190 Magnolia Street RES24-0048 PermitOWNER:ADDRESS:CITY:STATE:ZIP:
MOORE WILLIAM
SHAUGHN 190 MAGNOLIA ST ATLANTIC BEACH FL 32233-4006
COMPANY:ADDRESS:CITY:STATE:ZIP:
TYPE OF
CONSTRUCTION:
REAL ESTATE
NUMBER:ZONING:BUILDING USE
GROUP:SUBDIVISION:
170614 0000 SALTAIR SEC 01
JOB ADDRESS:PERMIT TYPE:DESCRIPTION: VALUE OF WORK:
190 MAGNOLIA ST RESIDENTIAL SIDING T-111 SIDING ON THE
NORTH & SOUTH SIDE, TRIM $1100.00
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
BLDG 2ND PLAN REVIEW FEE 455-0000-322-1006 0 $50.00
BUILDING PERMIT 455-0000-322-1000 0 $60.00
LIST OF CONDITIONS
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
1 BUILDING IN-PROGRESS INSPECTION REQUIRED INFORMATIONAL
Notes:
IN-PROGRESS INSPECTIONS ARE REQUIRED FOR EXTERIOR SIDING, WINDOW, AND DOOR INSPECTIONS, AND SHOULD BE SCHEDULED FOR THE FIRST
DAY OF WORK.
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 county, and there may be additional permits required from other
governmental entities such as water management districts, state agencies, or federal agencies.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT
IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLORIDA BUILDING
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
1 of 2Issued Date: 3/19/2024
PERMIT NUMBER
RES24-0048
ISSUED: 3/19/2024
EXPIRES: 9/15/2024
RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
BUILDING PLAN CHECK 455-0000-322-1001 0 $30.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.10
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $144.10
2 of 2Issued Date: 3/19/2024
PERMIT NUMBER
RES24-0048
ISSUED: 3/19/2024
EXPIRES: 9/15/2024
RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
Final Plumbing
Final Electrical
Final HVAC
CC Final
Final Building*
Swimming Pool Steel
Swimming Pool Safety
Electrical Grounding & Bonding
Swimming Pool Final (Bldg)
Swimming Pool Final (PW)
Formed Columns/ Beams*
Masonry Cell Fill
Structural Steel*
OTHER:
OTHER:
OTHER:
OTHER:
OTHER:
Power Pole
Silt Fence
Piers/ Stem Walls
Underground Plumbing
Underground Electric
Foundation/ Footing
Slab**
Retaining Wall Footing
Driveway
Sewer (Building Dept)
Sewer Tap (Utilities Dept)
Rough Electric*
Rough Plumbing/ Top Out*
Rough Mechanical*
House Wrap
Wall Sheathing
Roof Sheathing
Tie-down Framing Connections
Rough Framing
Roofing In Progress
Window/Door In-Progress
Insulation Ceiling
Insulation Wall
Exterior Lath
Stucco Scratch Coat
Exterior Siding In-Progress
Brick Flashing & Ties
Early Power
Gas Rough
Gas Final*
* When all rough electric, plumbing, mechanical are complete but before any work is
covered up.
* When all gas piping is complete and wallboard is installed but before gas is
attached to any appliance. All outlets must be capped and pipe pressurized at a
minimum of 15 lbs.
* For new living space: When all construction work including electrical, plumbing,
mechanical, exterior finish, grading, required paving and landscaping is complete
and the building is ready for occupancy, but before being occupied
Additional inspections may apply to your project if your project
contains these elements:
INSPECTIONS REQUIRED FOR BUILDING PERMITS
To verify compliance with building codes, inspections of the work authorized are required at various points of the construction.
The following inspections are typically required for residential projects:
Date: Initial: Date: Initial:
____________________________________________________
Permit No.
___________________________________________________________
Job Address
____________________________________________________
Contractor
POST THIS CARD WITH PERMITS AND PERMIT
DOCUMENTATION IN FRONT OF BUILDING
Construction Hours per City Code: 7am—7pm Weekdays; 9am—7pm Weekends
Building Department Public Works/Utilities Fire Department
Phone: 904-247-5826 Phone: 904-247-5834 Phone: 904-630-4789
Fax: 904-247-5845 Fax: 904-247-5843 Fax: 904-630-4203
* When forms and reinforcing steel, anchor bolts, sleeves and inserts, and all
electrical, plumbing and mechanical work is in place, but before concrete is poured.
* When all structural steel members are in place and all connections are complete,
but before such work is covered or concealed.
** FORM BOARD ELEVATION CERTIFICATE MUST BE ON-SITE FOR SLAB INSPECTION
_____________________________________________________
Permit Type
DESCRIPTION ACCOUNT QTY PAID
PermitTRAK $144.10
RES24-0048 Address: 190 MAGNOLIA ST APN: 170614 0000 $144.10
BLDG SUBSEQUENT PLAN REVIEW FEES $50.00
BLDG 2ND PLAN REVIEW FEE 455-0000-322-1006 0 $50.00
BUILDING $60.00
BUILDING PERMIT 455-0000-322-1000 0 $60.00
BUILDING PLAN REVIEW $30.00
BUILDING PLAN CHECK 455-0000-322-1001 0 $30.00
STATE SURCHARGES $4.10
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.10
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL FEES PAID BY RECEIPT: R26493 $144.10
Printed: Tuesday, March 19, 2024 11:21 AM
Date Paid: Tuesday, March 19, 2024
Paid By: MOORE WILLIAM SHAUGHN
Pay Method: CREDIT CARD 1239740870
1 of 1
Cashier: AG
Cash Register Receipt
City of Atlantic Beach
Receipt Number
R26493
ri- -vi--,, BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USEONLY,`
1CityofAtlanticBeachBuildingDepartmentPERMIT# Z ` d 1 S
800 Seminole Road, Atlantic Beach, FL 32233 ALL information required to process
0't2
v
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address 1 (ID cyNA5kovg sesta?r ( *t4N-tSrk EL. 3Zl33 RE#
Legal Description ge 5;ocntf4,)
Valuation of Work(Replacement Cost) $ I), % 0. ,o 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 12Residential • 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) 12/No
Describe in detail the type of work to be performed:
lacif4 'r tit 5'o;"4 % ShEE-rS ON Nxik5;vc of i-lousC et heels au 5000.1
of u5E• 1`1( I'I"T v.\Ike 04‹,c.meir-Onl Mor* .. SIf. y_ IDsIx4 {3 •U k'ici4"
Souk VflE of t.1at-)sE 3- ‘ ky k tQ' E I1- 1,‘ 1-1 )( % '
Florida Product Approval# For multiple products use Product Approval Information Sheet)
Property Owner Information Name 'Atiplfn JkA 4,4 i (L Phone Cipi-1 -1-W4 - li
Address 1 rx-)A 4 iq S7( T City 1 iC Ea State L Zip 32233
Email ND N F
3
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 befound 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.
cJWnnti t'Niluch,,,% `M.corF_
Signatbr -df Owner or Agent) Signature of Contractor)
Signed and sworn to(or a ir' ed)before meth' , day of Signed and sworn to(or affirmed)before me this day of
fEboil-r by ALAIN 1.i., = • -by
Signature of Notary Q,Signature of Notary
I Personally Known OR [ I Produced Iden 'ica on Personally Known OR [ ] Produced Identification
Type of Identification:Type of Identification:
ZB<., TONT GINDLESPERGER
Ir. ::
t• MY COMMISSION#HH 407122
i EXPIRES:October 6,2027
Vr1 +•P1 OWNER BUILDER AFFIDAVIT
S
Cityty of Atlantic Beach Building Department JOB ADDRESS:
r f)
v800 Seminole Road, Atlantic Beach, FL 32233
of - 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. s. ' 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. t 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. V 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. /1 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. V 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. V 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.
13.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: 19D ingq„,b`;R 5 (ici H-414eKii f,rf ck FL. 233 RE#
Owner Name: [
11:n;AM SkAt141,,i McnrE Phone Number: q'py_Lgt}_Li
Mailing Address: `'1J) mc'c 0\i ,A S,-, City:AA`A,Aic (jrAe i, State:cL Zip: 32233
a.,-.,,,:-:__
TONI GINDLESPERGER r
u ''- MY COMMISSION#HH 407122 vi.,,:Sign of Owner or Agent)
FOF..ocs EXPIRES:October 6,2027 r
Signed and sworn to(or •rmed)before me this ,&-L.o day of
Signature of Notary c/
Personally Known OR [ ] Produced Id ti ication
Type of Identification: .. .
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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:
4\ \)P r k e4) A.V1.1;vu0) ts" C ?c4r-\ 'a4 i,c r..
p± DO "OkrA4P.
l" rot.Ark r)nc til\ 5-'0 c)5 •
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'-1E g
i/ 800 Seminole Road, Atlantic Beach, FL 32233
ALL informatrun required to process
i 9V Phone: (904) 247-5826 Email:: Building-Dept@coab.us
COcJobAddress ( 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:
0144-,"43 'r_ ttt 5 ;oI..d) — 1O S1-1E.-rS oNN-^r.0k5i-.0 cri-1uuSEICI Sheets o^.t SnoklA
5iorc AF %-k° AE • '1( Li"T9'ir"i-ke(%\alrcm,F.4 •ont Mor es S'inc, Li- ID. 1x4 {3 - t . *4-
6 t_ftly\ cane cc uc)L.)4E 3- \ Nt4 k \d' c 11- ix ti x R '
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.
11,11fh'. '\AU !-yr ,,r `CVkcc;1 f`
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
1TypeofIdentification:
t
Type of Identification:
p4;:TONI GINDLESPERGER
A4.''MY MMON t+HH420072;22
p` EXCOPIRESISSIOctober 6.
0!...hiv OWNER BUILDER AFFIDAVIT
City of Atlantic Beach Building Department JOB ADDRESS:
800 Seminole Road, Atlantic Beach, FL 32233v°
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.