1679 SEMINOLE RD UNIT 1 RESO24-0017 i1•1-1"`1 BUILDING PERMIT APPLICATION FORINTER'AL OFFICE USE ONLY
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s'' ty of Atlantic Beach Building Department PERMIT# 'IS£SoZ4—OO 17
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800 Seminole Road, Atlantic Beach, FL 32233 **ALL information required to process
9. Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address /6 179 S42,yytjyl,4,1e , ` RE# /QS. -D/OO
Legal Description c2a,,.\ 6c a v e 4A'I I-I L_01-z Ri cD o)R. /`)) 18 -'Z(l
Valuation of Work(Replacement Costj /V/ h p Heated/Cooled SF Non-Heated/Cooled SF
•Class of Work: ❑ New ❑Addition ['Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
•Use of existing/proposed structure(s): ❑Commercial ❑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) ❑ No
Describe in detail the type of work to be performed:
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Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner Information Name 711 ITS U h w o a i.L. Phone ( / &/- L /o2
Address I t'9 D S S Qui ho(e .. i City ,I��L g e State FL Zip 3 Zz?3
e j�O'^wner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information Namedf CompanyPhone
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)---2 / 1 (Signature of Contactor)
Sined and sworn to(or of irme.)before me thiv day f Signed an sworn to(or affirmed) ore me this day of
Fe0 , 0 by�[ �m .4 - _ i �le�
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Signature of Notary • Signature of Notary
[ ]Personally Known OR [ ] Produced Identification [ ] Personally Known/ OR [ ] Produced Identification
Type of Identification: Type of Identification:
"prP TONI GINDLESPERGER
„� *= MY COMMISSION#HH407122
EXPIRES:October 6,2027
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,'=A''I REVOCABLE ENCROACHMENT AGREEMENT
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�+ City of Atlantic Beach **ALL INFORMATION
800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
existing and the laws oftpe State of Florida, ereinafter referred to as "CITY"and
/lit rINL_ V A. w o f of Atlantic Beach, Florida, hereinafter
referred to as "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 e6,V . z k)zl(k_ w - .
Any facility maintained, repaired, erected, and/or installed in the exercise,ef-% a 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 f C. '7 $e_. ,w t..N.T, i& ,'w` A3 t l-.. 3 Z Z 35
• 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 assum d by the USER.
Date Z i 7 0 / Z A
Property Owner/Agent(signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL ,
The foregoing instrument was acknowledged this CT) day of Fe_b , 20 ,
by0t^� U •-1-1 `'" a"Q...._ i
(printed name of Signer),who personally appeared
before me and acknowledged that he/she signed the instrument voluntarily for the purpose expressed in it.
(--1
eyP TONI GINDLESPERGER
:._fa- - • COMMISSION#HH 407122
e'��o?• EXPIRES:October 6,2027
of c..
Department Approval:
Signature of Notary Public,State of F
liti,
[ ]Personally Known
[ ]Produced Identification(Type) . - Public Works Department Date
Revision Date:05/09/2023
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rOwner Builder Affidavit **ALL INFORMATION
(:. ' HIGHLIGHTED IN
Imo• i-,.
City of Atlantic Beach Building Department GRAY IS REQUIRED.
\'J �/ 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: l ? .1`.t „ate, v1�-.k9.`/w�n ( A l.`> , i 7Z Z-
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Owner Name: 1l rswv (JV't.c _.4'v-r0-DL A Phone Number: 1 7 ”'&DY"' 6/0 2..
Mailing Address: J4 7c' Se..tiv�x`61C 6. l City: ,fit 1 -v.-t'i;r: State: Ft., Zip: 3 Z Z.3 '
Notarized Signature of Owner) -
Th oing instument was acknowledged before me this2Cday of — 0 , 2( gin the State of Florida, County
of �
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IP ,
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Sign:::: y:::n:I ]
f ic
° ^ TONIGINDLESPERGER (or'''------"-----
Produced Identification
MY COMMISSION#HH 407122 I
' EXPIRES:October 6,2027
F°`°`°' Type of Identification: I-Mt_
Updated 10/24/18
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