190 MAGNOLIA ST RES24-0048 revision 3-8-24 Revision Request/Correction to Comments **ALL INFORMATION
HIGHLIGHTED IN
`s City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
"019)- Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: l� j 24 - b�4�
❑ Revision to Issued Permit OR ❑ Corrections to Comments Date: L
Project Address: \aD ��4,t�\ �a 51c_- (Vv 17c...\\_. 3 2.,Z33
Contractor/Contact Name: l,J‘\\\:4th .5ha-u 51 N\iza
Contact Phone: O‘.py- 41(60-1- A9.00\ Email:
Description of Proposed Revision/Corrections:
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affirm the revision/correction to comments is inclusive of the proposed changes.
(Printed name)
• Will proposed revision/corrections add additional square footage to original submittal?
❑No III Yes (additional s.f. to be added:
• Will proposed revision/corrections add additional increase in building value to original submittal?
❑No ❑*yes (additional increase in building value: $ ) (Contractor must sign if increase in valuation)
*Signature of Contractor/Agent:
(Office Use Only)
Approved I Denied I Not Applicable to Department Permit Fee Due $
Revision/Plan Review Comments
Department Review Required:
Building
Planning&Zoning Reviewed By
Tree Administrator
Public Works
Public Utilities
Public Safety Date
Fire Services updated 10/17/18
�s v,i,,, BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
1J City of Atlantic Beach Building Department PERMIT# �� - �U'-1
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\' i/ 800 Seminole Road, Atlantic Beach, FL 32233 **ALL informatrun required to process
,i 9V Phone: (904) 247-5826 Email:: Building-Dept@coab.us
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Job Address ( N 5N.c?l,c S'tee i RAb,4+.(_Srk EL• ZZ33 REtt 1 .706i 4 -6000
Legal Description 30.1+C)1/4-t' Sec, I Lcr ,4( 0
Valuation of Work(Replacement Cost) . ‘ ‘ '-, ' 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 PResidential • 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) [2'No
Describe in detail the type of work to be performed:
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Florida Product Approval U (For multiple products use Product Approval Information Sheet)
Property Owner Information Name iac,aM &A ,u Mon(i_ Phone (�--) -%jai\ • Il g•C
Address \C J p)pi iC.i t R \(CC'`i City AkIn„A IC UEAC)♦ State EL_ Zip SL..13.3
Email NON F 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/Registrationfl
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.
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(SignatUre-df Owner or Agent) (Signature of Contractor)
Signed and sworn to(or a it ed) before_me this 2,L day of Signed and sworn to(or affirmed)before me this day of
fEli`114ry by v ,.11oh- c \ Ct1 r' , by
Signature of Notary �� - Signature of Notary
[ j Personally KnownII OR [ I Produced Iden ica on I I Personally Known OR [ ] Produced Identification
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Type of Identification: t Type of Identification:
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•`!:� :. TONI GINDLESPERGER
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p` EXCOPIRESISSIOctober 6.
0!...hiv OWNER BUILDER AFFIDAVIT
. '` City of Atlantic Beach Building Department JOB ADDRESS:
800 Seminole Road, Atlantic Beach, FL 32233
"- v°j Phone: (904) 247-5826 Email: Building-Dgpt@'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. k,: 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
my own contractor with certain restrictions even though I do not have a license.
2. ✓ 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.
3. ‘, 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. I. I understand that,as the owner-builder, I must provide direct,onsite supervision of the construction.
6. v. - 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. / 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.