351 19th ST RES22-0082 *.., Building Permit Application U edro/9/18
), City of Atlantic Beach Building Department ..Aa INFORMATION
r 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
ll) IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us r
Job Address: 351 191h St Permit Number: IRE S 2Z - v C)E7
Legal Description 36-64 09-2S-29E Seiva Manna Unit 12-A Lot 13 RE?t 172020-1258
Valuation of Work(Replacement Cost)$s(1.°°° Heated/Cooled SF 1468 Non-Heated/Cooled 480
• Class of Work: ❑New [JAddition []Alteration •Repair []Move [JDemo ❑Pool LiWindow/Door
• Use of existing/proposed structure(s): OCommercial •Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes •No
• Will trees)be removed in association with proposed project?CYes(must submit separate Tree Removal Permit) •No
Describe in detail the type of work to be performed:
nwa h was w-cnaseb m slate Of disrepair Ac>mates are scorn to repsr anaror correct ertperatrebracer arobr',lasing ere, d &MAC,lieu.garbing,asrrc•c partitions,bm^,fascia aerial morsdrywall
noperat+re gluing cofnoonects,parw o sroscaso ttlernlarlft Overall goat U elErt ec to Alar.b toner rsowo r stale aro 9;yOlaMfreeppreli of EAe 10.16 cormiumity.Mbyte.MA be carred a,t r.a:.crra•ue sari 2S,2t
i--ao,a,9aaiarc Cat*i-JOtug Be:nrg.Ttr,Lit.O-O N'TUt 4 REPAIRS
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name Jat Hale LLC Address PO Box 330717
City Mantic Beach State a Zip 32233 Phone 904-372-3595
E-Mail Mxt"rtelnk "att "
Owner or Agent(if Agent,Power of Attorney or Agency Letter Required) NA
actor Information
Name of t. •...ny 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 o Expiration Date
Application is hereby made to obtain a permit to do the work and installa .• 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 . •• - the standards of all the laws regulating
construction in this jurisdiction.I understand that a separate permit must be secured for E -••I:ICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE:In ad' • to the requirements of this
permit,there may be additional restrictions applicable to this property that may be found in the public recor. • this county,and
there may be additional permits required from other governmental entities such as water management districts,stat- .:-ncies,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 F NANCI , CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING ,`•U',0 'CE OF COMMENCEMENT.
ill,•ature of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this 7 y
day of Signed and swo o(or affirmed)before me this day of
i►x,,,s•.9, , 2&l- by T h n J in &a.1 i k., , by
64 -P_
(Signature of Notary) -p .ture of Notary)
[ ]Personally Known OR [ I Personally Known OR
VProduced Identification • [ ]Produced Identification
Type of Identification: F-1- On i ver LI Ce(/( 5 fi Type of Identification:
Gy.2D- 470 -� 7 - 374, - D
Owner Builder Affidavit **ALL INFORMATION
.#4107"i HIGHLIGHTED IN
-i0 City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT it:
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: 351 19th st
Owner Name:Jax Home Link LLC Phone Number: (904)372-3595
Mailing Address: PO Box 330717 City: Atlantic Beach State: FL Zip: 32233
Notarized Signature of Owner
The foregoing instrument was acknow d ed before me this day of Mar GG1 ,202-2,in the State of Florida, County
of /) iiq, ) � ,in h n . ph
)
Signature of Notary Public tel( N7/ VGA ZC
'6 DONNA L.BARTLE [ ] Personally Known OR [ Produced Identification
U '
MY COMMISSION#HH 085656
w• ��.a: EXPIRES:May 14,2025 Type of Identification: r - LY t Ve r L 1 _ vi SCS
,4,?!.« :•• Bonded Thru Notary Public Undetvmters
Updated 10/24/18
NOTICE OF COMMENCEMENT
State of FLORIDA Tax Folio No. 172020-1258
County of DUVAL-
To
UVALTo 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: 36-64 09-2S-29E Selva Manna Unit 12-A Lot 13
Address of property being improved: 351 19th Street,Atlantic Beach,FL 32233
General description of improvements: Rrepair and/or correct inoperative, broken and/or missing original components
Owner: JAX HOME LINK LLC Address: PO BOX 330717,ATLANTIC BEACH FL,32233
Owner's interest in site of the improvement: 100%
Fee Simple Titleholder(if other than owner):
Name: N/A
Contractor: VARIOUS I A x /` P '\
Address: /�U rad K rT So�-r 1 A-14-€4,3 L 3 2z 3 3
Telephone No.: ` 4 - 3 3'Z- 3 3 Fax No:
Surety(if any) NIA _
Address: Amount of Bond$
Telephone No: Fax No:
Name and address of any person making a loan for the construction of the improvements
hoc 1t 202L063605 OR BK 20177 Page 1821,
Name: N/A Number Pages: 1
Address: Recorded 03/09/2022 12:11 PM,
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL
Phone No: Fax No: COUNTY
RECORDING $10.00
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may
be served: Name: N/A
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: N/A
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a different date is
specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
Signed: \ `\ Date: ( /' G�Z 2"
Before me thi 7 day of M N^''G 10.22 in the County of Duval,State
&`= Of Florida,has personally appeared 1; 4r J U.Sq)I- G-cA ,I k
P •, DONNA L.BARTLE
:2�:• "' •.�., Notary Public at Large,State of Florida,County of Duval.
MY COMMISSION#HH 085656 My commission expires: rM 1`11) 2-02..5
c= EXPIRES:May 14,2025 Personally Known: ' or
FoF g Bonded Thru Notary Public Underwriters e-
(;420
------- ter, Produced Identification: F Uy )Vet/. L j L' C't 5 f.-
G420-470 -('7 -371 -O