351 19th St TEMP22-0018 Electrical Permit Application **ALL INFORMATION
S JHIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
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j 800 Seminole Rd, Atlantic Beach, FL 32233 Pzz ooi e
"' Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
JOB ADDRESS: SJ , I/4f.PROJECT VALUE $ /aft . e/i)
JEA INFORMATION REQUIRED ON ALL PERMITS: CDd AMPS 240 VOLTS I PHASE
❑ NEW SERVICE: ❑ Overhead oUnderground ❑Underground up Pole
❑Residential(Main)Service:
❑0-100 amps o101-150amps o151-200amps ❑ amps #of Meters
❑Commercial(Main)Service:
❑0-100 amps o101-150amps o151-200amps ❑ amps ❑CT Service amps
Conductor Type Size
❑Multi-Family(Main)Service:
❑0-100 amps o101-150amps o151-200amps ❑ amps #of Unit Meters
TEMPORARY POLE: (v0 amps
❑ SERVICE UPGRADE: ❑ amps oCT Service amps
❑ NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES, ETC.):
❑100 amps ❑150amps o200amps o amps ❑CT Service amps
❑ ADDITIONS, REMODELS, REPAIRS, BUILD-OUTS,ACCESSORY STRUCTURES, ETC:
Outlets/Switches: 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:
oSwimming Pool oSign oSmoke Detectors (Qty) ❑Transformers KVA oMotors HP
n FIRE ALARM SYSTEM (Requires 3 sets of plans):
Qty volts/amps
❑ REPAIRS/MISCELLANEOUS:
oReplace Burnt/Damaged Meter Can oSafety Inspection oPanel Change ❑OH to UG
oOther: 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: --iq x L,/ -,k t 1 (. - 10 LA 6G. [:F( Phone Number: �a c-498-/373
Electrical Company: A?plc Ck e- Office Phone: 5O4 -4 1-6-7-35 Fax:
Co.Address: ( I Oh, alavAQ +'i' rkd City: .v .,.14 State: 1-1., Zip: .7Z)to
License Holder:,_y -.10(..-1 61q 1; iS State Certification/Registr tion#:
•Notarized Signature of License Holder I! • %„. C) 1 r l 2 ck
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The foregoing instrument was acknowledged before me this 9 day o ThIMI I A . the 'tate of Florida,County of 11161)vt -
AlkSignature of Notary Public _ Erma.- 4111
yYC TONI GINDLESPERGER ��v 40
,;;:
MY COMMISSION#GG 353178 -[ I Personally Known OR[ ] Produced Identification
';s Po EXPIRES:October 6,2023 Type of Identification:
'"' or vs Bonded Thru Notary Public Underwriters
; 1
;•tyL Owner Builder Affidavit
-,: tt City of Atlantic Beach Building Department
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT 1t:
I. FLORIDA STATUTES;CHAPTER 489, FLORIDA STATUTES,PART 1"CONSTRUCTION CONTRACTING"REQUIRES
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.
2,4 14/ 1
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.
3 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 licensed 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.
4. \ I understand that I may build or improve a one-family or two-family residence or a farm outbuilding. I
Nic
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 improved 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
sale o lease, which violates the exemption.
I understand that, as the owner-builder. I must provide direct, onsite supervision of the construction.
6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons
wo -ng 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 property owner obtain an
ow r-builder permit that erroneously implies that the property owner is providing his or her own labor and
materials. I, as an owner-builder, may be held liable and subjected to serious financial risk for any injuries
sustained by an unlicensed person or his or her employees while working on my property. My homeowner's
insurance may not provide coverage for those injuries. I am willfully acting as an owner-builder and am aware of
the limits of my insurance coverage for injuries to workers on my property.
8. I understand that I may not delegate the responsibility for supervising work to a licensed contractor who
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 laws
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
abs 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 taws, ordinances, building codes, and zoning regulations.
10.
I understand that I may obtain more information regarding my obligations as an employer from the
AInte al 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/DBPR/construction-
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 rstand that I am the party legally and financially responsible for the proposed construction activity at the
following address: 351 19th St,Atlantic Beach,FL 32233
1 I agree to notify the Atlantic Beach Building Department immediately of any additions, deletions, or
chap s to any of the information that I have provided on this disclosure.
1 Licensed contractors are regulated by laws designed to protect the public. If you contract with a
per 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 wilt be responsible for verifying whether the contractor is property 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.
H. 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 IF A PERSON ISA 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,Atlantic Beach, FL.32233
Owner Name: Jax Home Link LLC Phone Number: (904)372-3595
Mailing Address: PO Box 330717 City: Atlantic Beach State: FL Zip: 32233
4 lit 0 °-s
a
Notarized se of Owner y `
The foregoing instrument was acknowledged before me this /L► day of 4u 1L,1 ,20 L2,in the State of Florida, County
of �u tAo1 1 •
•
Signature of Notary Public
[ [Personally Known 0111 [Produced Identification
Type of Identification: L
TO";I GIN�DLESPERGER
MY COfY1toISSiON#GG 353178
EXPIRES:October 6,2023
FpF F��P
Bonded Thru Notary Public Uncle
.--- rwriters
Updated 7/12/22
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