351 4th St DWAY22-0055 Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
2 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 35 stf o �� Permit Number: . (-014 Z - OCD
5
Legal Description NA),, 151 O1 Loi 18 -+ 1 e4 (_ ."rZA , ocl. ,,pp R�E ���__j L . 9839 .
Valuation of Work(Replacement Cost)$Z..o p° Heated/Cooled SFO.0 IVon-}T {ed7Co fr-cl
• Class of Work: pew ElAddition ❑Alteration ❑Repair ❑Move Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial yResidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes 17Vo
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit] ANo
Describe in detail the type of work to be performed:
� i-v{C b 1 o..� �,J I r a.
- e f") vt._LAJ W ' ?'—('1 ►p,) 'j l -'I . 5.
Florida Product Approval# fbr multiple products use product approvaYform
Propert Owner Information
Name - - Address -
City .A,.f-'art, " e-Ct,„.ti State F t Zip Na..133 Phone 9c -1
E-Mailpi,_�. 1,p p mp) ( ,o
Owner r Agent(If Agent, power of Atorney or Agency Letter Required)
Contractor Information 1
Name of Company 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❑ Expiration Date
Application is hereby made to obtain a permit to do the work and installations 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 to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county,and
there may be additional permits required from other governmental entities such as water management districts,state agencies,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 Y9UR PAYING TILVICE FOR IMPROVEMENTS TO YO� PROPERTY. IFYOU INTEND
TO 0•T' FINANCI G, CON ULT WITH YOUR LE ER •RAN ATTORNEY BEFO'
REC• ' •I G YOUR OTICE OF OMMENCEMENT —!-'
(Signat e o ent) gnature of Contractor)
Signed and sworn to(or affirmed)before me his�j� day of Signed and Sworn to(or affirmed)before me th's-3(tay of
•
•
O�etQ4�, 3.4 by Lv\\ z(� 3•01` by \\
(Signature of Notary) ` (Signature of Notary)
PY.
[ ersonally Known R:; �' 4�: COLLEEN A.KEOJNG [ Personally Known 0-11) ft :it•"'`Vit': COLLEEN A.KEELING
[ ]Produced Identific •-i, *; Commission#HH 200166 [ ]Produced Identification (A; `o Commission HH 200166
Type of Identification: ",:?f,z ` Expires December 7.2025 Type of Identification: "' ' �:� ' Expires December 7,2025
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
i 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: l - �—. &(—. . �t 1 3 a 3
Owner Name: ) 'r v -� t Phone Number: 9 0
Mailing Address: A City: ft B State: ( Zip: 3 .733
Notarized Signature of Own•r /
The foregoing instrument •asa .•• -••-• •- • - . is \$day of O \4,2A, 2071.4in the State of Florida, County
r Iof \:� __ `' t.._• /
Signature of Notary Public A
Personally Known OR [ J Produced Identification
Type of Identification:
COLLEEN A.KEELING Updated 10/24/18
:• Commission#HH 200166
'•.'roe q;: Expires December 7,2025
L'-4, REVOCABLE ENCROACHMENT AGREEMENT
Rs **ALL INFORMATION
�+� City of Atlantic Beach
;- HIGHLIGHTED IN GRAY
\� -;..)i800 Seminole Road,Atlantic Beach, FL 32233
IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
exl ting under the laws of the State of Florida, hereinafter referred to as"CITY"and
�...).,` Lr t 4. `; t,`Q of Atlantic Beach, Florida, hereinafter
referred to as"USER".
WITNESSETH:
That the CITY does hereby grant the USER permission on a revocable basis as described herein the right to enter upon
the property for the purpose as described in the City of Atlantic Beach.
This work is generally described as _ _ • - • -- .. .
Any facility maintained, repaired, erected, and/or installed in the exercise of the privilege :ranted remains subject to
relocation or removal on thirty(30)days'notice by CITY to USER,said notice to USER shall be given by certified mail,return
receipt requested,to the following address 35--‘ r\ ,...,\-y-te--- A -- 1 31\3
3
• In the event it is necessary for the CITY or the City's approved representative or other franchised utility to enter
upon the above described easement or property of the CITY, the USER shall replace at the USER's sole expense,
any and all material necessarily displaced during the action of maintaining, repairing, operating, replacing or
adding to of the utilities and facilities of the CITY or franchise utility provider.
• The facilities allowed by the permit shall meet the current requirements of the City Code, Building Codes, Land
Development Code and all other land use and code requirements of the CITY, including City Code Section 19-7(h)
which states "Driveways that cross sidewalks: City sidewalks may not be replaced with other materials, but must
be replaced with smooth concrete left natural in color so that it matches the existing and adjoining sidewalks."
• The USER, prior to making any changes from the approved plans and/or method, must obtain written approval
from the City of Atlantic Beach Public Works Department, for said change within 30 days after the day of
completion.
• This permit shall inure to the benefit of, and be binding upon, the USER and their respective successors and
assigns.
• USER shall meet the terms and conditions of this permit and to all of the applicable State and CITY laws and/or
specifications, to include utilities locate requirements and use limitations/requirements of easements, public
• -• - •ublic land. USER further agrees that the CITY and its officers and employees shall be
,t-of-wa
•d harmless by the USER fro .ny of the work herein under the terms of this permit and that all of said
ilities ar: hereby assumed by the U .
MID' Date ) U -3 I - 2
•roperty Owner/A.ent(signed in presence of Notary Public) Z
STATE OF FLORIDA COUNTY OF DUVAL — yy
The foregoing instrument w s acknowledged this_ s3 I day of ( �cit , 20 -22-
by VOL P,I'14 1 l [; ,who personally appeared before me and
printed n.••e of ':ner)
ac • ledged t - s e signed the instrument voluntarily for the purpose expressed in it.
1111
__ :................ �"`��-`°`"'r"R Department Approval:
Signature of Notary Public,St to o Florida ;_. • -53178
[ ]Personally Known :•: ,?�•` .._. 2023
'. 6.,,,;.0::,....; 6or: .nru :. . nder,'tars
[ ] Produced Identification(Type) —. ,. -- Scott Williams, Public Works Director
,,:F;�G-,,, TONI GINDLESPERGER
H:\Applications&Forms\Word&Excel Document Ori a \2r'.$f 31 vegte f166kf1t0liF er3bkinemi nt.docx Revision Date:8/31/18
EXPIRES:October 6,2023
-''•'F ,,OF,°`' Bonded Thru Notary Public Underwriters t
301503
MAP SHOWING SURVEY OF
THE WEST 15 FEET OF LOT 18 AND ALL OF LOT 20, BLOCK 6, ATLANTIC BEACH, AS RECORDED IN
PLAT BOOK 5, PAGE 69 OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA.
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•NO BUILDING RESTRICTION LINE BY PLAT, BUT THERE n 0
MAY BE RESTRICTION LINES OR EASEMENTS THAT AFFECT v1/ / T �,/C///7V/i,
RECORDS OF THISTHIS PROPERTY ZOCOUNTYNING
RECORDED IPUBLICN THE �
THAT ARE NOT SHOWNON THIS SURVEY, G�L,lu,/L 2 E - `.
'THIS PROPERTY LIES IN FLOOD ZONE "X” BY FLOOD MAPS '
REVISED 4/17/1989, COMMUNITY PANEL NO.120075 0001 D, I HEREBY CERTIFY TOC CHARLES D.PICKETT 8 VALERIE
PICKETT ;STFWART TITLE GAR. CO.; PONTE VEDRA NATIONAL
BANK;BARTLETT, MILLER 8 MOREHEAD
THAT THIS SURVEY MEETS THE MINIMUM TECHNICAL
STANDARDS AS SET FORTH BY THE FLORIDA BOARD OF
PROFESSIONAL LAND SURVEYORS, PURSUANT TO SECTION
472.027 FLORIDA STATUTES AND CHAPTER 61017-6
4 FLORIDA ADMINISTRATIVE ODE.
DURDEN LAND
SURVEYORSINC, PROFESSIONAL LAND SURVEYOR 7C7 FLORIDA
LB 1048 N. BRUCEDe,PDE , -4e.
DATE: JUNE 5, /995
1 103 SOUTH THIRD STREET SCALE: /"= 20'
JACKSONVILLE BEACH, FLORIDA 32250
(904) 249-7261 FAX.(904) 241-1252
THIS SURVEY NOT VALID UNLESS THIS PRINT IS EMBOSSED WITH THE SEAL OF THE ABOVE SIGNED.