Permit 378 6th St °J 800 Seminole Road
;. , : t o Atlantic Beach, Florida 32233
; Telephone (904) 247 -5800
FAX (904) 247 -5845
Oil 1
June 9, 2011
Darwin Roth and Barbara O'Reilly
378 6th Street
Atlantic Beach, Florida 32233
Re: Expired Building Permit /Siding — 378 6 Street, Atlantic Beach, Florida
Permit #10-142
Dear Mr. Roth and Dr. O'Reilly:
Please be advised, this letter is to inform you that permit number 10 -142- issued for work
at the above referenced address has or will expire on June 21,2011 in accordance with the
Florida Building Code Section 105.4.1 which states "Every permit shall become invalid
unless the work authorized by such permit is commenced within six months after its
issuance, or if the work authorized by such permit is suspended or abandoned for a period
of six months after the time the work is commenced." Work is considered abandoned
when an approved inspection is not obtained within a six -month period.
Failure to obtain an approved inspection within the next thirty days will result in
additional fees being required to renew your permit as required by Section 6- 26(a)(9) of
the City of Atlantic Beach Code of Ordinances to wit:
Building permit renewal fee:
Completed inspections Amount of renewal fee
No inspection conducted 100% of original fee
Slab inspection approved 80% of original fee
All rough inspections approved 50% of original fee
Insulation inspection approved 30% of original fee
Your cooperation is requested, if you have any questions, or need additional information
please contact my office at 904 - 247 -5826. l
• Sincerely, l
t.,
Michael Griffin, CBO, CFM 1
BUILDING OFFICIAL I � ∎ ,/
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CITY OF ATLANTIC BEACH
800 5EMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5826
Application Number 10-00000141 Date 2/10/10
Property Address 378 6TH ST
Application type description ROOF PERMIT
Property Zoning TO BE UPDATED
Application valuation 2204
----------------------------------------------------------------------------
Application desc
REROOF
----------------------------------------------------------------------------
Owner
------------------------
ROTH
378 6TH STREET
ATLANTIC BEACH FL 32233
Contractor
------------------------
OWNER
----------------------------------------------------------------------------
Permit ROOF PERMIT
Additional desc .
Permit Fee 65.00 Plan Check Fee .00
Issue Date Valuation 2204
Expiration Date 8/09/10
----------------------------------------------------------------------------
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total
Plan Check Total
Grand Total
65.00 65.00 .00 .00
.00 .00 .00 .00
65.00 65.00 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
...
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Date:
Job Address:
Owner of Property: _
Address:
Roof Contractor:
Contractor's Address:
CITY OF ATLANTIC BEACH
ROOFING PERMIT APPLICATION
cl
4
Telephone: ~ c~ f - (.7 ~f`'[ (/ Fax: Email:
Scope of Work: 1~,~ ,C ~'c, ~ Roofing Material
FL Product Approval # ~`' ~ ~ J I ~ ~ ~ ~ Valuation of Work: $ ~7if7 T. / ~
Required Inspections: Sheathing /In Progress-Dry In /Final
If re-roof: Assessed Value of Structure: _ < $300,000/_>$300,000; Roof-to-wall improvements required?
( Applies to single family structures only)
Sworn to and subscribed before me this
State of Florida, County of Duval
"WARNING TO OWNER: YOUR FAILURE TO RECORD 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 IN ~f?CTIO F,~'OU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE REC /NG R OTCE OF COMMENCEMENT" (~ ff11- M
j ~ ~ ~ LJ IJ
SIGNATURE OF OWNER: ~, Date: ~° /~ D
AS TO OWNER: ~ FEB 10 2010
~p ~ day of 20 ~v
Notary's Signature:
'Personally known
'` (] Produced identification
I Type of identification pi
F
SIGNATURE OF CONTRACTOR: Date:
!0//d
~Db 4126
18St'~fiY~~'
PuW1c~UndilWrkef!
~~~ryNOaN
~c~ad~
FEB 10 2010
AS TO CONTRACTOR: ~ UU '-'
Sworn to and subscribed before me this ~~ ~ day of 20l ~ ~V
State of Florida, County of Duval ~ /I BY
Notary's Signature: ~•t
Personally known ~~~
~ Produced identification r L~"' 06BOHR~~ND0834128
.~ MYGOMM M~ @1 g~ii
Type of identification produced ~` ' ~t Y .
dlhru ~N~uhl~UntleNl~B
' ~ ~,.~
800 Seminole Road • Atlantic Beach, Florida 32233-5445
Telephone: (904) 247-5800 • Fax: (904) 247-5845
F:\roof permit applicaton 2010
10-V/~l
Telephone: ~ ~/ " ~/,~~~j1
License Number: ""-
DISCOUNT DIRECT METAL ROOFING, INC
9169 New Berlin Road
Jacksonville, FL 32226
Ph: 904-696-9700 Fax: 904-696-9039
www.ddmetal.com
Bill To Invoice
Da~ R~ h ~ / ,(
/l7 ,IL~/,~ S~'r Pe G'
Date Invoice #
Q ~ f d~ ti G ~eQ ~ '` r
I_ lj ~ 2 33 2/5/2010 14834
m ~~ ~ FL Approval #
FL4541-R1
Phone PO Number Due Date Terms
519-0056 2/5/2010
Quantity Description Price Each Amount
520 26 Ga. Color Panel CHARCOAL 26X18' 4X13' 2.75 1,430.OOT
5 Ridge Cap Standard 5/12 17.50 87.50T
13 Trim-Gables 12.50 162.50T
1 Valley Flashing 22.50 22.50T
28 Inside Closures 1.50 42.OOT
28 Outside Closures 1.50 42.OOT
1,560 2" Color Screws 0.12 187.20T
120 1/4x7/8 D-Color Lap Screws for Ridge 0.10 12.OOT
1 Delivery Charge 80.00 80.00
Sales Tax 7.00% 139.00
4" ~, ~-~
<f~ ~"~-
Balance Due $2,204.70
Caution--Wear protective gear when handling panels, metal roofing may have sharp edges! Do not
handle panels in high wind, avoid contact with electric lines. Do Not cut panels with a Skil Saw or other
rotary devices. Clean all screw shavings from panels. Do not stack Galvalume products outside without
a cover, water will cause electrolysis within the stack and will ruin your panels a d warranty. This
product meets Florida Product Approval requirements. FL Approval #4541. -- ~tf
~s ~f , + ~ ~
r ~ ~ CITY OF ATLANTIC BEACH
`~ - ~ ' ®WNER /BUILDER AFFIDAVIT
;r:>,.,•
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 BUII.,D OR IMPROVE AONE - 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
TT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY NOT
HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR YOUR CONSTRUCTION MUST
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 MUNICII'AL LICENSING
ORDINANCES.
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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT (247-5826) IF IN DOUBT.
V. ACKNOWLEDGEMENT; (HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
-~ ~ - ~~~~d~J~
ADDRE~£r> PHONE NUMBER
t~
PRINT NAME
ID / D
SIGNATURE DATE
Before me this /" ~ ay of 20~ in the county of
Duval, State of Florida, has personally appeared h rin by himself /herself and affirms that
all statements and declarations are/trDue and accurate.
Notary Public at Large, State of`^ ~"~ ~ ,Count of~~ ~ ~ ----~_
D
ersonally Known y ~~• MY COMMN # DD 634126
Produced Identification - EXPIRES: May 2011
P,f„ - BorKied Thru Note 21,
,' / W` ry ~ Underwriters
Notary Si~nature• L~/~ /Gt..
F:BLDG/Owner-Builder Aft'adavit; REVISED: 4/16/2009
SKETCH/AREA TABLE ADDENDUM
Property Address 3786th. Street
City Atlantic Beach State 1=lorida
Borrower Darwin Roth & Barbara O'Reilly
Lender/Client Comcass Bank - Sherrv
Duval
A
16.8'
........................
t:
10.1' E~;~~'~i`4f~@$R~{.' ~;:FI
t
E~:
19.6 ti~i>';:?i ~ i<:iiS~'x~>3~ i
........................
.......................
Bedroom Kitchen Dining
Bath Area
30.2'
Bedroom Bedroom
35.8'
11.3'
me rvv. CiUB
!Code 32233
10.1'
15.9
Family Room
13.2'
14.2'
SCALE: finch = 12.00 feet
AREA CALCULATIONS SUMMARY
Area Name of Area Size Totals
GLA1 First floor 1298.96 1298.96
PiP Wood Deck 160.46
P/P Screened Porch 169.b8 330.14
GAR Garage c4~.00 240.00
TOTAL LIVABLE (rounded) ~ 1299
Coast Appraisal Service
LIVING AREA CALCULATIONS
Breakdown Subtotals
52.30 X 13.20 b90.3b
35.80 X 17.00 bO8.b0
1299
MCS. a Oivk(en of AC1 i7iwateem~nt tatY11a07J7a4
2009 NOTICE OF AD VALOREM TAXES Si NON AD VALOREM ASSESSMENTS
REAL ESTATE PROPERTY TAX
DUVAL COUNTY/CITY OF JACKSONVILLE
MIKE HOGAN, TAX COLLECTOR
231 E FORSYTH STREET ROOM 130 JACKSONVILLE, FL 32202-3370
TAX COLLECTOR INQUIRIES: (904) 630-1916
WEB SITE: www.COj.net/tc
7 - 41511
ROTH DARWIN R & BARBARA M
OREILLY
378 6TH ST
ATLANTIC BEACH FL 32233-5348
I~i~~iii~ilnl~~ullnil~~i~~liii~li~lii~~u~i~n~~l~~~iu~~~~
ACCOUNT NUMBER: 169874-0000
FOLIO NUMBER: 1329104.0000
PAYOR CODE/NAME: 000202-COMPASS BANK
LOCATION ADDRESS: 378 6TH ST
32233
LEGAL DESCRIPTION:
5-69 16-2S-29E
ATLANTIC BEACH
W1/2 LOT 31,LOT 33 BLK 7
DO NOT PAY- INFORMATIONAL NOTICE ONLY
THIS TAX BILL HAS BEEN SENT TO YOUR ESCROW AGENT.
AD VALOREM TAXES
ASSESSED EXEMPT TAXABLE TAXING MILEAGE TAX EXEMPTIONS
SING AUTHORITY VALUES VALUE $ VALUE 3 DISTRICT RATE AMOUNT $ P LIE
CITY OF JACKSONVILLE 371392 50000 321392 USD3 5.4480 1750.94
ST JOHNS RIVER WTR M6MT DIST 371392 50000 321392 USD3 0.4158 133.63
FL INLAND NAVIGATION 371392
50000
321392
USD3
0.0345
11.09 HX,HB
USO 3 371392 50000 321392 USD3 3.1553 1014.09
SCHOOLS 371392 25000 346392 USD3 7.5820 2628.35
AD VALOREM TOTALS 16.6356 5536.10
NON-AD VALOREM ASSESSMENTS REMARKS:
AUTHORITY PURPOSE A OUNT
IF PAID BY: NOV 30 2009 DEC 31 2009 JAN 31 2010 FEB 28 2010 MAR 31 2010
4% DISC 3% DISC 2% DISC 1 % DISC GROSS AMT
PLEASE PAY: s 5314.66 i 5370.02 t 5425.38 S 5480.74 S 5536.10
MAKE CHECKS PAYABLE TO MIKE HOGAN, TAX COLLECTOR
IF PAYING THROUGH AN ONLINE BILL PAYMENT SERVICE, USE THIS ACCOUNT NUMBER: 169874-0000
Please detach and return bottom section with payment. This becomes a receipt after validation.
DUVAL COUNTY/CITY OF JACKSONVILLE 2009 REAL ESTATE TAX NOTICE
ACCOUNT NUMBER:
FOLIO NUMBER:
PAYOR CODElNAME:
TAXING DISTRICT:
OWNER NAME:
LOCATION ADDRESS
169874-0000
1329104.0000
000202-COMPASS BANK
USD3
ROTH DARWIN R & BARBARA M
:378 6TH ST
32233
MIKE HOGAN, TAX COLLECTOR
231 E FORSYTH ST STE 130
JACKSONVILLE FL 32202-0370
1..11...I.I..I~III~~~~~I~I~~11~~~11~1~~~111~~~1~1~~1~1~~11~~~1
IF PAID BY: PLEASE PAY:
DO NOT PAY INFORMATIONAL
NOTICE ONLY -THIS TAX BILL HAS BEEN
SENT TO YOUR ESCROW AGENT.
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5826
Application Number 10-00000142 Date 2/10/10
Property Address 378 6TH ST
Application type description SIDING PERMIT
Property Zoning TO BE UPDATED
Application valuation 600
----------------------------------------------------------------------------
Application desc
SIDING
Owner
------------------------
ROTH
378 6TH STREET
ATLANTIC BEACH FL 32233
Contractor
------------------------
OWNER
-----------------------
Permit --------------------------------
BUILDING PERMIT ---------------------
Additional desc .
Permit Fee 55.00 Plan Check Fee 27.50
Issue Date Valuation 600
Expiration Date 8/09/10
-----------------------
Fee summary
----------------- ---------------
Charged
---------- -- -----------------
Paid Credit ---------------------
ed Due
Permit Fee Total
55.00 -------- -------
55.00 --- ----------
.00 .00
Plan Check Total 27.50 27.50 .00 .00
Grand Total 82.50 82.50 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
F ~ '' CITY OF ATLANTIC BEACH
_~ ~~~ 800 SEMWOLE ROAD, ATLANTIC BEACH, FL 32233
OFFICE: (904)247-5826 ~ FAX NO.:(904)247-5645
`' ~ VWNN.COAB.US
lti~.l -~
''~~~' BUILDING PERMIT APPLICATION
10- ...____~_~..~~__.~__~..___~
nl ninl (`rlI IAITV
1. J09 ADE~tESS 2. VALUATION OF 1hORIC 3 SQ. ~ UNDER ROOF
3 o 1,2 v~
4_ LEGAL DESCRIPTION- 5. CLA55 OF'~IvORK 8. USEGF STRUCTURE:
~ t ~I E~ 3 ^ NEW BUILDING ^ DEMOLITION ~ "~i ~•i- IAL
LOT _ t ~ r ;P. ~ e C :' ^ ADDITION ^ CONVERTING USE ^ ' ~+~~r ?CIAL
7. DESCRIPTION OF NORY, ^ ALTERATION ^ ACCESSORY BLDG. B FlRE SPRINKLER.
^ REPAIR ^ POOL /SPA ^ ~ _5 ^ i. -.
~ ^ MOVE THER NO
PR ERTY OWNER: CONTRACTOR: ARCHITE T I ENGINEER:
9. NAME: ~
15. COMPANY NAME: 23. COMPANY NAME:
//\~
~
/
_I /may ~~ (~ 16. NAME: 24. LICENSEE NAME:
:/ ~'a..
70. ADDRESS: 17. STATE OF FLORIDA LICENSE NO.: 25. STATE OF FLORIDA LICENSE NO.:
~`
3 ~ S ~ ~
~
re e
5 18. ADDRESS: 26
ADDRESS:
.
11. OFF H NE;
~~ 12. FAX NO.: 19. OFFICE PHONE: 20. FAX NO.: 27. OFFICE PHONE: 28. FAX NO.:
13. CELL PHONE: 21. CELL PHONE: 29. CELL PHONE:
14. EMAIL ADORES
~ .EMAIL ADDRESS: 30. EMAIL ADDRESS:
e' Q Yt! .~r
~ @
FEE SIMPLE TITLE HO DER:
pF OTHER THAN 041M~R1 BONDING COMPANY: MORTGAGE LENDER:
31. NAME: 33. NAME: 35. NAME:
32. ADDRESS: 34. ADDRESS: 36. ADDRESS:
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 laws regulating construction in this
jurisdiction. This permit becomes null and void if work is not commenced within six (6) months, or if construction or work is suspended or
abandoned for a period of six (6) months at any time after work is commenced. I understand that separate permits must be secured for
Electrical Work, Plumbing, Signs, Wetls, Poois, Furnaces, Boilers, Heaters, Tanks, 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. I will not occupy or use the referenced building or any part therof, until all inspections are finaled and
prior to obtaining a certificate of occupancy or completion issued by the building official, as required by law.
*** 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 AT ORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
O o GENT CONTRACTOR
(it Aflenoy L~terRegcared) laualfier o+~y)
Signed: pate: l ~ ~ Signed: Date:
Before me this day of , 2010 in the county of Before me this day of , 2010 in the county of
Duval, State of Florida, has personall appeared Duval, State of Florida, has personally appeared
herin by himself /herself and affirms that all statements and declarations are herin by himself /herself and affirms that all statements and declarations are
true and accurate. ~j ~,-,, ~
Notary Public at Large
State of
~
County of ~~~ "" ~ true and accurate.
Nota
P
blic
t L
St
t
f
C
,
,
, ry
u
a
arge,
a
e o
,
ounty of
ersonally Known - ~ ^ Personally Known
Produced Identifi o ^ Produced Identification -
Notary Signature: - il.J Notary Signature:
,'+R1~r riiy~: DEBORAH A. WHITE
*: ,~ MY COMMISSION # DD 634126
~`• o'= EXPIRES: May 21, 2011
'%fpP~~~~~ Bonded Thro Notary Public Underwmers
Bldg Permit Application 20
sue.
v ~,
~, ~ ~~ CITY OF ATLANTIC BEACH
~' - ~ ®WNER /BUILDER AFFIDAVIT
~ilJita''
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 IIvIPROVE 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
HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR YOUR CONSTRUCTION MUST
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.
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. TELEPHONE THE
BUILDING DEPARTMENT (247-5826) IF IN DOUBT.
V. ACKNOWLEDGEMENT; THEREBY 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.
3
~ LJ ~ ~
g i-Q~~o
PHONE NUMBER
PRINT NAME
SIGNATURE - ~ ~
/
Before me this ~ day of , 2a l ~ in the county of
Duval, State of Florida, has perso Ily ppeared h rin by himself /herself and affirms that
all statements and declarations are true and accu e.
Nota
P
bli
t L
St
t f~ ~
r^^
ry
u
c a
arge,
a
- ounty of
~
personally Known ~
^ Produced Identification - u
~, ~~
Notary Signature:
0 ~
DATE
mpIRES'MaYZ ~~ ~i2s
~ry P u~a~'NterB
F:/BLDG/Owner-Builder Affadavit; REVISED: 4/16/2009