83 Nicole Ln PLRS23-0040 COAB Permit Form with ConditionsOWNER:ADDRESS:CITY:STATE:ZIP:
WALSH SUSAN 83 NICOLE LN ATLANTIC BEACH FL 32233-5979
COMPANY:ADDRESS:CITY:STATE:ZIP:
TYPE OF
CONSTRUCTION:
REAL ESTATE
NUMBER:ZONING:BUILDING USE
GROUP:SUBDIVISION:
169519 0825 TIFFANY BY THE SEA
JOB ADDRESS:PERMIT TYPE:DESCRIPTION: VALUE OF WORK:
83 NICOLE LN PLUMBING RESIDENTIAL Water Heater $3000.00
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
PLUMBING BASE FEE 455-0000-322-1000 0 $55.00
PLUMBING FIXTURES 455-0000-322-1000 1 $7.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $66.00
LIST OF CONDITIONS
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
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.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT
IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLORIDA BUILDING
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
1 of 1Issued Date: 3/10/2023
PERMIT NUMBER
PLRS23-0040
ISSUED: 3/10/2023
EXPIRES: 9/6/2023
PLUMBING RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
Plumbing Permit Application ALL INFORMATION
s''''.
Ci(1ty of Atlantic Beach Building Department
HIGHLIGHTED IN
GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
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Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: T(1.5 2)
W lQ
JOB ADDRESS: @3 Wi CD f-P //A iie,e9-_-6 PROJECT VALUE $ 31()00
NEW OR REPLACEMENT INSTALLATION and/or 1=1 RE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank& Pit
Clothes Washer Shower
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Water Heater X.
Other Fixtures Water Treating System
MISCELLANEOUS 1 c c ( e(l rJSewerReplacement
Back Flow Preventer 01_1Q5 S u. I
Lawn Sprinkler System (number of sprinkler heads)
s (.36GreaseInterceptor (Trap) gallons (Requires 3 sets of plans) I Gc+/ t ls
Well **SJRWD Well Completion Form.Completed form to be submitted to the Building Department for final inspection. **
Other
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months.
I hereby certify that I have read this application and know the same to be true and correct. All provisions of laws and ordinances
governing this work will be complied with whether specified or not. The permit does not give authority to violate the provisions
of any other state or local law regulation construction or the performance of construction.
Owner Name: ti(,±)G1)1 I cJ 11 Phone Number:9OL( ) !/'g\s3J 4
Plumbing Company: Office Phone:x
Co. Address: ' 41 . " , e , r " -ii City:'= '-X State: ip:3
1 JLicenseHolder: R State Certification/Registration # rl//
Notarized Signature of License Holder A,OA/in J PI L Ilkjk-)
The foregoing instrument was acknowledged before me this ID day of mGIr&h , 202-g, in the State of Florida,
County of OUIJA;'
Signature of Notary Public
VANESSA ANGERS
MY COMMISSION#HH 244118
Personally Known OR [1.1/Produced IdentificationEXPIRES:Istarch 23,2026
Tori:°`' 1/047-0-161.3TypeofIdentification: R, o1 lv.- gi - G S ca4 t vc€Ls kl
Updated 10/17/18
ci1 r,'.Owner Builder Affidavit ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
9"
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: R- 523-00,10
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: g3 Ab r.
pe11 /` q p 13
Owner Name: `f/vGa'Y) U)a 14) Phone Number: ?0C-1 -7'I 55---84,
Mailing Address: 63 AL c i7 I-P, L A i7 P City: rf.13 State: Zip: 3 a q`-3
Notarized Signature of Owner yl 24,0014,0 li LCJ.1.--,,
The foregoing instrument was acknowledged before me this ID day of rV1ar'dt , 2023, in the State of Florida, County
of DJviT.(
Signature of Notary Public
se* VANESSA ANGERS Personally Known OR [ roduced Identification
MY COMMISSION#HH 244118
zf?.;?r,?;- EXPIRES:March 23,2026 Type of Identification: 91.- 1V 24--113-5(0-;8i -Q Sar lAtiii,Sli
Updated 10/24/18
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