175 15th St RES22-0059 owner builder S1 LJ%_
Owner Builder Affidavit **ALL INFORMATION
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HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
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J� 800 Seminole Rd, Atlantic Beach, FL 32233
\ Phone: (904) 247-5826 Email: Building-Dept@coab.us
PERMIT#:Rl�SX.�' OLDS
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. fl
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: )75' /S — �;, . x /Vfl� ��,
Owner Name: $` r I ` l iZK , C/-j Al rt./ Phone Number: joy .11. D 2 ,
Mailing Address: ) 7.sIS- t C. i R ELT ity: fi ASIC BP_A--14 State: Zip: �2 Z3 Z
Notarized Signature of Owner it_ 11- `pZ- -
The f regoi g instrument was acknowledged before e this ZOikday of U(4-�i'r{ , 202Z, in the State of Florida, County
of �i!Uu I
Signature of Notary Public 0IIIIIr
.'�o,''o TERRY KENNETH STEPHENSON [ I Personally Known OR [A Produced Identification
`,����1��` Notary Public•State of Florida
I 'S` ! Commission N HH 287349 I (� 1
"'°... My Comm.Expires Jul 13,2(126 ` Type of Identification: '"� tI/�
Updated 10/24/18