172 POINSETTIA ST RFNC23-0007 `—'', Building Permit Application Updated l0/9/18
J
' City of Atlantic Beach Building Department **ALL INFORMATION
�,< 800 Seminole Road, Atlantic Beach, FL 32233
HIGHLIGHTED IN GRAY
''; IS REQUIRED.
Phone: (90447-58`26 Email: Building-Dept@coab.us (�
Job Address: I 22_ COI 1 1) J C //I a 5+• Permit Number: I�P NC., Z3'5007
Legal Description IV Z . 2. E4 L0 lO cQ l0 •S0.(. c i r.-Se iji# (7C) &3 8 "000 O
Valuation of Work(Replacement Cost)$ . / () y q Heated/Cooled SF 13 r7 3 Non-Heated/Cooled
• Class of Work: New ❑Addition l‘eration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial 2-Fesidential /
• If an existing structure,is a fire sprinkler system installed?: ❑Yes �No
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) Co
Describe inetail the type of work to be performed:
�ef (q(1 '_ 6 e,nce-
Florida Product Approval# for multiple products use product approval form
Property Owner Information 1 i
Name ( LA 10L) Y[-'i Address 1 'Pr 1 ! r.ti, �-'tCitIre.1
(�^' i l C, Q-a.r State L,Zip 31-2-9):.,..22 Phone rIc'et -(.} ._`) 3
E-Mail —ti,5'11 h 11 1 i e( )---( ?moi L°.C ' C YY j
Owner or Agent Of Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company t? e...--1\1€ ra `_L (-- Qualii ing Agent
Address - 3 ' ?lit G .t) +rf0/< fi('f I ) k, City ('('t � re fir —State r(� Zips?2- (1.:3Office Phone CI l_ (I - 17 3 - %'(;'i 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 th ork 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 ATTORNEY BEFORE
RECORD} YOUR NOTI OF OMMENCEMENT.
(Signature of wner or Agent) (Signature of Contractor)
S ned and sworn to(or a _.)bIfore is 2-3dayof Signed and sworn to(or affirmed)before me is day of
AIIMILA dp. p-&-
1P-!-. r IIIIM! (Signa re of Notary)
[ ]Personally Known OR -- -l Known OR
[ ]Produced Identification ;moo"'�Y.`�4�:; TONI GINDLESPE[R���duce, Identification
Type of Identification: , „ ;'.' MY COMMISSION# � i? ie I ification:
•.,.,„:7 ,,,,•,, - �- - - .• ober 6, 023
°°F,F;°•' Bonded Thru Notary Public Underwriters
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
J
2';,'H 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: 14-; a_ k- Pt-
Owner Name: L�t� -1 ----ttzt 1210 Ct ro(
Phone Number: qb q'C''
Mailing Address: rU]}'1 S Pel 1 (_ City: r41614i (%i1 State: C l/ Zip: 3 2,2-33
Notarized Signature of Owner ? ? !2 )
The�oing instrument was acknowledged before me this ')clay of r\ , 20,n the State of Florida, County
of L >U
O
Signature of Notary Public ? ��
[ I Personally Known OR [ ] Produced Identification
Type of Identification:
Updated 10/24/18
......... TONI GINDLESPERGER
,' MY COMMISSION#GG 353178
EXPIRES:October 6,2023
'41F o °Q• Bende:i—+hru Notary Public Underwriters
Fence Addendum Updated 1/14/2021
INV City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233 PERMIT #
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Add ss: Date:
7z roi riSt %/0 JI imarif)c P.-cUte (,25? 2,:3
Property Type: Lot Type/ Features:
/Residential G— ne Street frontage (interior lot)
❑ Commercial ❑ More than one street frontage (corner lot, through lot,
etc.)
D Swimming Pool
Fence Material: Fence Height (select all that apply):
E ' lood ❑ Four Foot (4ft)
❑ Chain Link L4Sx Foot(6ft)
❑ Vinyl ❑ Other
O Block/Stone (Plan details required for footings and/or
retaining walls)
O 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?
❑ Yes (must submit separate Revocable Encroachment Agreement)
[i�lo
Will tree(s) be removed in association with proposed project?
❑ Yeess(must submit separate Tree Removal Permit)
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.
02-714 e
23 v, MAP SHOWING BOUNDARY SURVEY OF �, L y
Z OF LOT 8Co BLOCK -*— AS SHOWN ON MAP OF
SEC 77Util Ivo.3 Sp c_T,a/,i
AS RECORDED IN PLAT BOOK /0 PAGES /(o OF THE PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA
CERTIFIED FOR: L. -71-77X1 /-1 U 5 4720; GtJA SI-1 I AtJC9 7QkJ MUTUAL (-lo/' E LOA s bye,;
13,4eR1 S7E,e? L AltAJ •/0/M TITLE; [./A J/-7-Er 6-6-71J GA2,4 L 7/71.-E //lam' .,'
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THE PROPERTY SHOWN HEREON APPEARS TO LIE WITHIN FLOOD HAZARD ZONE X AS SCALED FROM FLOOD
INSURANCE RATE MAP / FOR THE CITY OF ,aTL_s+.T l c FLORIDA, DATED 4-17- 0 9 . AND
IS SHOWN AS A COURTESY ONLY AND DOES NOT CONSTITUTE- A CERTIFCATION OF SAME.
TRI-STATE LAND SURVEYORS, INC.
8411 BA YMEADOWS WAY SUITE #2, JACKSONVILLE, FLORIDA 32256 (904) 731-7235
LEGEND trtnh7Nc. 8,a V a sty vguagm/-
■ CWC MON
• IRON Cao. THIS SURVEY DOES NOT REFLECT OR DETERMINE OWNER'H/P.
(SET wrTN LAP Ls 4144) NOT VALID WITHOUT THE SIGNATURE AND THE ORIGINAL RAISED SEAL ,
x-FENCE OF A FLORIDA LICENSED SURVEYOR AND MAPPCR.
o IRON C .(FOUND)
® CROSS CUT
aR.L BLINDING RESTRICTION UNE LARRY G. EDDY, P.L.S. No. 414
E9u7 EASEMENT GLENN M. BROADSTREET, P.S.M. No. 5814
R/W mai T-OF WAY -----
- /
COV. aobERED AREA SCALE: /111-- T CJ
€ CEN TD?UNE - .
A/C AIR CONDITIONING PADClitISTERED SURVEYOR AND MAPPER,
(R) RADIAL DISTANCE DATE: (o'70-0( STATE OF FLORIDA (LB #4921)
1-1 CONCRETE
F.B. F3(S PG. 3o ORDER NO. oI-?S94