224 S OCEANWALK DR PLRS22-0159 Plumbing Permit Application **ALLINFORMAT1I0N
HIGHLIGHTED IN
J+ `' City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
�PL RSZZ-d(59
`"';'`'! Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
JOB ADDRESS:%Z% VCCClj 1/Ct_if C i(/eJSf2w PROJECT VALUE$.h/ ..2O
� 1 f/ QnK--r 'c 6e _c � 1C/. 322-3 "
L�"NEW OR REPLACEMENT INSTALLATION and/or ERE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank & Pit
Clothes Washer Shower 2—
Dishwasher
Dishwasher Shower Pan 2-
Drinking Fountain Slop Sink
Floor Drain 2- Three Compartment Sink
Floor Sink 2-- Toilet 2-
Hose
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Water Heater
Other Fixtures Water Treating System
CI MISCELLANEOUS
Sewer Replacement
Back Flow Preventer
Lawn Sprinkler System (number of sprinkler heads)
Grease Interceptor (Trap) gallons(Requires 3 sets of plans)
Well **SJRWD Well Completion Form.Completed form to be submitted to the Building Department for final inspection. **
Other
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: .//�i/ A .ti Phone Numbe(QUT )7Zp v!/GQ
Plumbing Company: (a✓'Qlie a/--s., 7L" Office Phone: Fax
Co. Address: 2Z vaeopvce,ex/oerii7( City:47L-A/2 /7 C-- State:/`l Zip: 3 ZZ 3
License Holder: OW A Ptate C ification/Registration #
Notarized Signature of License Holder -e
(Jv
The foreg ' strument w acknowledged before me this 1 A day o tit 4 , 20 n the State of Florida,
County of� u V 0,_.
OP si
Signature of Notary Public �`
6--- _
..E v PersonallyKnown OR Produced Identification
�P� TCNI GINDLESPERGER
1 ,..0:..�'�,'1.1 MY COMMISSION#GG 353178 Type of Identification:
J✓fiEXPIRES:October 6,2023
" ",f.':r';°''' bonded Thru Notary Public Underwriters Updated 10/17/18
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:
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: 22 (7/ C)C Plre'1 wet,(4(v"/ v-( SO(�JL7
Owner Name: /01"e 62 UI`S2- L Phone NNumbef q % 7Z ^(��j 9 g
Mailing Address22 y d�PGr� wail(di/(/�So hAr/C�4/7 C /3eaState: P7 Zip: g2-2 3 3
Notarized Signature of Owner 1111. f
Thrfoxegoing instr ment was acknowledged before me this day of 0e-4- , 202_41 the State of Florida, County
of V'f .—
6
Signature of Notary Public
[ ] Personally Known OR [ ] Produced Identification
Type of Identification:
°1 F • - TONI GINDLESPERGER
I Updated 10/24/18
MY COMMISSION#GG 353178
>,;.: EXPIRES:October 6,2023
__ Bonded ihru Notary Public UnderwTlets
4