2135 SEMINOLE RD DWAY23-0009 Building Permit Application Updated10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
= }✓ IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us 72 �-y�
Job Address: '2I-t S tinolf 11 c( 1A+(4vk+'� S3QGtcl�t FL3� emit Number: t)wf�f Z 0
3- 0 9
Legal Description PPT l.ni- ( O/lZ- t 1 O(o/(Sol) St-c_ t - RE# 1�q 515 C 2 O
Valuation of Work(Replacement Cost)$x ��000. 00 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition 1:19Alteration ❑Repair ❑Move EDemo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial INIResidential
• If an existing structure,is a fire sprinkler system installed?: :Wes '19No
• Will tree(s)be removed in association with proposed project?❑Yes(must submit separate Tree Removal Permit) tNo
Describe in detail the type of work to be performed: 12Q-p (ace t-CeNC Pok'V 4
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name Lt4 (IAA( l e5 Address 2-13S vu no I
City A - 1 0 -t1L. P cc e l State F Zip 3-2-2 3 3 Phone SO —O('a
E-Mail ()Achy LA-( c,'Dt( (tc ) nwtLoo ,fan
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
tractor Information
Name • ompany Qualifying Agent
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Regist . .•n# 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 - and installations as indicated.I certify that no work or installation has
commenced prior to the issuance of a permit and that all work ' •e performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a separate permit m •e secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONER , • . NOTICE: In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be fo : 'n the public records of this county,and
there may be additional permits required from other governmental entities such as water man..- ent 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 comp i. - 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
BTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
kali' 1 RDING YO R NOTICE OF COMMENCEMENT.
T,.
i Z (Signature of Owner or Agent) (Signature of Contractor)
3 3.c d and sworn to(or affirmed)before me this2 I
3 day3of Signed and swor o(or affirmed)before me this day of
• ,2,13 , by Ma r14 a.r(eS - by
un d
_ • i (Signature f Notar121—
( :••ture of Notary)
om
� v �
.p A .2
N N O
o c 7.
P a[ J4 rsonally Known OR [ ;Personally Known OR
't educed Identification [ J Produced Identification
Type of Identification: F L 'D L C4.4251518330' Type of Identification:
FKp R- 13-203o
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: 2-k 3'S c..4c4,14..; o (24 , A i (a,k--k i c I c_C,1,--,/ L -2,2:2 --);3
Owner Name: /1/(61. y C („cc; (Cs- Phone Number: 1-C4- 2',-7C' -r' 1-b 3-
Mailing Address: 2--PDS s4v,,ti;ncl_ (L-c( City: 11 4,7.A-;(._ e, c k State: it-•- Zip: 3 Z2 3 3
Notarized Signature of Owner ,t:///,
/7/,,,,
�i .--�
The foregoinginstrument was acknowledged before me this Z,�day of Ct,br�cu-t , 202.3 in the State of Florida, County
of DWJo.
-4 Signature of Notary Public (?/
[ ] Personally Known OR Produced Identification
S �"`t CHRISTY RIGNEY
1 , .; Notary Public•State of Florida (
:� ,"; Fl- -DC. C6112. S85-7 � - Q 33-o ye .---
' ...,�or��,; Commission p HH 274720 Type of Identification: r
My Comm,Expires Jun 9,2026
,�
Updated 10/24/18
eiv,---,,\ REVOCABLE ENCROACHMENT AGREEMENT
City of Atlantic Beach **ALL INFORMATION
HIGHLIGHTED IN GRAY
800 Seminole Road, Atlantic Beach, FL 32233 IS REQUIRED.
.ur�IP)
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
existin under the laws of the State of Florida, hereinafter referred to as "CITY" and
GI I'y U r le—S of Atlantic Beach, Florida, hereinafter
referred to ds "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 �on/'e-f' Oljf I vre L.J .
Any facility maintained, repaired, erected, and/or installed in the exe ise of the privilege granted 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 213 S 5 t ✓l (C, CLO) /4--1at✓t+C 'ac,l� fL
32-2-33
• 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
right-of-ways and other public land. USER further agrees that the CITY and its officers and employees shall be
saved harmless by the USER from any of the work herein under the terms of this permit and that all of said
liabilities are hereby assumed by the USER.
Date 5 (2/2o 2
Property Owner/Agent(signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL `�
The foregoing instrument was acknowledged this -3 day of Mp )-C .j , 20 L ,J,
by , 0_17-10, /.leS who personally appeared before me and
• inted namA•of Signer)
ac a• ledged that 411 s' • signed the in ument voluntarily for the purpose expressed in it.
�� I :,'!4 ;, TONI GINDLESPERGER Department Approval:
Signature of Notary Public,St.41 f Florida '.• / MY COMMISSION 353178
-:,- .z`.: EXPIRES:October 6,2023
[ ]Personally Known `:-:P,'F,4`••' Bonded Thru Notary Public underwriters
[ ]Produced Identification(Type) '" Scott Williams, Public Works Director
H:\Applications&Forms\Word&Excel Document Originals\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
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