(if other than owner):
Name:
Contractor: e-
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:
Address:
Telephone No: 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 fro date is
P YV
specified): a ��. TCrJ!G!NDLESPERGER
MISSION#GG 353178
=;,v'��: