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141 SEMINOLE RD RESO21-0096 s`='"'',- Building Permit Application ��,u � Updated 10/9/18 _ City of Atlantic Beach Building Department **ALL INFORMATION 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY riri vr' IS REQUIRED. Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address: I y f -S-,Cnl:newt� '2k 4t 1 'a c.-L\ Permit Number: iESUZ ( — 009 Legal Description SCa4'(i.►C e_e_ t CD I 71 Lri-t- (Lz3L Lni (,,33 RE# ).7C")Cc,1 0 —0©©C Valuation of Work(Replacement Cost)$ 04'0, `'C.) Heated/Cooled SF Non-Heated/Cooled • Class of Work: ❑New ❑Addition DAlteration )3Repair ❑Move ❑Demo ❑Pool ❑Window/Door • Use of existing/proposed structure(s): ❑Commercial CA3Residential • If an existing structure,is a fire sprinkler system installed?: ❑Yes lallo • Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) C No Describe in detail the type of work to be performed: I ^ I .4-e FS / r \arc i-c,, Florida Product Approval# for multiple products use product approval form Property Owner Information Name (Y1.c-1,%c•-,c 4 Address IS(i 'S'e or%No.c., ‘e 2 City J1-4-t ci-+. r ,, Zca.e._1A State \ '- Zip 3Z Z 3 3 Phone '(3 7 7`F ( 7 C+ Z5 E-Mail Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Contractor Information Name of Company Qualifying Agent Address City tate 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 work and ins .Ilations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will i e performed to meet the standards of all the laws regulating construction in this jurisdiction. I understand that a separate permit • ust 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 RECORDING-YOUR NOTICE OF COMMENCEMENT. I,— _ it _....... (Signature of Owner or Agent) (Signature of Contract. �Sig d and sworn to(or a •,before me thilI w,ay of Signed and sworn to(or affirmed •efore me this day of ���i Ib � '.� • A l . )S - by ,. a (Signature of Notary) [ ]Personally Known OR ,,�,rn pi' ,. ,_, ,r]personally Knpw •R MY [ ]Produced Identification r Iti t [ 1 Produced Identi' ation Type of Identification: I `•+ Type of Identifiaak=o Owner Builder Affidavit **ALL INFORMATION AIS HIGHLIGHTED IN jCity of Atlantic Beach Building Department GRAY IS REQUIRED. 800 Seminole Rd, Atlantic Beach, FL 32233 c� Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:RESC�( 'U0 i 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: 14 t S c n1 me, kr_ R.„.1 Owner Name: m..t- � \ A rysc, S Phone Number: ?c3 771(( 76 'a Mailing Address: r'-( i Sci ' re t• 'k,c� City: Ai-( (3, (el State: L Zip: 32Z--3 3 Notarized Signature of Owner .)•-0,---.0 (4c----- The7ficrFe,goingng inst ment was acknowledged before me this ZEday o _ , 20- , n the State of Florida, County of Jl?Vc c-- C Signature of Notary Public 6----Th� � V [ ] Personally Known OR [ ] Produced Identification TONIGiNDLESPERGER ,l MY COMMISSION#GG 353178 Type of Identification: 8-,..H., EXPIRES:October 6,2023 'j ,Ey'dF�°•` Bonded Thru Notary Public Underwriters Updated 10/24/18 *.. 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