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486 AQUATIC DR RES22-0311 C **AL- �s�'U'i-k, Building Permit Application Updated l0/9/18 E.): City of Atlantic Beach Building Department L INFORMATION �, 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY SDR IS REQUIRED. Phone:/ (904) 247-5826 Email: Building-Dept@coab.us r I Job Address: ‘:116 Ai Va' (.- / 7 . Permit Number: 1 C,S Z' 7 �3 1, 1 legal Description T31'1 1 I 'i —?sem 1,3, , RE# /7 / U l r S./62- ,-Valuation of Work(Replacement Cost)$ aac oo Heated/Cooled SF ti Non-Heated/Cooled • Class of Work: blew ❑Addition DAlteration DRepair ❑Move ❑Demo ❑Pool ❑Window/Door • Use of existing/proposed structure(s): ❑Commercial L4idential Ir • If an existing structure, is a fire sprinkler system installed?: DYes �o Zp O M v • Will tree(s)be removed in association with proposed project? ❑Yes(must sub it separate Tree Removal Permit) 174.1< Describe in detail the type of work to be performed: • IQer/Ace roller, l 1 -/1 <J.q e ic/ �-,-).) 4 (/ f7) 4 (/ � ( e0eil 4 a . S Florida Product Approval# for multiple products use product approval form Property Owner Information / 'i / Name U-4C >,'1 6/. /14e Address 4114 111t ,9 . City ti 1 State / Zip 1.2 .33 Phone goci- FS`j - 1`7')&5 E-Mail 4r 6 ,Mef a Ie/ ‹-c)0-14-1 . &e>-- //,,w / / >L . / ' ~1� Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) .iic `�f4 4 - frier6.' frier Contractor Information Name of Company Qualifying Agent Address City State Zip Office Phone Job Site Con . Number State Certification/Registration# E-Mail Architect Name&Phone# Engineer's Name&Phone# Workers Compensation Insurer OR Exempt D Expiration Date Application is hereby made to obtain a permit do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permi 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 OBTAI'1 FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDIN 4O NOTICE OF COMMENCEMENT. (Signature of Owner or Agent) (Signature of Contract. Signed and sworn to(or affi md)) efore me thisZ3day of Signed and sworn to(or affirmed) •• ore me this day of N©v ,Z02 _b Cx_s : • !-t r`a .e_. ,by re • 01►0 (Signature of Notary) �;a TONT GINDLESPERGER P: .onall Know OR [ ]Personally Known OR ; [ ]Produced Identification ',,.sea"... �'COMMISSION#GG 2O2 ) Pr 1.uced Id- ification "° EXPIRES:October 6,207i 1 ^;' �!''O= I Identification: Type of Identification: : >, . .e: ,•, . , ,, Uodet,Tiapte� 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: `--/ i/ f iev -4 a. /41/ h. f �-)d .,T� Si,Owner Name: .7-4,‘, -) /] A . U 'KSS /� / Phone Number: / 1( - e2 7 y- 2 2 Mailing Address: !. 2(., ,.4 vG� 40,C �7. City: 1�L A. State: 117 Zip: . ..)__?3 -.:7,„ "Notarized Signature of Owner The facegoing inst[rument was acknowl ged before me this Z3day of \ 020 in the State of Florida, County of -J A]Ct Signature of Notary Public _c� __.(91.. .: [ ] Personally Known OR [ ] Produced Identification Type of Identification: A>• L — - e Updated 10/24/18 ;!'" " TONI GINDLESPERGER . MY COMMISSION#GG 353178 ''" 47,;:', M EXPIRES:October 6,2023 •d;PF?�?•••• Bonded Thru Notary Public Underwriters