824 CAVALLA RD ERES22-0153 Sri%-hr� Electrical Permit Application **ALL INFORMATION
HIGHLIGHTED IN
', \'1'' City of Atlantic Beach Building Department GRAY IS REQUIRED.
i
~ 800 Seminole Rd, Atlantic Beach, FL 32233
�P1- 'r Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: �—R(SZZ—I)15_
JOB ADDRESS: 3214 C,40gA-`Ia Pd PROJECT VALUE$ 10O
JEA INFORMATION REQUIRED ON ALL PERMITS: Ivo AMPS 2LIO VOLTS I PHASE
❑ NEW SERVICE: ❑ Overhead ❑Underground ❑Underground up Pole
❑Residential (Main)Service:
❑0-100 amps o101-150amps o151-200amps ❑ amps #of Meters
❑Commercial (Main)Service:
❑0-100 amps E101-150amps o151-200amps ❑ amps ❑CT Service amps
Conductor Type Size
❑Multi-Family(Main)Service:
❑0-100 amps E101-150amps o151-200amps ❑ amps #of Unit Meters
❑ TEMPORARY POLE: amps
❑ SERVICE UPGRADE: ❑ amps ECT Service amps
❑ NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES, ETC.):
❑100 amps ❑150amps ❑200amps ❑ amps ECT Service amps
[LI ADDITIONS, REMODELS, REPAIRS, BUILD-OUTS,ACCESSORY STRUCTURES, ETC:
Outlets/Switches: 1$ 0-30amps 31-100amps 101-200amps
Appliances: 0-30amps 31-100amps 101-200amps
A/C Circuits: 0-60amps 61-100amps
Heat Circuits: # circuits @ kw
Number of Lighting Outlets, Including Fixtures:
❑ OTHER ELECTRICAL PROJECTS:
❑Swimming Pool ❑Sign Smoke Detectors (Qty) ❑Transformers KVA ❑Motors HP
n FIRE ALARM SYSTEM (Requires 3 sets of plans):
Qty volts/amps
❑ REPAIRS/MISCELLANEOUS:
❑Replace Burnt/Damaged Meter Can ❑Safety Inspection ❑Panel Change DOH to UG
❑Other: Updated 10/17/18
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have
read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether
specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of
construction.
Owner Name: Pat latrcA - 'lA.Silri elkr5aun 4-4-5 Phone Number: /21-7412—9228
Electrical Company: J Office Phone: Fax:
Co.Address: City: State: Zip:
License Holder: D0.1 &Cc- C-1a-vi t t,S State Certification/Registration#:
Notarized Signature of License Holder `1 Dialog-X-C. . • V" �/
The foregoing instrument was acknowledged before me this �
day o ���� _ A ,20_2 in the State of Florida,County of p(,(li,zi
Signature of Notary Public AL.:✓. .. :.s►
WILIP
l..,,0! MADISON GETZAN
# °# Commission#GG 930813 [ 1 Personally Known OR[ Produced Ide 'if' ation
fry ;,;311 �� Expires November 12,2023 Type of Identification: fL on4.4,6to
l'f'P f\OQ\ Bonded lieu Budget Notary Services
Owner Builder Affidavit **ALL INFORMATION
(��� HIGHLIGHTED IN
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#:
I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION CONTRACTING" REQUIRES
OWNER/ BUILDER TO ACKNOWLEDGE THE LAW:
I 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: zLQ
1 ccwa ii, `
Owner Name: \1�t0A6-F- ` -k5A-��`n C'1l�c,rc n.k5 Phone Number: -727 - 7`12 922g
Mailing Address: crq C i&i N& 2-a City: i l ,h - c.11) State: i'L- Zip: ;32Z33
o
Notarized Signature of Owner
c---N C-1,lc� 7
The o going instrument was acknowledged before me thts L day o ,20C- 4rthe State of Florida, County
of �V c..).
t ...271v...,,
Signature of Notary Public
6—
[ ] Personally Known OR [ ] Produced Identification
;..,1:, :;:.('' , TONT CNDLESPERGER
• �; ype of Identification: ---
,,. ._ MY CCMMISSION#GG 353178
:,1f
N• EXPIRES:kl.tober 6,2023
''�P,?,Ft°`'` Bonde!Thru Notary Pubic Underwriters Updated 10/24/18