110 S SARATOGA CIR RFNC22-0028 `y'1'i/ Building Permit Application Updated 10/9/18
i") City of Atlantic Beach Building Department **ALL INFORMATION
g
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
=''`}� IS REQUIRED.
Phone: (904) 247-5826 //Em11 ail: Building-Deept\�@coab.us }� �l
Job Address: 1 1 0 6.4.it}4 1A, VA Af!'1 t�.� DPl� k f L 0• 1 "w:j�Permit Number: ` (��'� v��
Legal Description --I-zy J —gS--R ` RE# Ii l 1961 - CW
Valuation of Work(Replacement Cost)$ 5, Heated/Cooled SF O/>a Non-Heated/Cooled /C f�•1
• Class of Work: C 'New DAddition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial 1?1/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) a'No
Describe in detail the type of work to be performed:f )
FeGki'0 t7N U �tir�I'MeC f 4.* pT ii.,c.K yel r •
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name S}tQ�c.A 1cvt;5 1Ae�+ Address 110 S,.r•.i-c L•'' S
City A1-1•4•thr.Be•.cA fLState •per fL Zip 32,z1. Phone qa(i-q‘8 -c8`/Z or 6-,113-Raoo
E-Mail 5 feiguvtd4).tNs1.4•.f+e 504.;(.co."
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information 3 ,-, *v n rets 1--k as- 4 Cn? - l . co
Name of Company `i' Qualifying Agent
Address City State Zip
Office Phone Job Site Contact Nu 5e
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 if stallations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will .e 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 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.
(Signature of Owner or Agent) (Signature of Contractor)
i ned an sworn to(or aff)before me this f day f ` Signed and sworn to(or affirmed) before me this day of
ZOO Z `jN � ) t- t't.._.
, by
' - Ogna A •.• -• ,(Signature of Notary)
----.. \
1 GINDLESPERGEP, W
[ ]Personally Known OR
f....ef:°: ;:::, MYCOMMISSIpy 0PA.3A ?II,PKnfiiwn OR
[ ]Produced Identification *'
EXPIRES:O�tq' 9d�iL�e'tl lde�k:ton:tion
Type of Identification: "''` o`? 7 ' d ry' `'on:
YP � Bonded Thru Nota_
y,,,_ Owner Builder Affidavit **ALL INFORMATION
�S 1r,, HIGHLIGHTED IN
S "' City of Atlantic Beach Building Department GRAY IS REQUIRED.
r oj
-7
800 Seminole Rd, Atlantic Beach, FL 32233
J'`--- 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
1 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: to5,..c,„.4.-c5,,, L' - jiL i(- ' b r, , 1.t , f 1 t 5
Owner Name: C01„,-vi i-F.-LI^� Phone Number: �7��.. '1' 1(.,t"
Mailing Address: i�L 71�1Y,`6.1 Cis 4) City: ktLiLl t 1 % �'L‘tL-k State: rt— Zip: .
Notarized Signature of Owner �7, -- /-'•-'
The-foregoing instr ment was acknowledged before me this' (,-) day o k'k 1- '\202Zn the State of Florida, County
ofd 0 r
•
Signature of Notary Public �_ C-)--
[ ] Personally Known OR [ ] Produced Identification a
Type of Identification: b 1
Updated 10/24/18
r ,,
;• ^ ;c .: TONI GINDLESPERGER
MY COMMISSION#GG 333178
='•� �: EXPIRES:October 6,2023
8 '',.°P F`,°P Bonded Thru Notary Puha,-t i,,A.,,,,44 ..
=%S+''` , Fence Addendum Updated 1/14/2021
ri,
l ' City of Atlantic Beach Building Department
K -:,J,i V 800 Seminole Road, Atlantic Beach, FL 32233 PERMIT #
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: Date:
11c .rti4-on G,c S, Af(htt}.'c Brhct4 i-ri / 333
Property Type: Lot Type/ Features:
gResidential CVOne Street frontage (interior lot)
❑ Commercial ❑ More than one street frontage(corner lot,through lot,
etc.)
❑ Swimming Pool
Fence Material: Fence Height (select all that apply):
❑ Wood ❑ Four Foot(4ft)
❑ Chain Link "Six Foot(6ft)
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)
C'No
Will tree(s) be removed in association with proposed project?
❑ Yes(must submit separate Tree Removal Permit)
Er No
Conditions of Approval:
• Roll off container company must be on City approved list. Roll off container cannot be placed on City right-of-way.
• 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.
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NOTICE OF COMMENCEMENT
State of fl6i lek. Tax Folio No. ii 11019 .-O(k')('
County of y0'vul,t
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' this NOTICE OF COMMEN EMENT.
Legal Description of property being improved: ,! 5 36 --2 -3 -a-1 E
Address of property being improved: I j 0 5=i.f7n.T ` O1, Li( 5 )
General description of improvements: f .1ict, ,) Ta perk Yt'w ft h INu'
. 4 i L y
�� ff i LL r , � lI
—Owner: �}t`���'tt 4'; i; t Address: 116 .14C;- w ( l� i t ,47 Lc • r i''` ,.:/ R.
/
Owner's interest in site of the improvement: -5;''' '-
Fee Simple Titleholder(if other than owner): ._Q --e ►M4 ' e _
Name: .
Contractor: ccwt.-e 'i ow vl.V'
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 fr.--- -•'a e o rgFogalja @E� iffer= t date is
specified): .. ` COMMISSION#GG353178 1
wA, ' :. M1�IRES:Octo•-r•,
THIS SPACE FOR RECORDER'S USE ONLY OWNER ''•Fo �'' Banded ThruNoWry Public UnderwriterSJ
Signed:_g_ t.----(16t —
Date: L I C 27
Before me this ( , day of 1 0 A 70Z i e Cou ty of 1 val,State
Doc#2022070063,OR BK 20187 Page 1491, Of Florida,has personally appeared , Cat-
Number Pages: 1 Notary Public at Large,State of Florida,Coun IF9uv. ,
Recorded 03/16/2022 09:42 AM, My commission expires:
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL Personally Known: .- . l
COUNTY or
RECORDING $10.00 Produced Identification: _ • PM