1912 Oak Circle 17-FNCE-3709 s,ari;y�� City of Atlantic Beach APPLICATION NUMBER
(6'? t� Building Department (To be assigned by the Building Department.)
;., 800 Seminole Road i _F„J Lt 3 1--ci
j`v� , Atlantic Beach, Florida 32233-5445 !� II
Phone(904)247-5826 • Fax(904)247-5845 Date routed: b''o9- 1 a--
�J;319' E-mail: building-dept@coab.us
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: lona OGt,K c_t,i ctk_ Department review required Yes
pp No
uidl f—
A
Applicant: 0 Wf\t / Planning &Zoning
CUL( Tree Administra or
Project: itlattt.Q,. Ij -V-DO-k LA)ook -nLQ public Work
s7)
N\ (itecUtiliti
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Approved. ❑Denied.
(Circle one.) Comments:
:UILDING
PLANNING & ZONING
Reviewed by: )/ Data '1 7/ 7
TREE ADMIN. Second Review: Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
Building Permit Application ►.,privir,r., -0 —
City of Atlantic Beach
ut800 Seminole Road, Atlantic Beach, FL 32233757 .4) �a , nri ;
°�' yr Phone: (904) 247-5826 Fax: (904) 247-5845 6-4_,..2 `.., ' :;,, . y
Job Address: I 11 DAV, Lf 2.j( Permit Number: II— FNC6 3-1
Legal Description RE#
Valuation of Work(Replacement Cost)$ /�7 OO`'a Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): OS Addition Alteration Repair Move De Pool Window/Door
• Use of existing/proposed structure(s)(Circle one): Commercial esidentia
• If an existing structure, is a fire sprinkler system installed?(Circle one): Yes No N/A
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work to be performed:
4,LX(il OA c) 1 0°Oa& )3 F' -i.J C- -)\- K4--tA ---1-00A iLl‘/Y1 ei_12
Florida Product Approval# for multiple products use product aproval form
Property Owner Information , /'
Name: j A6 ; ce _ Address: � ��,� J? V ' PC:_, e
City :fi k ■ State /, Zip n Phone 9OLP
E-Mail ��-f' ' C 1r 3,.bgen?' et't ^C�''` ".1 (A IJIT(l"
Owner or Agent(If Agen , Power of Attorney or Agenc Lehr Required)
Contractor Information
Name of Company: Qualifying Agent: J ,
Address City 3tatle -° `7iij u w [- .'i�
Office Phone Job Site/Contact Number
State Certification/Registration# E-Mail APR 7 2017Architect Name& Phone#
Engineer's Name&Phone#
Workers Compensation _
Exempt/Insurer/Lease Employees/Expiration Date
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 regulationg
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.
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 YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR OT CE OF COMMENCEMENT.
--14-6')I‘AL\ eL
(Signature o ner or Agent including Contractor) (Signature of Contractor)
Si ned and sworn to r affirmed)before me this i t--day of Signed and sworn to(or affirmed) before me this day of
�; . ` ,) by ,by
.0' JENNIFER JOHNST• :
a, .• MY COMMISSION*Gs
' -' M' .: EXPIRES:October 27, ,,r `ign.� re of Notary) (Signature of Notary)
",:*:Vo' Bonded Nu Notary Public Underwriters
[ ]Personally Known OR [ ]Personally Known OR
1)4]Produced Identificatior? [ I Produced Identification
Type of Identification: K 1 J Q-t '_� 11 C-f o 1 () Type of Identification:
'r,rD1!
14114;rte �` CITY OF ATLANTIC BEACH
s
(OWNER / BUILDER AFFIDAVIT
•
I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION
CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.103(7),FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED
CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPTION TO THAT
LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY,TO ACT AS
YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST
SUPERVISE THE CONSTRUCTION YOURSELF. YOU MAY BUILD OR IMPROVE A ONE-OR
TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD OR >""'
IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS. THE BUILDING
MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE.
IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR
AFTER THE CONSTRUCTION IS COMPLETE, THE LAW WILL PRESUME THAT YOU BUILT
IT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY NOT LU
HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST I--
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. IT IS
YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE
LICENSES REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING
ORDINANCES. CD
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. EL!
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER A
CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE N = J CO
455-228(1). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALIM V01 0
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTOFS. Q 02 H
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE TM LU H a
BUILDING DEPARTMENT(247-5826) IF IN DOUBT. 0 CO O O Q
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSUFW < G CI
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF VI cc 2
OWNER-BUILDER PERMIT. 0 0
ADDRE1SS OK- C1 wle PH�iNUMBERR5? 9`10g a
S {L
OD AYE' . "IL
-
PRI ' 1 111
�L/ :. ` _Iles/ 1 g
SIGT URE DAT:
at
Before me this day o A• n 1 ,20 lain the county of
Duval,State of Florida,has personally appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of Ft_ ,County of tAkki4 I ,.K;?. JENNIFER JOHNSTON
-• , 'L MY COMMISSION#GG 042984
❑Personally Known 911 • EXPIRES:October 27,2020
Produced Identification- 11� { S 1� �Y tJ i /1;;-:=7Bonded Ttw Notary Public Underwriters
_► -- I
Notary Signature:
F:BLDG/Owner-Builder Affadavit;REVISED:4/16/2009
e?/-JoNPz'
,, .r. EB6 101 1011Ai1S ant '531 1011011 . 6z.o/-/ AF/1e/72g7v/v//
''' . . ,----i--7/-0-i;;;;---/ )c•,...:-., _ BERG '1 1 3111
' :, - 00 -�/ ]1YMS
/ 9L6 'OF 1.70 1110
1018011 ']111AMOsaOYr •S113113101313 Cl 31Y 31311 Cl!
- ', ' ' 1011113 3A011 311 11 1HOIS SY SIMYI 311
- S/1OA3A/10S ONY1 'SNI ''Q1AYi'f HIM03 0313511S 3A11 1 1111 A111131 113131 1
97Jd'/J a'b'0
•
• .479.9r
- -.- ---, I o----- • --od/1.100
•
. do
c? O H Aa
. 74,/7t 2' _4---,', ' .c9/_1 _INO?.. _ ' . w \ -7'.a Sd
E.,,,
2861 6 . . 1"' a N vz ti t o
CI o
• ,9 t'� ; o� a.� 'Zi:
1.111p771%,... ti� 9 �� 37NPC,S?3' ° ..
as.. -•IAGV �, �:-s'v ' .• 1"Z -
1Vdtl 'I) •P N-- it1S z A •
�q r), .,.�� ,0.6: /i"
.N F Kl ,
.0 . 'f� '.p.,-'�X) if •51,2pC1 'V
yam../� ---
'Ci 'ill- a.' "Ai! '-' (1) ii, '14 --• O ,-14rL _._._--
:dssrl. 6"e. .oar , ,v .»y1 °J • I
' 0 tc i/ 0 .
•
. 'L ,o /J
-.. I' 2861 £ ZZ>,adV • N
1.13tl39 3Illd i' Alli n
Cl3A\ 2id ='`d /
.\...\.A-; .V:Q s�
CA \ 1111 ti
— 1 s34,1 Not H 0 3
. 'Y018013 ' A1NI100
—7/7•4720 30 5080331 011901 3H1 30 ;=, 33Yd v61002 !Y14 NI 030/10338 SY
Ado0 �le�eor _
-• _ 6'-2/ a/V 1/N/? bN/d'b'!/Y b/735 I f 107 ---
JO A3AIIOS ONIMOHS dbW . . .
Sim,-.4., City of Atlantic Beach APPLICATION NUMBER
is r � Building Department (To be assigned by the Building Department.)
.A. _:E 800 Seminole Road , I _�, I L` _
�� Atlantic Beach, Florida 32233-5445 .. /v G j
J* Phone(904)247-5826 • Fax(904)24 45
o;ii0. E-mail: building-dept@coab.us 4 R 1 0 2011 f ' Date routed: LI IOM(II
City web site: http://www.coab.us
BY ji
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1 9 1 a o ct,k CA.- r CIC Department review required Yes No
uidi
Applicant: 0 w Pla"nning &Zoning
re Tree Adminis ra or
Project: ,k L ��.A,L.Q, U —V-Do-\--o-\ uJ O okn V 1LQ Cublic Works
Ca- 5+S V1 cAttuo L Public Public Safety .
Fire Services
Review fee $ Dept Signature `)cry
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Approved. ❑Denied.
(Circle one.) Comments: �/
BUILDING '" /Pt-
PLANNING &ZONING Reviewed by: Date: i �(/ 17
TREE ADMIN. Second Review: A roved as revised.
❑ pp ❑Denied.
_ C WORD Comments:
PUBLI TILITIES
cf /if)'7
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: Approved as revised. I (Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
S1..Ly;l� City of Atlantic Beach APPLICATION NUMBER
��s Building Department (To be assigned by the Building Department.)
800 Seminole Road C'E'll _� C1--Flt (- _ _1
s Atlantic Beach, Florida 32233-54 „� ) G
my)
Phone(904)247-5826 Fax(9 24d ! 109-111"�r I�
"!�,3i,r E-mail: building dept@coab.us Q 201? Date routed: ll4
City web-site: http://www.coab. �Y---
�
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1 4 1 a, o ct Ct r L l-C De artment review required Yes No
ui di
Applicant: 0 w A Planning &Zoning')
I (�� Tree Administrator
Project: it� c1LL (I —V-Dto-� i,)0 OP-r) CC . Cublic Works
dIrgrangrS�
CQ-- SAV V\ Cit-OL0�,2- _
Public Safety •
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
. Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APP ICATION STATUS
Reviewing Department First Review: Approved. I 1Denied. Q .149;17
(Circle one.) Comments: fee Airteigi W/� l?/
getIY
BUILDING / 4242—
PLANNING & ZONING
Reviewed by: i Date Y
L
TREE ADMIN. Second Review: Approved as revised. ❑Deni d.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: QApproved as revised. ❑Denied.
Comments:
Reviewed by: Date: I
•
Revised 05/14/09
MAP SNOWING SURVEY OF
LOT /1 SEL Y!Q /1/1/1X7/N4 UN/T N'_ /2-.41 "- -
AS RECORDED IN PLAT BOOK -36 PAGE 6.4 OF THE PUBLIC RECORDS OF OU -4e—..
COUNTY , FLORIDA.
FOR TOM IVES 7- ____
41, lk
\ /\(?-/‘ e
? k\?N 1.11111.."'-- ) ',,/ A.; PR�J169 �VED
n 'Cj'� rY CITY iF ATL INTIC BEACH
,s-csD �,,� 11 n+ �� 4�l 8 ILDIpNG OFFICE
\� V ' APR3 1982- , -_.
6)"'-- -
J ' F.c•••-• ' to
.�c)T6
to1 e, T/ieev. Az. ,e,a. ,3 9.i,,ras''
/ "sf,« o4' 4-4e
1.. IN o (1/ Deeks. .4 (X)14,d,c. -Aes .
W -A H, f�A-�.�v5i
_i.: /9.ON �G,„ ,,% h4- �? .d
O
vi 2 STY. --�; Q• q, AP"! s BY SPECIAL
2.; %.F".2AME \ ADVI;�' '11' r13 'I.RD -
R.55/OENCE a 2c G' Qti .-.411,1
.S Wow
O o a`��1
ti 22.c.:' ' �0 .0 i
`, - N Q . Lni:: • 19 1981 _
O 2/a' / Q
2.5'8.,e, -e,
ri v t,
ti oQti 0
o FQ .Q
/S/6' 3 '551Y (� 1,-encs --_.
OAK C//PCL E _
I IEREDY CERTIFY TRAT I RAVE SIRYEYEP EDWIN J.TAYLOR, INC. LAND SURVEYORS
TIE LARDS AS SROYII II IRE ABOVE CAPTIOI JACKSONVILLE. fIORIDA /
ARP THERE ARE ID EICROACRMERTS.
DATE OCT 30, /978
SCALE / 30 - ,,, /
FI I E II. 78 78 _(<,,...-/x..,..:.�u1-�f„ ' •, , :' •• •..
/7VAL 5e-IRYEY ,/-/D-79
- FLORIDA RM LARD SIRYET01 u. 983 ,
F8 N� C-I?