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780 SABALO DR RESO24-0018 erS1=Y''lof,, CityBUILofDINGAtlanticPERMITBeachAPPLICATIONBuilding FOR INTERNAL OFFICE USE ONLY Department , s, PERMIT# RCSDZ�t 00 Ig '' 800 Seminole Road, Atlantic Beach, FL 32233 *ALL information required to process -DR i Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address r i ' YlcA io 4 4 3 I 1 RE# 1-7148Z—boC) �/Legal Description ? o{ p-f 0 C1 c (oJtns U rlc t 7 A Lo-k 13 (j( k 3 Valuation of Work(Replacement Cost) vld Q6 , Heated/Cooled SF Non-Heated/Cooled SF dig s li •Class of Work: ❑ New ❑Addition 'FA Alteration 1=1 Repair 1=1 Move ❑Demo ❑Pool ❑Window/Door • Use of existing/proposed structure(s): ❑Commercial K 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) g No Describe in detail the type of work to be performed: 0 k5,'.�1 (-1 C,(, : (rise far coy - a,-i o* w4 Ovtf Cit.,14 `-i )( ' t D ' €z 4i, __...,0' 1.06iC. t O 45-42 ©dt E X14 i•—( d 60,e Qs-(c;! -744N0 C-(1 ..44'tij. Florida Product Approval# (For multiple products use Product Approval Information Sheet) Property Owner Information Name A j£ I ie,,2_,_ J// Phone 7f7 F''/ LIL,12_ Address 0/, City 4,74,4"/ 0 5�l6c 2,-4 State Zip Z,3j Email L 12i4m,'"A 0It 7.. ,,, Owner or Agent(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 TTORNEY FORE RECORDING YOUR NOTICE OF COMMENCEMENT. (Signature of Owner or Agent) (Signature of Contractor) Wed d sworn to(o . 'rmed)be me s C •ay of Sign:. and sworn to(or affirmed)before me this day of I— ,�, � 4 •y !'� .. • _ m Vby Signature of Notary 0 ��' Signature of Notary [ ] Personally Known OR [ ] Produced Id•nti ication [ ] Personally Known OR [ I Produced Identification Type of'dentificiro."',`-'>. INDLESPERGER Type of Identification: _ n; * MY COMMISSION#HH 407122 ^��� '.,FbF F'4:.P EXPIRES:October 6,2027 (-11.Air?,,-, OWNER BUILDER AFFIDAVIT ,, '; City of Atlantic Beach Building Department JOB ADDRESS: 9 V 800 Seminole Road, Atlantic Beach, FL 32233 ® /� � / ' oa'. 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- (4_ builder permit under an exemption from the law.The exemption specifies that I, as the owner of the property listed, may act as my own contractor with certain restrictions even though I do not have a license. nAIc I 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. 34 I 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. ` I 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. 5.1 I understand that, as the owner-builder, I must provide direct,onsite supervision of the construction. 6. ( " I understand 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. .f-N• 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. I 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. 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 must comply with all applicable laws,ordinances, building codes,and zoning regulations. 10.4' 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.` T I am aware of, and consent to, an owner-builder building permit applied for in my name and understand that I am the party legally and financially responsible for the proposed construction activity at job address listed on this document. 12. ( I 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. 1 j, 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. I Job Address: :%, -..4-y 7�� � •1 RE# Owner Name: Ck, ",sh 2 Phone Number: Mailing Address: -ji51) f14� - / Jj, �--Cify: {a„,, �, 23nL,\ State: (LZ Zip: J Z Z -_.? 41/ ( ( is nature of Ow • or Agent) Ali Si:n-. a d sworn to(. •ffirme )bef.- e this Z day of Signature of Notary gall 1, [ ] Personally Known OR [ ] Produced Id: tification Tq� of Identification: !Pry TONI GINDLESPERGER MY COMMISSION#HH 407122 :^Fo'v F`o"; EXPIRES:October 6,2027 PRODUCT APPROVAL INFORMATION SHEET FOR THE CITY OF ATLANTIC BEACH, FLORIDA (*REQUIRED) a7 O _ I *Project Address: ` 8 C ����� `D G• Permit#: *Owner/Project Name: /LE £ As required by Florida Statute 553.842 and Florida Administrative Code Rule 61G20-3, please provide the information and product approval number(s) for the building components listed below as applicable to the building construction project for the permit number listed above. You should contact your product supplier if you do not know the product approval number for any of the applicable listed products. Information regarding statewide product approval may be obtained at:www.floridabuilding.org. Category/Subcategory Manufacturer Product Description Limitation of Use State# Local# A. EXTERIOR DOORS 1.Swinging « 71 2.Sliding 3.Sectional 4.Garage Roll-Up r `kc?.' 5.Automatic > 6.Other r B.WINDOWS 1.Single hung 2. Horizontal slider 3. Casement 4. Double hung 5. Fixed 6.Awning ),4 `1// x pl i k 7. Pass-through 8. Projected 9. Mullion 10.Wind breaker 11. Dual action 12. Other Page 1 of 4 Updated 06/21/21 Category/Subcategory Manufacturer Product Description Limitation of Use State# Local# C. PANEL WALL 1.Siding 2.Soffits 3. EIFS 4.Storefronts 5. Curtain walls 6.WaN louvers 7.Glass block 8. Membrane 9.Greenhouse 10.Synthetic stucco 11. Other D. ROOFING PRODUCTS 1.Asphalt shingles 2. Umderlayments 3. Rong fasteners 4. Nonstructural metal roof 5. Built-up roofing 6. Modified bitumen 7.Single ply roofing 8. Roofing tiles 9. Roofing insulation 10.Waterproofing 11.Wood shingles/shakes 12. Roofing slate 13. Liquid applied roofing 14. Cement-adhesive coats 15. Roof tile adhesive 16.Spray applied polyurethane roof 17. Other Page 2 of 4 Updated 06/21/21 Category/Subcategory Manufacturer Product Description Limitation of Use State# Local# E.SHUTTERS 1.Accordion 2. Bahama 3.Storm panels 4.Colonial 5. Roll-up 6. Equipment 7.Other F.STRUCTURAL COMPONENTS 1.Wood connector/anchor Ofir cr ,:044-4/c (yL'1U <c 2.Truss plates O 3. Engineered lumber 4. Railing 5. Coolers-freezers 6. Concrete admixtures 7. Material 8. Insulation forms 9. Plastics 10. Deck-roof 11.Wall c7()(41 12.Sheds 13.Other G.SKYLIGHTS 1.Skylight 2.Other H. NEW EXTERIOR ENVELOPE PRODUCTS 1. 2. Page 3 of 4 Updated 06/21/21 In addition to completing the above list of manufacturers, product description and State approval number for the products used on this project, the Contractor shall maintain on the job site and available to the Inspector, a legible copy of each manufacturer's printed specifications and installation instructions along with this Product Approval Sheet. I certify that this product approval list is true and correct to the best of my knowledge. I further certify that use of different components other than the ones listed in this document must be approved by the Building Official. *Contractor Name (Print Name) Z J ` *Contractor Signature: *Company Name: *Mailing Address: n �6 Cx (e' Y ` *City: � *State: *Zip Code: 3 2_Z *Telephone Number:(366'7 rc( c/9 *E-mail Address: Cell Phone Number: 3iZ'( Fax Number: Page 4 of 4 Updated 06/21/21