351 19th OWNER BUILDER Owner Builder Affidavit
City of Atlantic Beach Building Department
\- 800 Seminole Rd,Atlantic Beach, FL 32233
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""� Phone:(904) 247-5826 Email: Building-Dept@coab.us P��rf�. B-
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I. FLORIDA STATUTES;CHAPTER 489,FLORIDA STATUTES,FART 1"CONSTIW fON CONTRACTING"REQUiR[S
OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
To qualify for exemption under this subsection, an owner must personally appear and sign the building permit
application and must satisfy local permitting agency requirements,if any, proving that the owner has a complete
understanding of the owner's obligations under the law as specified in the disclosure statement in this section.
However,for purposes of implementing a"United States Department of Energy SunShot Initiative: Rooftop Solar
Challenge"grant and the participation of county and municipal governments,including local permitting agencies
under the jurisdiction of such county and municipal governments,an owner's notarized signature or personal
appearance to sign the permit application is not required for a solar project,as described in subparagraph(a)3.,if
the building permit application is submitted electronically to the permitting agency and the owner certifies the
application and disclosure statement using the permitting agency's electronic confirmation system. if any person
violates the requirements of this subsection, the local permitting agency shall withhold final approval, revoke the
permit,or pursue any action or remedy for unlicensed activity against the owner and any person performing work that
requires licensure under the permit issued.The local permitting agency shall provide the person with a disclosure
statement in substantially the following form:
DISCLOSURE STATEMENT Please initial Items 1 - 13.
1. I understand that state law requires construction to be done by a licensed contractor and have applied
for owner-builder permit under an exemption from the law.The exemption specifies that I,as the owner of the
property listed, may act as my own contractor with certain restrictions even though I do not have a license.
2_,•N\ I understand that building permits are not required to be signed by a property owner unless he or she is
responsible for the construction and is not hiring a licensed contractor to assume responsibility.
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►+ I understand that,as an owner-builder, i am the responsible party of record on a permit. I understand
that may protect myself from potential financial risk by hiring a liceraed contractor and having the permit filed in
his or her name instead of my own name. I also understand that a contractor is required by law to be licensed in
Florida and to list his or her license numbers on permits and contracts.
1\ I understand that I may build or improve a one-family or two-family residence or a farm outbuilding. 1
may also build or improve a commercial building if the costs do not exceed$75,000.The building or residence must
be for my own use or occupancy. it may not be built or substantially cnproved for sale or lease, unless i am
completing the requirements of a building permit where the contractor listed on the permit substantially
completed the project. If a building or residence that I have built or substantially improved myself is sold or leased
within 1 year after the construction is complete, the law will presume that I built or substantially improved it for
sate + tease,which violates the exemption.
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\ I understand that, as the owner-builder, I must provide direct,onsite supervision of the construction.
6. 111-, I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons
.�+'rig on my building or residence. It is my responsibility to ensure that the persons whom I employ have the
licenses required by law and by county or municipal ordinance.
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7. I understand that it is a frequent practice of unlicensed persons to have the o'opecty 0,,v ed obtain an
o-r-builder permit that erroneously implies that the property owner is providing his or her own tabor and
materials. I, as an owner-builder, may be held liable and subjected to serious financial risk for any injuries
susta&Ped by an unlicensed person or his or her employees white working on my property.tiny homeowner's
insurance may not provide coverage for those injuries. I am willfully acting as an ownee-builder and am aware of
the limits of my insurance coverage for injuries to workers on my property.
84I understand that I may not delegate the responsibility for supervising work to a licensed contractor who 41
is not licensed to perform the work being done. Any person working on my building who is not licensed must work
under my direct supervision and must be employed by me, which means that I must comply with laws requiring the
withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act
(FICA)and must provide workers'compensation for the employee. I understand that my failure to follow these taws
may subject me to serious financial risk.
9. I agree that, as the party legally and financially responsible for this proposed construction activity, I will
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aim by all applicable laws and requirements that govern owner-builders as well as employers. I also understand
that the construction must comply with all applicable laws,ordinances, building codes, and zoning regulations.
10. I understand that I may obtain more information regarding my obligations as an employer from the
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Inte at Revenue Service, the United States Small Business Administration, the Florida Department of Financial
Services, and the Florida Department of Revenue. I also understand that I may contact the Florida Construction
Industry Licensing Board at (850)487-1395 or http://www.myfloridalicense.com/DBPRlconstruction-
industry/for more information about licensed contractors.
I am aware of, and consent to, an owner-builder building permit applied for in my name and
un nd that I am the party legally and financially responsible for the proposed construction activity at the
following address: 351 19th St,Atlantis Beach,Ft 32233
1 ` iiiaI agree to notify the Atlantic Beach Building Department immediately of any additions, deletions, or
than to any of the information that I have provided on this disclosure.
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1Licensed contractors are regulated by taws designed to protect the public. If you contract with a
pe`.n who does not have a license, the Construction Industry Licensing Board and Department of Business and
Professional Regulation may be unable to assist you with any financial toss that you sustain as a result of a
complaint. Your only remedy against an unlicensed contractor may be in civil court. It is also important for you to
understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your
property,you may be held liable for damages. If you obtain an owner-builder permit and wish to hire a licensed
contractor,you will be responsible for verifying whether the contractor is properly licensed and the status of the
contractor's workers'compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property
owner and returned to the local permitting agency responsible for issuing the permit. A copy of the property
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owner's driver License,the notarized signature of the property owner,or other type of verification acceptable to
the Local permitting agency is required when the permit is issued.
II. INJURY UABIUTY;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 IFA PERSON ISA LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904-
247-582608 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,Atlantic Beach,FL 32233
Owner Name: lax Home Link LLC Phone Number. (904)372-3595
Mailing Address: PO Box 330717 City: Atlantic Beach State: FL Zip: 32233
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Notarizediaibrrr of Owner ,`� N. "
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The foregoing instrument was acknowledged before me this !L1 day of .4 u I ,2012,in the State of Florida, County
of .7)u girt 1 .
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Signature of Notary Public ,
I I Personally Known OR( )Produced Identification
Type of Identification: l..-.
;=os"•"•YP �; TO"N;GINDLESPERGER
;. MY COMMISSION#GG 353178
':,7;><;o; EXPIRES:October 6,2023
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Bonded Thru Notary Public Underwriters
Updated 7/12/22
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