65 19th St DWAY23-0062 - Application Ys'--vi,, BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
�R v City of Atlantic Beach Building Department PERMIT# 1Jb�i A`�23--- U0L�
0 " 800 Seminole Road, Atlantic Beach, FL 32233
**ALL information required to process
>
ar phone: (904) 247-5826 Email: Building-DeptPcoab.us
Job Address t / I�t4-k- ST / o?
. RE# 4. 9 3 -/1990
Legal Description /7-g/ O ? -.q5 - (99C• `7 ' 0r '1 11/44h'6 gelte'1a/1i/ 34P E-.40047-Lora, ' OicT
ha r
Valuation of Work(Replacement Cost)4 13 l��o Heated/Cooled SF Non-Heated/Cooled SF
•Class of Work: ❑ New El Addition NIAlteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial gResidential • If existing structure, is a fire sprinkler system installed?:❑Yes1No
•Will tree(s)be removed in association with proposed project? ❑Yes (Must submit separate Tree Removal Permit) 1KNo
Describe in detail the type of work to be performed:
Rasp l s x,S-i-,) ) C' / r e- cc. -c9- pox>cr" w' '•- rIac-�/e_y5. �1
✓p 1J e v <, eS 7r S C4 are ke ��e.'�
Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner Information Name Pa._,J,_ IVA(4-4--1.-.1/V (`—_ Phone '0(-1 1(3)- lq y
Address (c 5 /o1 4-4^- .. City 4 • State Fz.,_ Zip 2 3-- 3 3
L
Email el,‘`[�N r‘,k ,(yMci1. Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contract, Information Name of Company Phone
Address City State Zip
Qualifying Agent State Certification/Registration#
Email Job Site Contact Number
Worker's Compensation Insurer OR Exempt ❑ Expiration Date
Architect's Name Email Phone
Engineer's Name Email Phone
Application is hereby made to obtain a permit to do the work 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 city/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 YOU PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT
MUST BE RECORDED AND POSTED ON THE SITE OF THE IMPROVEMENT BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BE ORE RECORDING YOUR NOTICE OF COMMENCEMENT.
A6<S), /Y._ ___________
(Signature • • ne e Agent) 3 15+ (Signature of Contractor)
Sind and sworn to(or affir ed) before me this day of Signed and sworn to(or affirmed) before me this day of
OC he✓' , 20 -23 by P it MG. I nc l , by
Signature of Notary -P97v7Q -.ea Signature of Notary
[ ) Personally Known OR [ Produced Identification [ •- ••. .•• • • •a • •• ed Identification
(%L PKI Vey, `iCZviSe DONNA L.BARTLE
Type of Identification: Type ,f• a ti, 3t yISS1ON#itFt985656_
/11352 -6.8'7- CU S '_U ),-41-.g., EXPIRES:May 14,2025
''Fo':'Fy?"• Bonded Thru Notary Public Underemters
**ALL INFORMATION
rt'--�%�,, Owner Builder Affidavit HIGHLIGHTED IN
s City of Atlantic Beach Building Department GRAY IS REQUIRED.
o
73 800 Seminole Rd, Atlantic Beach, FL 32233 ��
°fSVP Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: M 123—C(7IL'2_
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: �m z
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.
ob Address: (05 /1
M
L Phone Number: 49� 1 `�
)caner Name: ��-�,� / r t �"�
C l i State: � — Zip, 2L3 3
Mailing Address: 6,5 lc, J '� City: ` ,
Notarized Signature ofe /v
Nota g Owner
-fhe foregoing instrument was acknowledged before me this day of OCIV her , 20 23, in the State of Florida, County
Of Duval
/ �G�2Signature of Notary Public 04-tA'1_et
D0
my BARTLE
t.1YC04MISSION#HH085656 [ ] Personally Known OR [ Produced Identification
{).,;.: EXPIRES:May 14,2025 j
-
�' Bonded Thru Notary Public Underwriters
Type of Identification: L Driver ,/'`�^ - `�' 05 3—a
Updated 10/24/18
NOTICE OF COMMENCEMENT
State of �� Tax Folio No. /l 9 723'/0i/o
County of 1)
To Whom It May Concern:
The undersigned hereby informs you that improvements will be made to certain real property, and in accordance with Section 713
of the Florida Statutes,the following information is stated in this NOTICE OF COMMENCEMENT.
Legal Description of property being improved: LI 1 -1 I 01'- 2 S -2_9 E - i ( y COMMENCEMENT. .
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e Q_,c_eN w 3 ( p C i o FT L WI— 3 tJ H 0 FT Lc LI
Address of property being improved: 6, S j 1' S
General description of improvements: Re t� e - L Y` s 4---,::�� Co^ s ce � 4'f'
Vc.../.2_7c f `Ve w ct 4-L_ v \fC(-5r —
Owner: ...v...� �ek`�"`F`�i Address: CO 5 (9-4" S 4--
Owner's interest in site of the improvement:
Fee Simple Titleholder(if other than owner):
Name:
moc o
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Contractor: �k,Wiei 72 /DA V(-4 / ll&eS rnO°c000c
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6�s- /q ��3 Pi 2a a3 2
ro2
Address: Q j G' v;0i c
-vo-6 (6) Fax No: II o 0 _rn
Telephone No.: r
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Surety(if any) m m
Address: Amount of Bond$ 0 4, x
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Telephone No: Fax No: c
Name and address of any person making�a loan for the construction of the improvements o 2
Name: 0.,-v\ r° 4�4-1 �5``� ....,o
Address: (, I +� 91 5'
D
Phone No: Cie`I �-1 S �o 9 1 5 Fax No: r
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other docum
be served:Name:
Address:
Telephone No: Fax No:
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section
713.06(2)(b),Florida Statues. (Fill in at Owner's option)
Name: —
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is one (1)year from the date of recording unless a different date is
specified):
7-4,4-.i
///
THIS SPACE FOR RECORDER'S USE ONLY OWNER , �J /
Signed: �Q1t/YL6( �•//y3")------C-
THIS
Date: I �3I/ZQZ.3
Before me this 31S-1- day of OC fit' 2023 1 the Coy�nty of Duval,lllState
Of Florida,has personally appeared ( ( M(4 h5/�(
"''"wDONNA BARTLE Notary Public at Large,State of Florida County of Duval. �J
r}t ° : _
'_•: `�� '•`• �OOMMISSIONN HH 085656 My commission expires: /� � � ZD ZS
'. .n. ` or
;:-'�"'�: EXPIRES:Ma 14,2025
—
•'•EOff`�t`• Y Personally Known:
Bonded NuNotary Public Underwkers Produced Identification: FL til ver L JCe✓I se
435Z .- 6t7-61, - 053 -0
MAP SHOWING BOUNDARY SURVEY OF
THE EAST 10 FEET OF LOT 3, AND THE WEST 40 FEET OF LOT 4
A REPLAT OF TRACT A P(ORTH ATLAN1T1 C BEACH UNIT
ACCORDING TO THE PLAT THEREOF RECORDED IN PLAT BOOK 47, PAGES 91 AND 91A,
CERTIFIED TO: OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA.
PAUL G. MATTINGLY, II AND LYNN M. MATTINGLY, HOME POINT FINANCIAL CORPORATION,
FIRST AMERICAN TITLE INSURANCE COMPANY AND GIBRALTAR TITLE SERVICES, LLC
TRACT I"3"
SEMINOLE DUNES
O.R.B. 5793, PAGE 776
1/2- N 89'45'52" E 50.00' (C) 5/8. 1/2"
IRON PIPE
REBAR N 89'48'46- E 50.00' (M) PSM 4690 (CHR)
0.8'X r°.i' ,0, SUBDIVISION BOUNDARY 0,8•-.1 x y0.1' 0.47' E'LY
f fir'-IH 0 T 0 0' ).._-L7—64 20.00' (R)
50.00' (R) ON UNE 10.00' (R)I TUB x-1.5'
(WALL) II
PAVER - STEPS ;:-.-- 0
RETAINER - __ .- --^ - • ID-........1.I
WALL W000= -7-1 1, ROCK
0 _:DECK— _
0.2' 10: '
(WA)..0 24.0' D
WOOD llSNOWER I 2
1_ n STEPS 'ter CC
0.6-1 ;,...?.6'..._ ,'� r.`` �' 7.6b..
5.4• 2-STORY 5.3•
o ip STUCCO PAVER I) vo
0 0 0.1 -.1 NO. 65 WALK I o
00 0.6'- o 0 o •20.1' l o` 0
12.2' a 0
�� O 1 o � / r = W
WEST 50' 3 w 0- m SECOND STORY t
OF LOT 3 to �9. CONC 7,3COVD ' OVER CAR PORT Nw
w �/�BLOCK \ N D3
CO CD m 7.7... /\1 �'ALLS \ 7.6'.. o O
,,,/// 7.3'
UPPER WOOD 7 o .,
•
g ROCK E❑❑ DECK OVER tO "'
CAR PORT
z CONC �Qa� - 5 b ,�
O PAVERS O I O ( 1.8•
PAVER
o N
Z 4
in ., WEST 0' DRIVE
o F-m OF LOT 4 M _AST 20'
I--
fOF LOT 4
w0 V�-
I CONC �--'
WATERLINE EASEMENT / DRIVE
AS PER O.R.B. 5372. PAGE 831 /// i._4R
144
_ rrt 9' „ti
'n 50.00' (R) •10.00' (R)1 40.00' (R)
—OU—OU—OU—OU— U-- OU OU—OU • OU
1/2 GE OF PAVEMENT 5/8• N 89'41'07' W 193.25' (M) N&D
IRON PIPE REBAR N 89'45'52' W 193.20' (C)
LS 3848 BEARING REFERENCE PSM 4690
S 89'45'52' W 49.89' (M)
S 89'45'52" W 50.00' (C)
19TH STREET
(40' R/W)
FLOCO ZONE-X" - AREAS DETERMINED TO BE OUTSIDE THE 0.2%ANNUAL CHANCE FLOOD PLAIN / FLOOD ZONE "X(SHADED)" - AREAS CF 0.2%ANNUAL CHANCE FLOOD: AREAS OF 1%ANNUAL
CHANCE NM AVERAGE DEPTHS OF IFAS THAN 1 FOOT OR WIN DRAINAGE AREAS LESS THAN 1 SQUARE MILE: AND AREAS PROTECTED BY LEWES FROM 1%ANNUAL CHANCE FLOOD.
v E Y 0 GENERAL NOTES:
ca, 1. BEPRINGS ARE BASED ON PLAT BOOK 47, PAGE 91 A.
J % s 2. STRUCTURE NO. 55 SHOWN HEREON UES WHIN FLOC() ZONES BEST DETERMINED
CO FROM F.E.M.A. FL000 MAPS PANEL N0.407 DATED 06-03-2013
ASSOCIATED SURVEYORS INC■ 3. THIS ISA SURFACE SURVEY ONLY. THE EXTENT OF UNDERGROUND FOOTINGS, PIPES AND
U1?J1ES, IF ANY, NOT OETrJW'NEO.
4. JURISDICTIONAL AND/OR ENVIRONMENTALLY SENSITIVE AREAS IF ANY, NOT LOCATED BY THIS SJRVI
I LAND A ENGINEERING SURVEYS 5. THIS SURVEYfBASED ON LEGAL DESCRIPTIONS FURNISHED. BLI
RNISHED. THE PUC RECORDS WERE