448 SKATE RD DWAY24-0024 ,i BUILDING PERMIT APPLICATION -
`�t
rt FOR INTERNAL OFFICE USE ONLY
rCi800 Seminole Road, Atlantic Beach, FL 32233ty of Atlantic Beach Building Department
PERMIT#DwcAL(Z4` 6024
**ALL information required to process
ur;i'` Phone: (904) 247-5826 Email:Buildin - ept@coab.us
Job Address // 3g4- !'t�-. 044.„.4,,, 1 ,,,LL irl�c1RE# 1716(.0z-600C
Legal Description pi.Ie.CA e7( s'"hVL a!'(ve..Loccy 0 A i+ZA, L04 19 80, i9
1
Valuation of Work(Replacement Cost)v 21 bo Heated/Cooled SF Non-Heated/Cooled SF
•Class of Work: E New ❑Addition niliAlteration ❑Repair U Move Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial ❑Residential • If existing structure, is a fire sprinkler system installed?:❑Yes E 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:
C-1.1\0 v4a- o I Co r\-C../"QA-t- a.4.-�v—w.1/4,-\ "" ,2,p 1p_c.,t. W-►� .. CAi‘Cy'e..---s•
Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner Information Name Ifj:It i e_ + Evict_ i t yr Phone 0(4 ?0.3- //O O
ivy 76 ,q.-k lid , City -�j c !%L.. State FL Zip 33
Email Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information Name of Company le`rc — T- w c w e NI- Phone
Address City St. • Zip
Qualifying Agent State Certification/Registrati.• •
Email.6efr 1 M;el ccy 6,a (') yr) . Com Job Site Contact Numb:
Worker's Compensation Insurer ` OR Exemp II Expiration Date
Architect's Name Email Phone
Engineer's Name Em.' Phone
Application is hereby made to obtain a permit to do the work an. 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.
Aii,§4a-
(Signature o wner or Agent) (Signature of Contractor)
i ned and sworn to(or a ' med)before me this 3&day of Signed and sworn to(or affirmed) before his day of
Z byft� • , . 0 Lr by
Signature of Notary ik Signature of Notary
[ ] Personally Known OR [ ] Produced Id tification [ ] Personally Known R [ ] Produced Identification
Type of Identification:i:: '. Type of Identification:
eP`��y'�`•. -: TONI GINDLESPERGER
N,
i ,r„ ;*, MY COMMISSION#HH 407122
•tfb Flo?;• EXPIRES:October 6,2027
RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
(r '' ,m, City of Atlantic Beach HIGHLIGHTED IN GRAY IS
Jvz r 800 Seminole Road, Atlantic Beach, FL 32233 REQUIRED.
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
Job Address c g ,c ; e /d• /4-1-ialq ie. Afeelik.:33-43ermit Number
Contractor Information
Company ,, LCh AM ail l'.e Qualifying Agent
Addressed 5k / Ci_ CityIQvt4«C ,AllCI State,'/. Zip 3x 33
Phone .7D 0 gU - i ( O c) Email
State Certification/Registration#
Architect Phone Email
Engineer Phone Email
Workers Compensation Insurers OR ExemptfExpiration Date
• Permittee declares that prior to filing this application they have ascertained the location of all existing utilities, both aerial
and underground and the accurate locations are shown on the sketches.
• Whenever necessary for the construction, repair, improvement, maintenance,safe and efficient operation,alteration or
relocation of all,or any portion of said street or easement as determined by the Public Works Director,any or all said poles,
wires, pipes,cables or other facilities and appurtenances authorized hereunder,shall be immediately removed from said
street or easement or reset or relocated hereon as required by the Public Works Director and at the expense of the
Permittee unless reimbursement is authorized.
• All work shall meet City of Atlantic Beach or Florida Department of Transportation Standards and be performed under the
supervision of ,Eitk Adt A1C �r (Project Superintendent)
with (Company Name) J Phone
• All materials and equipment shall be subject to inspection by the Public Works Director.
• All city property shall be restored to its original condition as far as practical, in keeping with City specifications and the
manner satisfactory to the City.
• A sketch of plans covering details of this installation,as well as a copy of a recent survey shall be made a part of this permit.
Calculations showing any increase in impervious area on owner's lot or in the City right-of-way are to be included with
this application.
• The permittee shall commence actual construction in good faith within days. If the beginning date is more than 60
days from date of permit approval then permittee must review the permit with the Public Works Director to make sure no
changes have occurred in the area that would affect the permitted construction.
• It is understood and agreed that the rights and privileges herein set out are granted only to the extent of the City's right,
title and interest in the land to be entered upon and used by the holder,and the holder will,at all times,assume all risk of
and indemnify,defend and save harmless the City of Atlantic Beach from and against any and all loss,damage and cost of
expenses arising in any manner of the exercise or attempted exercises by the holder of the aforesaid rights and privileges.
• The Public Works Director shall be notified 24 hours prior to starting work and again immediately upon completion.
`` l/t`iQ LieM1 Date
Pe ittee(signed in present of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL G ��
The foregoing instrument was acknowledged this 3 v day of 4�'r C ,20
by" , L4/C' /LIi I'i C e ' l ,who personally appeared before me a
(prtfited name of Permittee)
��""�•y��•., TONI GINDLESPERGER
ackno ged that he/sh igned t e instrument voluntarily for the purpose expressed in .::.i ': = my COMMISSION#HH 407122
�.fiAi
`� .;211:—.°1 EXPIRES:October 6,2027
Eor �°•'
[ ] Personally sown
Signature of Notary Public,State of Flit a [ ] Produced Identification(Type)
H:\Applications&Forms\Word Documents\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
OWNER BUILDER AFFIDAVIT
r City of Atlantic Beach Building Department JOB ADDRESS:
) 800 Seminole Road, Atlantic Beach, FL 32233
-On19'' 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. L /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. 6it) 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. On 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
uilding 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. 44 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. 11/) I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
pplicable 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.t'i evi 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.F;(A 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. 14 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. /(it
13. `(ji 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:4' S Ai, Al/0/4_,` ,8 cA /c j 3 1 RE#
Owner Name: ,�a 4� d_ /t/f !ML'e, Phone Number: `(d4) ?d3_//a0
Mailing Address: 3W ' ro fes'• l7'�k'dt/LliZeacA City: State:4 Zip: 3 2. 3 3
...-,•;;;;;.,
='�?'•=''°`p', TONI GINDLESPERGER po, \(Signature4t Owner or Agent) /'�
s i MY COMMISSION#HH 407122 Signed and worn to(or . `ir ed) before me this L-J day of
��'°` EXPIRES:October 6,2027
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��P, r . bya0 AA
Signature of Notary _ � -IIL _
[ ] Personally Known OR [ ] Produced4
: tification
Type of Identification: ,
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