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1985 MAYPORT RD SIGN24-0003 A Pik -I CQ,7GY1 Su am I rTEf ay I-oQ c,JoJso n yO H -3 4P(0 -a('1 . L BUILDING PERMIT APPLICATION „�l�T,Sdnfb�e3e 6�i�. Cofl') 01-/-,-4 +`�r FOR INTERNAL OFFICE USE ONLY Ci Cty of Atlantic Beach Building Department r PERMIT# IC 24 --bo( 3 890 Seminole Road, Atlantic Beach, FL 32233 **ALL information required to process ''pli 9' Phone: (904) 247-582 mail: : ildin:-De.t ' coab.us �f Job Address l g( C Free `1 gs Q p�� RE# ?a�� l J 6100 Legal Descripti -/W /7",095 We,, .7 /?11&.i R 7 / 2/ of need c/r? /97/Vao95 Valuation of Work(Replacement Cost) / OC, of-- Heated/Cooled SF Non-Heated/Cooled SF •Class of Work: ❑ New ❑Addition ❑Alteration ❑Repair ID Move ❑Demo ❑Pool ['Window/Door • Use of existing/proposed structure(s):JKCommercial ❑Residential • If 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)V No Describe in detail the type of work to be performed: A-lit{- 6f+ toy( b 14fi--u0,,Pe sic A) on FRoI r-of afx,p(i16 . Rei) /Tion✓ /9-t/-e�- re Cp a., eA,'" Q.._ct Florida Product Approval# (For multiple products use Product Approval Information Sheet) Com(71 Property Owner Information Name /9/0e I Phone q y��/p29' 2 9V/ Address M3/�� lea Aka"' 3 City —` e. State`s Zip L,y�1 Email/ 'y /4 d/ 74(c {el erk gent If Agent, Power of Attorney or Agency Letter Required) Contractor 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 BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. (Signature of Owner or Agent) 0.,_i (Signature of Contractor) Signed and sworn to(or affirmed)before me this /2 day of Signed and sworn to(or affirmed)before me this day of f k0--7 , - e zk.f by A Lr- / by Signature of Notary £t Signature of Notary Personally Known OR [ Produced Identification� [ ] Personally Known OR [ ] Produced Identification Ty l'!!1,l hi�Ahedt�c011 evaoat - N\V `{ `\ n_O stir\ Type of Identification: ',F/,• .r; Notary Public-State of Florida ( 'a `i Commission#1-04 056368 <or..? . My Comm.Expires Nov 12,2024 I Bonded through National Notary Assn. ..... - -�mm..-- - /Ma. --4i Owner Builder Affidavit **ALLINFORMATI ON -,,v< —r,, HIGHLIGHTED IN .),5r".1 City of Atlantic Beach Building Department GRAY IS REQUIRED. 800 Seminole Rd, Atlantic Beach, FL 32233 '``fi''4111 •`'r 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. j 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 $5,000 PENALTY UNDER FLORIDA STATUTE NO. 455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY SEE THE COUNTY"CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS CERTIFICATE"TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904- 247-5826 OR BUILDING-DEPT @COAB.US ) IF IN DOUBT. V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT. Job Address: /1('W %y,L ' 16• ,W/a, T/C _l l), C ( ; ,3.,_ Owner Name:/7/i 64/JJ/ //� ,,>> ( Phone Number: 90e-/ 5/421"$/k..)-26/./ Mailing Address: / 5/..7.5- ,L eav- J/ea Yrjcity: JLLX.. State: CZ Zip: , �U� Notarized Signature of Owner % :/l Y 64 The foregoing instrument was acknowledged before me this I '- day of i4,1r-,0..Y ,20.2 1jin the State of Florida, County of j)�-^ ter` \ — l' Signature of Notary Public ,1,- d r [-]Personally Known OR [ ] Produced Identification �'tY p i<' COLETTE.i POORE i Type of Identification: • fir: Notary Public•State o+=lorice i% Commission g NN 056368 or,..c,1!-; My Comm.Expires Nov 12,2014 P Bonded through National Notary Assn. 0 Updated 10/24/18 vzit.,....1trk— "-s.,,wg...-*--;:q .:- - ..... .:.._ .,,,ipz. v.. .. -,,,.....„.„„\- , s. .: ..• . , ...,... ,..._ utvx.„ N3/4-4,-.4.-- —.,44 --vt-.3. 1.....-.... 4.-....4.4-.,, „r**--,-,wi--, vAtiiii,,,,A; ,---,4 ,. :::.-,„ . • • -2,-4, - ,,,,ites.. • ,....; .4.,-....z, ,,,,,:...i.,-,- . '...-, , .,..,-...--,. - -..* -.. <,-.,,;,..11.....„-71.-, •.-it "1,.•_, 41.,,Aliett,':e.; ,-,•..• , ,•;,. 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