574 N NAUTICAL BLVD RESO24-0035 .,:o-APP,,,,, BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
:.t'3 ~ City of Atlantic Beach Building Department PERMIT# R.G�z "0 �
''-';WAY, 800 Seminole Road, Atlantic Beach, FL 32233
**ALL information required to process
.JS . Phone: 904) 247-5826 Emil: Building-Dept(Wcoab.us
Job Address 57'1 /raj-kJ DVA' RE# /Z77o3-03sa
Legal Description 35-69 / 7- 2.+S- a/ F. Sc s r /o t Lt fJjk
Valuation of Work(Replacement Cost) biz 000 Heated/Cooled SF Non-Heated/Cooled SF
•Class of Work: 27New ❑Addition ❑AlterationRepair ❑Move EDemo ❑Pool E Window/Door
•Use of existing/proposed structure(s): E]Commercial [)Residential • If existing structure, is a fire sprinkler system install ?:❑Yes❑No
•Will tree(s) be removed in association with proposed project? 171 Yes (Must submit separate Tree Removal Permit) [i No
Describe in detail the type of work to be performed:
-aq7 StPav,fS Rck_v e 92.1-1.0I�Z Surer'Sco.fC XL-
-50D
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Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner Information Namf 6 k ���p /J, fw, Phone --7/01)6.
Address Sly Afwt ,;ix
B IVci N l I City AR State Zip
Email Cbi/6/(oh-Roy{„p;o,,p ( Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
� i• .(01%,
Contractor Information Name of Company Phone
Address City State Zip
Qualifying Agent State Certif : ion/Registration#
Email J•• ite 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 . permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance , 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.
67-01
-of Owner or Agent) (Signature of •ntractor)
S(ied and sworn to(.4,y irmed)b- ore me this ZCS�p day of Signed and sworn to(or affir• ed)before me this day of
1 1 \a ro-k , T1 V I by�� _. I.. A%LA ISO(\ by
Signature of Notary Signature of Not.
[ ] Personally Known OR [ ] Produced I.4 tification [ ] Pers. ally Known OR [ I Produced Identification
Type of . Type of I.-ntification:
-v4•,
.,a:. - �`��:•., TONT GINDLESPERGER
,,q MY COMMISSION#HH 407122
`• PEXPIRES:October 6,2027
",'#;5,•i**
OWNER BUILDER AFFIDAVIT
City of Atlantic Beach Building Department JOB ADDRESS:
l " 800 Seminole Road, Atlantic Beach, FL 32233
�7 �p/G�ko /j(
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. CT- 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. Cfi 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. cT 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. Ck 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. CT I understand that, as the owner-builder, I must provide direct,onsite supervision of the construction.
6. (T 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.
9. Cl 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. 61r 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. Cr 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. CT 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. C\ 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: 574 #04/4-%1-*- \ BI V G/U RE# 17070 3.. 0:75,d,
Owner Name: 6a )( 1.11OVs"r,fw• Phone Number: Ai,' -7/ -9.9g5
Mailing Address: ,rj/41A/J-`'1 Ij[v� !" City: /4,R State: Zip:
TONI GINDLESP / (Sig 'TIT—of Owner or Agent)
-'= ERGER
MY COMMISSION#HH 4071P sday of
Aa:• and sw. n to(ora ed) bef• me this
EXPIRES:October 6,2027 t t' •
Signature of Notary ','fir
[ ] Personally Known OR [ ] Produced I. tification
Type of Identification: ' • ��
1 1111111.11111111
PROPERTY ADDRESS:574 NAUTICAL BOULEVARD N, ATLANTIC BEACH,FLORIDA 32233 SURVEY NUMBER: 2312 3867
2312.3867
BOUNDARY SURVEY
DUVAL COUNTY
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SURVEYOR'S NOTES:
SETBACK INFORMATION SHOWN ON PLAT,NOT VERIFIED re " o 15 30
FENCE OWNERSHIP NOT DETERMINED. > Sha' 1')
D.U.S.E.-DRAINAGE,UTILITY AND SEWER EASEMENT GRAPHIC SCALE(In Feet)
1 inch=30'ft.
SURVEYORS CERTIFICATION: POINTS OF INTEREST:
1.WOOD SHED OVER 10' D.U.S.E. 2.b'WOOD FENCE
```oottttlttttft77ko, I hereby certify that this Survey of the lands OVER 10'D.U.S.E.
`
p`�W. wq4 i'; described hereon was made under my direct •
c3 ��Num Ze.e.�� supervision,and to the best of my knowledge
> LS 6473'•' C S and belief is a true and accurate representation
' i of said lands and meets the Standards of
_ //�11 , , Practice set forth in Chapter 5J-15.050 through A
-. W' 5J-15.053,Florida Administrative Code, •EXACTA
O )Q pursuant to section 472.027,Florida Statutes. Exacta Land Surveyors,LLC
�� w
STATE ? This survey is not valid without the signature and . ElaLand SurvsyanUC 18P
, 8291
4, FLORIDA Q o:866.735.1916 f 866.744.2882
`r/O original raised seal of a Florida licensed surveyor 131 West Broadway Street Suite 1001.Oviedo.Ft3276s
,414 SURVE� O ������� signatu a and sealexcept
of awhen
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ed surveyor
ILEGA[IDESCRIPTION:
LOT 4, BLOCK 3,SEASPRAY,ACCORDING TO THE MAP OR PLAT THEREOF,AS RECORDED IN PLAT BOOK 35, PAGES 64 AND 64A,OF THE CURRENT
PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA.
GENERAL SURVEYOR NOTES:
1. The Legal Description used to perform this survey was 5. Alterations to this survey map and report by other than the the field location and may not represent the actual shape
supplied by others.This survey does not determine signing surveyor are prohibited. or size of the feature.
nor imply ownership of the lands or any fences shown
hereon.Unless the Title Commitment Number is 6. Dimensions are in feet and decimals thereof. 11. Points of Interest(P01's)are select above-ground
referenced on this survey,an examination of the abstract 7. Any FEMA flood zone data contained on this survey is for improvements,which may appear in conflict with
of title was NOT performed bythe signing surveyor to boundary,building setback or easement lines,as defined
9 9 Y informational purposes only.Research to obtain said data
determine which instruments,if any,are affecting this was performed at www.fema.gov and may not reflect the by the parameters of this survey.These P01's may not
property. most recent information. represent all items of interest to the viewer.There may
be additional P01's which are not shown or called-out as
2. The purpose of this survey is to establish the boundary of 8. Unless otherwise noted"SIRC"indicates a Set Iron Rebar POI's,or which are otherwise unknown to the surveyor.
the lands described by the legal description provided and with a Cap stamped LB88291,a minimum half inch in
to depict the visible improvements thereon for a pending diameter and eighteen inches long. 12. Utilitiesdcttheshew)ontthe subject recorded or u may or may not
financial transaction.Underground footings,utilities,or indicate existence of or unrecorded
other service lines,including root eave overhangs were not 9. If you are reading this survey in an electronic format,the utility easements.
located as part of this survey.Unless specifically stated information contained on this document is only valid if this 13. The information contained on this survey has been
otherwise the purpose and intent of this survey is not for any document is electronically signed as specified in Chapter performed exclusively by and is the sole responsibility of
construction activities or future planning. 5J17.062(3)of the Florida Administrative Code and Florida Exacta Land Surveyors,LLC.Additional logos or references
Statute 472.025.The Electronic Signature File related to this to third party firms are for informational purposes only.
3. If there is a septic tank or drain field shown on this survey, document is prominently displayed on the invoice for this
the location depicted hereon was either shown to the survey which is sent under separate cover.Manually signed 14. Pursuant to F.S.558.0035,an individual employee or
surveyor by a third party or it was estimated by visual and sealed logs of all survey signature files are kept in the agent may not be held individually liable for negligence.
above ground inspection.No excavation was performed to office of the performing surveyor.
determine its location. 15. Due to varying construction standards,building
10. The symbols reflected in the legend and on this survey dimensions are approximate and are not intended to be
4 This survey is exdusivelyfor a pending financial transaction and may have been enlarged or reduced for clarity.The used for new construction or planning.
only to be used by the parties to whom it is certified symbols have been plotted at the approximate center of
SURVEYOR'S LEGEND
LINETYPES Elevation C/P-Covered Porch FIR-FoundlronRod ORB-Official Records Book 51W-Sidewalk
---- C/S-Concrete Slab FIRC-Found Iron Rod&Cap ORV-Official Record Volume SBL-Setback Line
Boundary Line ityFire Hydrant _ CATV-Cable TV Riser FN-Found Nail 0/A-Overall SCL-Survey Closure Line
— -Center Line • Find or Set CB-Concrete Block FN&D-Found Nail&Disc 0/S-Offset SCR-Screen
-x-rr+ChainLinkorWire Monument
CH-Chord Bearing FRRSPK-Found Rail Road OFF-Outside Subject Property SEC-Section
Fence i;— Guywire or Anchor_ CHIM-Chimney Spike
--
OH-Overhang SEP-Septic Tank
- Easement O Manhole CLF-Chain Link Fence GAR-Garage OHL-Overhead Utility Lines SEW-Sewer
---'—_ Edge of Water ® Tree CME-Canal Maintenance GM-Gas Meter OHWL-OrdinaryHighWater SIRC-SetlronRod&Cap
-0-4: Iron Fence * Utility or Light Pole Easement ID-Identification Line SMWE-Storm Water
.--011---Overhead Lines ® Well CO-Clean Out IE/EE-Ingress/Egress Easement ON-Inside Subject Property Management Easement
-- ---- - CONC-Concrete ILL-Illegible P/E-Pool Equipment SN&D-Set Nail and Disc
Structure ABBREVIATIONS COR-Corner INST-Instrument PB-Plat Book SQFT-Square Feet
-----SurveYTie Une (C)-Calculated CS/W-ConcreteSidewalk INT-Intersection PC-Point of Curvature STL-Survey Tie Line
-o-0-#.--vinyl Fence (DI-Deed CUE-Control Utility Easement IRRE-Irrigation Easement PCC-Point of Compound STY-Story
..... 1 Watt or Party Wall (F)-Field CVG•Concrete Valley Gutter L-Length Curvature SV-Sewer Valve
I .e' Wood Fence
(M)-Measured D/W-Driveway LAE-Limited Access Easement PCP-Permanent Control Point SWE-SidewalkEasement
(Pt-Plat DE-Drainage Easement LBC-License No,(Business) PI-Point of Intersection TBM-Temporary Bench Mark
SURFACE TYPES PLS-Professional Land
(R)-Record DF-Drain Field LBE-LimitedBufferEasement TEL-Telephone Facilities
Surveyor
Asphalt (5)-Survey DH-Drill Hole LE-Landscape Easement TOB-Top of Bank
Brick or TilePLT-Planter
_ A/C-Air Conditioning DUE"Drainage&Utility LME-Lake/Landscape TUE-Technological Utility
- •• Concrete AE-Access Easement Easement Maintenance Easement POB-Point of Beginning Easement
ELEV-Elevation L58-LicenseNo.(Surve(Surveyor) POC-Point of Commencement TWp-
Covered Area ANE"Anchor EasementY Township
PRC-Point of Reverse
ASBL-AccessorySetbackLine EM-Electric Meter MB-Map Book TX-Transformer
///""" Water Curvature
-- B/W-Bay/Box Window ENCL-Enclosure ME-Maintenance Easement TYP-Typical
Wood PRM-Permanent Reference
��-/` BC-BlockCorner ENT-Entrance MES-Mitered End Section Monument UE-Utility Easement
SYMBOLS BFP-BackflowPreventer EOP-EdgeofPavement MF-Metal Fence PSM-Professional Surveyor UG-Underground
Benchmark BLDG-Building EOW-Edge of Water MH-Manhole &Mapper UP"Utility Pole
Y Center Line BLK-Block ESMT-Easement MHWL-Mean High Water Line PT-Point of Tangency UR-Utility Riser
QCentral Angle or BM-Benchmark EUB-Electric Utility Box NR-Non-Radial PUE-Public Utility Easement VF-Vinyl Fence
Delta BR-Bearing Reference F/DH-Found Drill Hole NTS-Not to Scale R-Radius or Radial W/C-Witness Corner
�r Common BRL-Building Restriction Line FCM•Found Concrete NAVDBB-North American R/W-Right of Way W/F-Water Filter
1.......4
Ownership BSMT-Basement Monument Vertical Datum 1988 RES-Residential WF-Wood Fence
A Control Point C-Curve FF-Finished Floor NGVD29-National Geodetic ROE-Range WM-Water Meter/Valve Box
-- FIP-Found Iron Pipe Vertical Datum 1929
® Catch Basin C/L-CenterLine OG-On Ground ROE"Roof Overhang Easement WV-Water valve
— - _- FIPC-FoundIronPipe&Cap RP-Radius Point
CERTIFIED TO: FLOOD ZONE INFORMATION:
CODY&HEATHER THOMPSON;LANDMARK TITLE;FIDELITY NATIONAL BY PERFORMING A SEARCH WITH THE LOCAL GOVERNING
TITLE INSURANCE COMPANY;BANK OF ENGLAND MUNICIPALITY OR WWW.FEMA.GOV,THE PROPERTY APPEARS TO BE
LOCATED IN ZONE X.THIS PROPERTY WAS FOUND IN CITY OF ATLANTIC
BEACH,COMMUNITY NUMBER 120075,PANEL NUMBER 0408 DATED
11/02/2018.
DATE SIGNED: 01/17/24
BUYER: CODY&HEATHER THOMPSON