303 SARGO RD ACC24-0002 c--------._01,-,itry,, BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
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v City of Atlantic Beach Building Department PERMIT# C1 C Z -DOtoprocess(7Z
\' 800 Seminole Road, Atlantic Beach, FL 32233 **ALL information required
\4.-cm 2' Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address 303 SARGo Qo4) 4Ttf}ri7tc do 'H1 FL 322331 Q RE# 171 04 —6000
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Legal Description RPca P0.(41S OAL.± ZA- '/f L f lZ Elk Z
Valuation of Work(Replacement Cost) ,OC:)'27--c2 Heated/Cooled SF Non-Heated/Cooled SF
•Class of Work: [ New ❑Addition ❑Alteration E]Repair El Move ❑Demo El Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial [v]Residential •If existing structure, is a fire sprinkler system installed?:❑Yes[ No
•Will tree(s)be removed in association with proposed project? El Yes (Must submit separate Tree Removal Permit) �v No
Describe in detail the type of work to be performed:
I NsZAu.'sJ6 A 3'x 3.r y' Conic PEE ?4-j) To INSTALL Aft ANTE-1441 Tot.'t Foe F/4'1''9-t)/O.
Florida Product Approval# (For multiple products use Product Ap royal Information Sheet)
Property Owner Information Name 'DAggeto CoLE2 Phone (90L/) 708'4537
Address 303 SA-,'60 RUN) City i9-rLAv7,C BtGlf State &L Zip 322 33
Email L14QRw.C,oLE'7 eft,CotlOwner or Agent(If Agent, Power of Attorney or Agency Letter Required) aMJ1/
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
INSPE ON. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
(44....10RNE BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
a
(Signature of ner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this `" day of Signed and sworn to(or affirmed)before me this day of
W„o(c wrl , c)-0T by (`('Wn\C\.A. <_oZ , by
Signature of Notary Signature of Notary
[ ] Personally Known OR krProduced Identification [ ] Personally Known OR [ ] Produced Identification
Type of Identification: _ c-'— _ Type of Identification:
ii�Y° TIMOTHY KELLY
.$ : Notary Public-State of Florida
.Wi Commission#NH 489089
°i.�`••` My Comm.Expires Feb 5,2028
01,-v .�� OWNER BUILDER AFFIDAVIT
s City of Atlantic Beach Building Department JOB
i 800 Seminole Road, Atlantic Beach, FL 32233
\0;i�� 303 SI}f�lio Pala) Uln►ADDRESS:S t3ca9cN FL 322;
Phone: (904) 247-5826 Email: Building-Dept@coab.us
**OWNERS MUST PERSONALLY APPEAR AT THE BUILDING DEPARTMENT TO SIGN THIS DOCUMENT**
I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION CONTRACTING" REQUIRES OWNER/ BUILDER
TO ACKNOWLEDGE THE LAW:
To qualify for exemption under this subsection, an owner must personally appear and sign the building permit application and must
satisfy local permitting agency requirements, if any, proving that the owner has a complete understanding of the owner's obligations
under the law as specified in the disclosure statement in this section. However, for purposes of implementing a "United States
Department of Energy SunShot Initiative: Rooftop Solar Challenge" grant and the participation of county and municipal governments,
including local permitting agencies under the jurisdiction of such county and municipal governments, an owner's notarized signature
or personal appearance to sign the permit application is not required for a solar project, as described in subparagraph (a)3., if the
building permit application is submitted electronically to the permitting agency and the owner certifies the application and disclosure
statement using the permitting agency's electronic confirmation system. If any person violates the requirements of this subsection,
the local permitting agency shall withhold final approval, revoke the permit, or pursue any action or remedy for unlicensed activity
against the owner and any person performing work that requires licensure under the permit issued.The local permitting agency shall
provide the person with a disclosure statement in substantially the following form:
DISCLOSURE STATEMENT- Please initial Items 1- 13
1. "- I understand that state law requires construction to be done by a licensed contractor and have applied for an owner-
builder permit under an exemption from the law.The exemption specifies that I, as the owner of the property listed, may act as
myowncontractor with certain restrictions even though I do not have a license.
2. del understand that building permits are not required to be signed by a property owner unless he or she is responsible for
the construction and is not hiring a licensed contractor to assume responsibility.
3. ,1f1'oll understand that, as an owner-builder, I am the responsible party of record on a permit. I understand that I may protect
myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my
own name. I also understand that a contractor is required by law to be licensed in Florida and to list his or her license numbers
on permits and contracts.
4. WI understand that I may build or improve a one-family or two-family residence or a farm outbuilding. I may also build or
improve a commercial building if the costs do not exceed $75,000. The building or residence must be for my own use or
occupancy. It may not be built or substantially improved for sale or lease, unless I am completing the requirements of a building
permit where the contractor listed on the permit substantially completed the project. If a building or residence that I have built
or substantially improved myself is sold or leased within 1 year after the construction is complete, the law will presume that I
built or substantially improved it for sale or lease,which violates the exemption.
5. dl understand that,as the owner-builder, I must provide direct, onsite supervision of the construction.
6. Wunderstand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my
building or residence. It is my responsibility to ensure that the persons whom I employ have the licenses required by law and by
county or municipal ordinance.
7. aq' I understand that it is a frequent practice of unlicensed persons to have the property owner obtain an owner-builder
permit that erroneously implies that the property owner is providing his or her own labor and materials. I, as an owner-builder,
may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or her
employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am
willfully acting as an owner-builder and am aware of the limits of my insurance coverage for injuries to workers on my property.
8. £2 understand that I may not delegate the responsibility for supervising work to a licensed contractor who is not licensed to
perform the work being done. Any person working on my building who is not licensed must work under my direct supervision
and must be employed by me, which means that I must comply with laws requiring the withholding of federal income tax and
social security contributions under the Federal Insurance Contributions Act (FICA) and must provide workers' compensation for
the employee. I understand that my failure to follow these laws may subject me to serious financial risk.
9. Imo" I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern owner-builders as well as employers. I also understand that the construction
mustucomply with all applicable laws,ordinances, building codes, and zoning regulations.
10. �"d I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue
Service, the United States Small Business Administration, the Florida Department of Financial Services, and the Florida
Department of Revenue. I also understand that I may contact the Florida Construction Industry Licensing Board at (850)
487-1395 or the DBPR for more information about licensed contractors.
11. /WI am aware of, and consent to, an owner-builder building permit applied for in my name and understand that I am the
partylegallyand financially responsible for the proposed construction activity at job address listed on this document.
12. WI agree to notify the Atlantic Beach Building Department immediately of any additions, deletions, or changes to any of the
information that I have provided on this disclosure.
13. X Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not
have a license, the Construction Industry Licensing Board and Department of Business and Professional Regulation may be
unable to assist you with any financial loss that you sustain as a result of a complaint. Your only remedy against an unlicensed
contractor may be in civil court. It is also important for you to understand that, if an unlicensed contractor or employee of an
individual or firm is injured while working on your property,you may be held liable for damages. If you obtain an owner-builder
permit and wish to hire a licensed contractor, you will be responsible for verifying whether the contractor is properly licensed
and the status of the contractor's workers' compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and
returned to the local permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the
notarized signature of the property owner, or other type of verification acceptable to the local permitting agency is required
when the permit is issued.
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: 303 5/tR 6O A0O-ti Ae'ltr+'Tic i3e9-WWI, FL 32233 RE#
Owner Name: DA-2R GOU Z Phone Number: (90 N) 70 S'-?S 3 7
Mailing Address: 30 3 54-R60 PON) City: /4-7Li9-N7/ /309-0HState: FL Zip: 3 2 2.33
(Signature of Own r Agent)
Signed and sworn to(or affirmed)before me this `-D day of
1� ,- , `)moi"y by Af`cnf�,!c 6:7412-2
TIMOTHY KELLY
( : `1 Notary Public•State o1 Florida Signature of Notary
L„,70
Commission 8 HH 489089 I [ j Personally Known OR ['Produced Identification
a A My Comm.Expires Feb S,2028
Type of Identification:
MAP SHOWING SURVEY OF
Lot 12, Block 25, as shown on the Replat of part of Royal Palms Unit 2A, as recorded in
Plat Book 31, Pages 16, 16A, 16B, 16C and 16D of the Current Public Records of Duval
For: -Wil-fredo Geiez '
cE B. GOLE2.
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