465 Inland Way ACC19-0043 Homeowner Transfer r`-"'-,,,,. Building Permit Application Updated 10/9/18
J City of Atlantic Beach Building Department **ALL INFORMATION
v 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
�'rs`fir IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
�J 3"_2.33
Job Address: 4 (O S �N1—Pr�17 IV�t i TL*3T%c- gi I1,fL Permit Number:
Legal Description 09 1 In (' OC_@Pr iALA 0t\) ii Ott RE# / foq/6,3 - /53-7
Valuation of Work(Replacement Cost)$ � ?RC-Ahab Heated/Cooled SF Non-Heated/Cooled S----00 sr
• Class of Work: ANew ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Windo`Door
vE
• Use of existing/proposed structure(s): ❑Commercial Residential EC
E• If an existing structure,is a fire sprinkler system installed?: ❑Yes I INo OCT 1 2 2021
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit arate Tree Removal Pe it) No
Describe in detail the type of work tfo,be performed: BY:
ay,/ otu,,
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name \)STIr.) A) E/fn)6 Address `I"la 5—__L- �L- rt-'D t'')A1
City Pr (—t rs l i C- 13 i°Ac...0 State Fc Zip 37,7_ 3 3 Phone 4 a/ -3 Z— bg91
E-Mail j n te-J i?,2-i n C .k'ock .I. co,,
Owner or Plgent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information a
Name of Company Peso QE"--TY U1../3We (.5ft- iv 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 E pt 0 Expiration Date
Application is hereby made to obtain a permit to do the work and installations indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be perfor ed 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, Cco1 LT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECO' ' " ' :fie ' 01-I r •• COMMENCEMENT.
(Signature of Owner or Agent) (Signature of Contractor)
Signe. •nd swor to(or affirm before me this 12 day of Signed and sworn to(or affirmed)befor- e this day of
OCT. , 2o 2.1 ,by JJ5T10.) 6 go.) , , by
Gl �-,01., ..
(Signature of Notary) (Signature of Notary)
��" CHRISTIAN Gllf
[ ]Personally Known OR =�' ��; SPersonaf/y Known OR
:,: MYCOMMISSION#HHtce Identification
[v]Troduced Identification y;__,4''4' .:*1
Type of Identification: FL Ps L. "!E•-04V EXPIR6S:Apr�13 of Idertification:
Jr ■ A
(f-c7,7-„ Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
Jj;t)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:
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: LI D ' l} T1 FL 3223
Owner Name: 1.--‘) S r,— -F- t ^��iw�JG42-4-) Phone Number:
Mailing Address: ct (a ec .yJ /fir») City: hi. l.-f1r-7Tt c f3'i kJt State: r-'L— Zip: 322. 33
Notarized Signature of Owner
Tf
he foregoing,in trument was .ckno edged before me this 12 day of OCT , 2021 , in the State of Florida, County
DV VfL
Signature of Notary Public Cj i7/v v`s
CHRISTIAN GILES
MY PersonallyKnown OR
[ ] [ K3roduced Identification
EXPIR&S:April 13,2025
. oR r;,,• Bonded Thru Notary Pubic Underwriters
Type of Identification: FL L-
Updated 10/24/18