642 AQUATIC DR RFNC22-0112 ''''''''', Building Permit Application Updotedl0/9/18
t- City of Atlantic Beach Building Department **ALL INFORMATION
,F 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
"'' IS REQUIRED.
Phone: (904) 247-5826r- Email: Building-Dept@coab.us
Job Address: CLI 2- Acf.•,�,f;,. Qv Permit Number: R jc_L 2 -- 0 i! 1
Legal Description 6100 ; 'i • • I 1,97WR# I-MrIFf d 52-)`t
Valuation of Work(Replacement Cost) $ 'SOO Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration 2<epair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Ef//esidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes Eo
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) CWVo
Describe in detail the type of work to be performed: RTI„
c.: 6 1 o1 -Ail-vt w - 44ve.. /f/
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name K;mL-ly Ahs Vrr4c Address C92.. /4ua4%t. 0r
City Ajrta,•,.t•; &uf.i., State 0 Zip 31_Z33 Phone 213 $GO 1-0y4'1
E-Mail 6oANy. — 6 az Lo+ww;I . an
w
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required)
Contractor Information p p
Name of Company Sv,ieriw t_ ce_ 1\•.;( Qualifying Agent ZciJ (cy4-0.,
Address 5'17O H51,unyAvt, City Sacsl,ccw:lit State Ft Zip 3ZZS-1
Office Phone 9611 C93 43,11 Job Site Contact Number
State Certification/Registration# J SYSe E-Mail ogl,,, ca .ce.„..m.,j c Ls„r .I)k. . „by.,
Architect Name&Phone#
Engineer's Name& Phone#,
Workers Compensation Insurer L :1....-4-y MA-t,1 OR Exempt 0 Expiration Date 12/1 Si Z.7-
Application
ZApplication 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 YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNE BEFORE
RECOFDING YOUR TICS OF COMMENCEMENT.
/ ,c �iIlli ..1,47
(Signature of Owner or Agent) Signature of Contractor)
•Signed and sworn to(or of ' • d) before me th' A\ dayof Signed and sworn to(or affirmed)before me this a day of
Xi: W , 7_02-a. , . WI)r\AE Vr, cu K k1 OQuufdl; a--1, by • • P i
1610'e �' 3181.1 HUSSAl%
.'gnat o \ • a� A41111116.F ` it a 4. OfPOtralr+j✓
I1C-state;':Crc3
IA_j Commissions i�2.6,t,.
(
;.\;';; TONI GINDLESGER .y Comm.Expires May 4. Z..4 (
G MY COMMISSION#GG 353178
[ ] Personally Known OR PersonallyKnown OR
:a• ;c; EXPIRES:October 6,2023 ]
[ I Produced Identification "' ''�o Fto"' Bonded ThruNotaryPublicUnderwriters )}Produced Identificatp .p /
Type of Identification: I "� pe of Identification: AD&dD/4 `ck J 2—LC P" e"
Owner Builder Affidavit **ALL INFORMATION
- HIGHLIGHTED IN
(: City of Atlantic Beach Building Department
kGRAY 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: ( 4', /4yu/i7;'C 7),2 1VG
Owner Name: k'vie Cit L,y v i TC k. Phone Number: WV ; 'i 2 6914
Mailing Address: (e v.2 /(Cj6!ii r;c. fir'-i V E City: /ITL,,tJTi c gEAcil State: /L Zip: 3,;?,,13 3
Notarized Signature of Owner /3:19-1-r-7/7X JA.,f_Z v
The foregoing instrument was acknowledged before me this o2 day of /1/01/c.416L , 20.22, in the State of Florida, County
of K vN.,
1111
Signature of Notary Public
[ ] Personally Known OR [ ] Produced Identification
._ D:.=3PERGER Type of Identification:
i7:7T---
; '°,"'•; MY CGty MISSiON#GG 353178 _.\
`' ..A4' EXPIRES:October 6,2023
,FodW 8gndea Thru Notary Public Underwriters Updated 10/24/18
Fence Addendum Updated 1/14/2021
�. City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233
PERMIT#
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: Date:
� z 4q uri r; i d& A-tLrq A,L EAcrt /O/may/ a-
Property Type: Lot Type/ Features:
Residential ❑ One Street frontage (interior lot)
❑ Commercial ❑ More than one street frontage (corner lot, through lot,
etc.)
❑ Swimming Pool
Fence Material: Fence Height (select all that apply):
Wood ❑ Four Foot (4ft)
❑ Chain Link X Six Foot (6ft)
❑ Vinyl ❑ Other
El Block/Stone (Plan details required for footings and/or
retaining walls)
El Other
Fence Location:
Please submit an accurate and current boundary survey showing all existing improvements (including building footprint,
driveway, swimming pool, etc.) and location of fence/wall and any gates. Plan details required for block wall footings and/or
retaining walls and any portion or fencing above 6ft in height.
Will the fence be built in an easement?
El Yes (must submit separate Revocable Encroachment Agreement)
X No
Will tree(s) be removed in association with proposed project?
❑ Yes (must submit separate Tree Removal Permit)
[,`No
Conditions of Approval:
• Roll off container company must be on City approved list. Roll off container cannot be placed on City right-of-way.
• All old fencing and debris must be removed from job site by contractor or homeowner.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
MAP `dHOWING SUAVE') OF
LOT /4C-__ BLOCK ' AS SHOWN ON MAP OF
. e _
AS RECORDED IN PLAT BOOK 58 ,PAGE 7//7/A __ OF PUBLIC RECORDS OF OUVAL. CO ,FLA
FOR 4"41.74-694""j,1O/4VT 4/1-4/72-/RE-
-
E:VTURE
- Nei.) 614 td ..c { e r P.z.�r
— x:51': CI t..1Cr-ti (eAw-4--
. F
.•.0
4AUAT/C DR/VE (5o71/W) .
t.
Zn.. .
t /14-72-1C-1- OZ.-H4. ,- wlifl /V37°431513.Z
p: : 5�: *. ,.:300.'. 330'0 210.0'••. '•. 337sa• -1
� C OAiC.. ', 4: 40'DD'J'f
. p.7' 21 �' /2 z' i •••••„_______r„...7:2\___'''
t Z lt9' i5 C�) ��
90 �'/' -140. Do 40' 40' .4 0: ,a.0' t.. • .
Cp O•UE STK-$'T/CCD ,c,C4'A,K! '.V Q .
LOT i s-A h I.: I ch , £ _:•� v :43
6%
. '.3o # 436. '-Of . z 4'410 w h
. PI
A. Q' �' �} r!�i.9' o Zed- .8' �.
z z• 3 �`
.,1/5' Gie.AiA/AGGi Unu nE '.J
s 4 • 3Ei./. .. E3 'r.
7 45 D' 30 D' 1' D• ¢S 0'
s r la ' D2" 4- )Eu
c.(ZE.Et., Pnau+ 1)U° ft-Pc&
R£PhAT of Pr of fi'DY,44 PALMS !/N/T TWO-A
/a& 3/ Pa /6 r /a t)
$• 'R/W ram 4/3A/NAG( F L r/L/T/ES
0•
AmE,vp2 ) i/-t7 D5 '2VAL s4-WY.,4Y wo //-BS-GG
4ree /two: i0•/G•Bs- FovvoAr�dr.✓Sr./41✓/✓ IA/Jdo.to45-#5,
AMENDED,>1D dS 11//LDii'a ;rnxi r 'co.,.15%17
GIPCHARLES BASSET-il & ASSOCIATES. INC.
Article Eleven
Declarations of the Principal
I understand that this Durable Power of Attorney is an important legal document. Before executing
this Durable Power of Attorney,my attorney explained to me the following:
(i) that this Durable Power of Attorney provides my Agent with broad powers to dispose of,
sell, convey, and encumber my real and personal property;
(ii) that the powers will exist for an indefinite period of time unless I revoke this Durable Power
of Attorney or I have limited their duration by specific provisions herein;
(iii) that this Durable Power of Attorney remains in full force and effect during my subsequent
disability or incapacity; and
(iv) that I may revoke or terminate this Durable Power of Attorney at any time.
Dated: January 7, 2021
K/11/ 471114 rmci
STATE OF FLORIDA )
) ss.:
COUNTY OF DUVAL )
The foregoing instrum t was acknowledged before me on January 7, 2021 by Kimberly Ann
Vitek (by means of/D physical presence OR ❑ online noarization, and D who is personally
known to me ORwho has produced . D✓1-1Cl /ci (— as identification).
[Seal]
Courtney Ray, Not Publi
13500 Sutton Park Drive outh, Suite 601
Jacksonville, FL 32224
.rr % Notary Public State of Florida My commission expires July 8, 2024
+P Courtney Ray
• r a •
Mypires 0Comm7/0iss8ion/2024 HH 019454 Notary registration no. HH019454
Ex
Durable Power of Attorney of Kimberly Ann Vitek
Page 31
Three Oaks Law, 13500 Sutton Park Drive South,Suite 601,Jacksonville,Florida 32224, (904)397-4444
Declaration of Witnesses
The foregoing Durable Power of Attorney was, on the day and year written above, published and
declared by Kimberly Ann Vitek, in our presence to be her Durable Power of Attorney. We, in
her presence and at her request, and in the presence of each other, have attested to the same and
have signed our names as attesting witnesses.
We declare that at the time of our attestation of this instrument, Kimberly Ann Vitek was,
according to our best knowledge and belief,of sound mind and memory and under no undue duress
or constraint.
Ma Ha ,Witne o e Hite,Witness
13500 Sutton Park Drive South, Suite 601 135 Sutton Park Drive South, Suite 601
Jacksonville, Florida 32224 Jacksonville, Florida 32224
STATE OF FLORIDA )
) ss..
COUNTY OF DUVAL )
The foregoi instrument was acknowledged before me on Januuary)T, 2021 by Mary Hartley (by
means of physical presence OR ❑ online notarization, and L - 'ho is personally known to me
OR El who has produced as identi ation) and Monique Hite (by
means ofphysical presence OR ❑ online notarization, and who is personally known to me
OR ❑ who has produced as identification).
[Seal]
fl-Gu -
Courtney Ray, Not Public
13500 Sutton Park Drive uth, Suite 601
Jacksonville, FL 32224
:w w, Notary Public State of Florida My commission expires July 8, 2024
9 1 Courtney Ray
Ay My Commission NH 019454 Notary registration no. HH019454
i'kor n ' Expires 07/08/2024
Durable Power of Attorney of Kimberly Ann Vitek
Page 32
Three Oaks Law, 13500 Sutton Park Drive South,Suite 601,Jacksonville,Florida 32224, (904)397-4444