Permit 393 1st StreetCITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5826
Application Number 10-00000729 Date 6/30/10
Property Address 393 1ST ST
Application type description RESIDENTIAL ADDITION
Property Zoning TO BE UPDATED
Application valuation 2000
----------------------------------------------------------------------------
Application desc
ground level deck
----------------------------------------------------------------------------
Owner
Contractor
------------------------ ------------------------
SIRMANS CHARLYN L OWNER
1715 LEBANON RD
LAWRENCEVILLE GA 30043
--------------------- Structure Information 000 000 ----------------------
Construction Type TYPE 5-A
Occupancy Type RESIDENTIAL
Flood Zone ZONE X
----------------------------------------------------------------------------
Permit BUILDING PERMIT
Additional desc .
Permit Fee 60.00 Plan Check Fee 30.00
Issue Date Valuation 2000
Expiration Date 12/27/10
----------------------------------------------------------------------------
Special Notes and Comments
*2007 FLORIDA BUILDING CODE W/'05-'06 SUPPLEMENTS.
2007 FLORIDA BUILDING CODE - RESIDENTIAL.
2005 NATIONAL ELECTRICAL CODE.
Roll off container company must be on City approved list
and contaner connot be placed on City right-of-way.
Fee summary Charged Paid Credited Due
Permit Fee Total
Plan Check Total
Grand Total
----- --
60.00 --------
60.00
30.00 30.00
90.00 90.00
.00 .00
.00 .00
.00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904} 247-5845
Job Address: 39 3 t! s ~ Sf • /~{1cti~.~-i BeL(.c~t , FL 3 a~3 Permit Number:
Le al Descri tionl~- ~S ~.9~ ~2 -~ t L' 25-2gE •D R/P ~ fz9
g P 7 Fla d=Cam 3 Parcel
oor ea o q. t. q. t
Valuation of Work $ ~~, d yU Proposed Work heated/cooled non-heated/cooled
Class of Work (circle one): New Addition Alteration Repair Move Demolition pooUspa windowJdoor
Use of existing/proposed structure(s) (circle one): Commercial Residential
If an existing structure, is a fire sprinkler system installed? (Cir e): Yes No N /A
Florida Product Approval #
For multiple products use pro uct approva orm i
Describe in detail the type of work to be
I£'~e
Property Owner Information:
Name: ~ {1Gl.~(~ y~ J 1 r-v~~N S
City Lawren ce t'~ le
E-Mail or Fax # (Optional)
Contractor Information:
is,
Company Name:
Address:
Qualifying Agent:
City State
Office Phone Job Site/ Contact Number Fax #
State Certification/Registration #
Architect Name & Phone #
Engineer's Name & Phone #
Fee Simple Title Holder Name and Address
Bonding Company Nasne and Address
Mortgage Lender Name and 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 sus~ppended or ahandoned for a_period of six16) months at any time after
wark is commenced. I understand that separate permits must be secured for EledricaCWork, Plumbing, Signs, Wells, Pools, [[~F'urnaces, Boilers, He ers,
Tanks and Air Conditioners, etc
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 NOTICE OF
COMMENCEMENT.
I hereby certify that I have read and examined this~plication and know the same to be true and correct. All provisions of laws and ordinances governing this
type o work will be complied with whether speci ed herein or not The granting of a permit does not presume to give authority to violate or cancel the
provisions of any other federal, state, or local law regulating construction or the performance of construction.
Signature of Owner ~J~~~~ ~~~j!~y~i!//~
Print Naive
...... ~1Q,r...1~.1'~. ~.~...s~. rW1Gt.CI,S ...........................................
Swo~o and subs •ibed b fore me
this Day of
Signature of Contractor
Frint Naive
Sworn to and subscribed before ine
this Day of , 20
No~uy Public ~Drgrg`~~~' PI„T Notary Pu c
ifll~9-l,~., CO1.Jl"I~T~Y F(?ItGIA
1~~ Ctrsissi~ Ii;r,iDires Ag~ril 1, 2012 Revised 01.26.10
Zip
Address: l ~ /Jr l~hanOh "IQd
Zip30o'~~3 Phone ~'i' ~7'yo Jr /~3 ~ S/ d r ~j `7U -'~'
•5 ~v d, ~ d rY~
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...
J ~S
~, ,.;. '.~1'~ CITY OF ATLANTIC BEACH
~v ®WNER / BUII.,DER 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 REQUIlES 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 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 BUII,T 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.
ill. 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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF,A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT (247-5826) IF IN DOUBT.
V. ACKNOWLEDGEMENT; (HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
X93 /~-T ~~
ADDRESS
~~~~r~~~ ~S~r/~i~~-s
PRINT ME L!~~~
SIGNATURE /
Before me this _ ~ _ day of ~ ~ , 20 `vin the courrty of
Duval, State of Floritla, has personally appeared herin by himself /herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large, State of .~G . Qounty of _~~ .
^ Persopally Known g?!~
duced Identificatio ~~o._;
?ar MMIS IOi~ ~ p
EXPIRES: F brJarv ?4, .U1 V
a '%•...•~P~ ters
~:, p~ ~~ Bondetl 7hru No Pulrl`u. Un e
Notary Signature: `~.-~~ ' -
77 ~ ~~~- 77~v
PHONE NUMBER
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:s!.:~+'~;~~+. City o$ Atlantic taeach
t3uilding ®epartrnent
~l
- ~ 80D Seminole Road
`; ~~ Atlantic Beach, Florida 32233-5445 ,.,-
.-:-~ --
~ ~~ ° Phone (904) 247-5826 Fax (904) 247-5845 --~,, i ~}a.,
~~Jjt ,`" E-mail: building-dept@coab.us .---~-"; ~~ ' ~. ~ ~~
City web-site: http://www.coab.us °'~~~' '' ,~~~(~
~~~j ~
~lPPL~CAI'I®~I R~VI~ ~N® T
l_~-; _ _ _.----
Pr®perty Address: ~~ 3 ~~ ~T~f ~~
Applicant: OGtrn~
Pr®ject: ~~ ~ ,~ -
APPLICATION NUMBER
(To be assigned by the Building Department.)
-~-._ Z c,
Date routed:
EVG ~®R~I
®epartrvsent review required Yes IVo
uild'
& Zonin
Tree Administrator
ub' or
ublic Utilitie
Public Safety
Fire Services
Rev~ew~fee .~ Dept. Signature
Other Agency Review or Permit Required Review or Receipt
of Permit Verified fay Date
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
PLANNING & ZONING Reviewed by:
TREE ADMIN. Second Review: ^Approved as revised. ^Denied.
P~l1/C~.BKS . Comments:
PUBLIC SAFETY
FIRE SERVICES
Reviewed by:
Third Review: ^Approved as revised. ^Denied.
Comme¢~ts:
Reviewed by:
Date: ~' ~'~D
Date:
Date:
Revised OS/14/D9
.i!.:~~~r,J,, City of Atlantic i3each
`~ _~ ~l i3uiiding ®epartrnent
~, ~ - s 800 Seminole Road
;y ,,-~ . ~ Atlantic Beach, Florida 32233-5445
~ ~^--~ Phone (904) 247-5826 Fax (904) 247-5845
• ! Jst yr E-mail: building-dept@coab.us
City web-site: http://www.coab.us
APPLICATION STATUS
roved. ^Denied.
Pr®perty Ae~~-ress:
~9 3 / a-r ~T,e~~,-~
Applicant: ~Gt~~~--
Pr®ject: ~ ~ - AGiGK~.
APPLICATION NUMBER
(To be assigned by the Building Department.)
Date routed: (o /~ /w
®e artrroent review required Yes No
uild'
& Zonin
Tree Administrator
ubl' or
ublic Utilitie
Public Safety
Fire Services
Review fee ~ Dept Signature
Other Agency Review or Permit Required Review or Receipt
of Permit Verified i3y Date
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:
Reviewing Department First Review:
(Circle one.) Comments:
BUILDING
LA NING & ZO G
ADMIN.
PUBLIC WORKS
PUBLIC UTILITIES
PUBLIC SAFETY
FIRE SERVICES
Reviewed by: Date: ~~ ,v 7~~~
Second Review: ^Approved as revised. ^Denied.
Comments:
Reviewed by:
Ti~ird Review: ^Approved as revised
Comments:
^Denied.
Reviewed by:
Date:
Date:
Revised 05/14/09
~5~.:~1~:,yJ,~ City of Atlantic t3each
~ ~,~; 13~aitdilrog ®epartrnent
•r~ I> 800 Seminole Road
~' r~ Atlantic Beach, Florida 32233-5445
:- - .:
~' ~' Phone (904) 247-5826 Fax (904) 247-5845
'~~~a;t ~r E-mail: building-dept@coab.us
City web-site: http://www.coab.us
APPLICATION NUMBER
(To be assigned by the Building Department.)
Date routed: LO /~ /~v
AP~~~CATI®GV R~VI~VV1/ AN® T~A~KIGdG FOR6~1
Pr®perty Address:
Applicant:
X93 /~ ~T,~f~,-~
QGtTY~~~--
®epartrroent review required Yes No
uild'
& Zonin
Tree Administrator
ubl' o
ublic Utilitie
Public Safety
Fire Services
Pr®~ect: ~~ ~ ,~
Review~fee $ Dept,Signature
_..~ ~.~,{,~.y v_.. _.._._
Other Agency Review or Permit Required Review or Receipt
of Permit Verified ~ ®ete
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:
Reviewing Department First Review
(Circle one.) Comments:
BUILDING
PLANNING & ZONING
TREE ADMIN.
PUBLIC WORKS
PUBLIC UTILITIES
PUBLIC SAFETY
FIRE SERVICES
APPLICATION STATUS
roved. ^Denied.
Reviewed by:
Second Review: ^Approved as revised.
Comments:
Reviewed by:
Ti~ird Review: ^Approved as revised. ^Denied.
Coo~vu~uents:
Reviewed by:
enied.
Date: G^ ~"~O
Date:
Date:
Revised 05/14/09
S «1+'J~!
.3 r ~ ,,
,~ SS1
.,.
~; ,r~
J : -~
~J33
City of Atlantic Beach
Building Department
800 Seminole Road
Atlantic Beach, Florida 32233-5445
Phone (904) 247-5826 Fax (904)
E-mail: building-dept@coab.us
City web-site: http://www.coab.us
'~5 ~ ~'l7~Ct
APPLICATION NUMBER
(To be assigned by the Building Department.)
Date routed: (o /~ /~~
Property Address: ~~ 3 ~~ ~T~ef ~-~
Applicant: OGV~~
Project: ,~~ L' ,~
De artment review required Yes IVo
uild'
' & Zonin
Tree Administrator
ubl' o
ublic Utilitie
Public Safety
Fire Services
RevTew~fee ~ Dept Signature
Other Agency Review or Permit Required Review or Receipt
of Permit Verified By Date
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
PLANNING & ZONING : ~/~~ Date: ~ lC~
Reviewed b
y
TREE ADMIN. Second Review: ,Approved as revised. ^Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
AFETY
PUBLICS
Reviewed b ~/`~- Date: ~` f/
Y
FIRE SERVICES 'T'hird Review: ^Approved as revised. ^Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5826
Application Number 10-00000730 Date 6/30/10
Property Address 393 1ST ST
Application type description FENCE PERMIT
Property Zoning TO BE UPDATED
Application valuation 0
----------------------------------------------------------------------------
Application desc
Eft fence
----------------------------------------------------------------------------
Owner Contractor
------------------------ ------------------------
SIRMANS CHARLYN L OWNER
1715 LEBANON RD
LAWRENCEVILLE GA 30043
----------------------------------------------------------------------------
Permit FENCE PERMIT
Additional desc .
Permit Fee 35.00 Plan Check Fee .00
Issue Date Valuation 0
Expiration Date 12/27/10
----------------------------------------------------------------------------
Special Notes and Comments
Roll off container company must be on City approved list
and container cannot be placed on City right-of-way.
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- -------
Permit Fee Total
Plan Check Total
Grand Total
35.00 35.00 .00 .00
.00 .00 .00 .00
35.00 35.00 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH -~_
800 Seminole Road, Atlantic Beach, FL 32233 ~ ~ ~ ~ Q }~
Office (904) 247-5826 Fax (904) 247-5845 ~
Job Address: ,3 ~3 15~ 5{- F}~ lA.rt-~-~'~. ~Qe~ ~L ,3~y,~3 Permit Num
Legal Description Ilo- a-S ~9s 2 ~ - ~~ 1 ~ - 2S- aqs~: Flo d~ ~"` s RAP ~ ~
o"l_ Y ~'arcel #
Valuation of Work $ , O40 u.,w .,L
Proposed Work uy.~ ~.
heated/cooled ~cl.rt
non-heated/cooled
Class of Work (circle one): New Addition Alteration Repair Move Demolition pooUspa window/door
Use of existing/proposed structure(s) (circle one): Commercial Residential
If an existing structure, is a fire sprinkler system installed? (Circle one): Yes No N /A
Florida Product Approval #
For multiple products use pro uct approva orm
Describe in detail the type of work to be performed: J / ~ •~,~- -~e ~ ~ ~,
Property Owner Information:
Name: C~r~ur, L ~ Sir
City L0.ww~.rl.~c Yi ! I P
E=Mail or Fax # (Ontionall !'
/,
Contractor Information: j ~ o
Company Name: Qualifying Agent: /~
Address: City State .
Office Phone Job Site/ Contact Number Fax #
State Certification/Registration # __
Architect Name & Phone #
Engineer's Name & Phone #
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and 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 wild 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 fora eriod of six (6) months at any time a/~er
work is commenced. I understand that separate permits must be secured for EledricaC Work, Plumbing, Signs, ells, Pools, Furnaces, Boilers, Heaters,
Tanks and Air Conditioners, etG
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 NOTICE OF
COMMENCEMENT.
I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this
type o work will be complied with whether sppeci ed herein or not The granting of a permit does not presume to give authority to violate or cancel the
provisions of any other federal, state, or local Zaw regulating construction or the performance of construction.
Signature of Owner ~ _ Si nature of ContraLt~
c g
Print Name C`1.a1/~_~.1~ l'~.......~-.~._....J,.~.r.Y.h..GL.1..:15 ........................ Print Name
Swo to and subscribed before me
this Day o FLF;~°~ZING 20
1~ T i I3
N ary Pu.~1ic~~on pines April 2 12
3iii
Zip
Sworn to and subscribed before ine
this Day of , 20
Notary Pu is
Revised 01.26.10
~f
l
1-
~.
~----
.~
'..,w
%
::.k .
i/c.
>Y~~
~. ;;~~ fir,
~~, ~Y:1` } CITY OF ATLANTIC BEACH
~~ ®WNER /BUILDER AFFIDAVIT
'~~` ~,tia''
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 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 WII,L 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.
ADDRESS PHONE NUMBER
PRIN
. G %~<`vv
SIGNATURE
Before me this _ p _ day of ~ ~. , 20~ in the courriy of
Duval, State of Florida, has personally appeared herin by himself /herself and affirms that
all statements and declarations are tru nd accurate.
Notary Public at Large, State of ~, CouMy of -~~ ~}l~l r <~
^~ ~Per~spnally Known /~ R
L.S-Produced Identification -
.o M DD 957760
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City ®f Atlantic i3each
i3uii~bir~g Cepartrnent
800 Seminole Road
Atlantic Beach, Florida 32233-5445
Phone (904) 247-5826 Fax (904) 247-5845
E-mail: building-dept@coab.us
City web-site; http://www.coab.us
APPLICATION NUMBER
(To be assigned by the Building Department.)
/~ ~ ~ ~ f~
Date routed: ~ / 7 / ~
~~~~~~e~ 1 ~~~ ff`~~~I~WW ~~~i~ ~~~~~fY~6V ~®~~
br®perty Address. ~ ~.~ /~-~ ~~
lppllcant: V ~~ ~'~
'r®~ect: ~
c
® Anent review- required Yes iVo
anning & Zon'
ministrator
ublic Wo
u iic Utiliti
Public Safety
Fire Services
men-~-~ r. ~ ~r -Y^~^ ~ ~ ~...t.....~~.,a.,._.~..w:.r~.~ Y ? ~.~
,Review; ee,,~~~ ,~~~ ~ _.i~.~y.~ Dept S>gna#tare.~~ {x~l .~:,:
Other Agency Review or Permit Required Review or Receipt
of Permit Verified Ry ®ete
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Wafer Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATI4hl STATUS
Reviewing Department I First Review:
(Circle one.) Comments:
BUILDIN
NG & ZO
TREE ADMIN
PUBLIC WORKS
PUBLIC UTILITIES
PUBLIC SAFETY
FIRE SERVICES
^Denied.
Reviewed by: ~,~ i~~'4~~'
Second Review: QApproved as revised. ^Denied.
Comments:
Reviewed by:
Third Review: Approved as revised. ^Denied.
Comments:
Reviewed by:
Date: D6 'D7iD
Date:
Date:
Revised 05114/D9
,r~~~;-d~, City of Atlantic Beach
,:'i ,".~. i3uii~iing ®epartrnent
'~nf~~~~.,;t~ 800 Seminole Road
s 4 .;, . '~` ~} Atlantic Beach, Florida 32233-5445 ~.,.
't~-~' Phone (904} 247-5826 ~ Fax (904} 247-5845 ,......,:--~=`'~•
~Jtt ~r E-mail: building-dept@coab.us _ ~ .~., `°' ~`"~~
City web-site: http:!lwww.coab.us ~~Y~''' ~`± ~,~ Zl ~ ~~~;'st~
~~ __
,~_ -
eppldcant: ~ ~~ ~-~
'ro ject: r-- ~ ~
c
APPLICATION NUMBER
(To be assigned by the Building Dnepartment.)
/~ ~ ~ ~ ~ v
Date routed: ~ / 7 / ~
~~~ F~~~
D ment r~v6ew required Yes No
anning & Zon'
ministrator
ublic Wo
u iic Utiliti
Public Safety
Fire Services
-^~- ~~~-'` ~ ` ~:---,- --~- -~ ~--- --sue ~-, r ~ a ~--r
f~evlew-fee: < u~: r ~~~° ~~ ~ QeptStgna#ure mot. ~ ~_~ kiw+l fl
Other Agency Review or Permit Required Review or Receipt
of Permit Verified i3y Date
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
Reviewring Department First Review: Approved. ^Denied.
(Circle one.) Comments:
BUILDING
PLANNING & ZONING
TREE ADMIN.
P W0R
I UTILITIE
P IC AFETY
FIRE SERVICES
Reviewed by:
Date: ~P -'l~ -/ ~
Second Review: [Approved as revised. Denied.
Comments:
Reviewed by: Date:
~'hird Review: []Approved as revised. ^Denied.
C®mpvuents:
Reviewed by:
Date:
Revised 05/14lQ9
s.a-~`~rd~,.~ City of Atlantic Beech r-...,_~
~`' ~L ~uil~9ing DePartrnent -~-~; ~,~-~-.
firi, ~-y r 800 Seminole Road ~"'~` ~'r '~ ~ ~ ~ _~
;' -- ~~ Atlantic Beach, Florida 32233-5445 i
~ ~,-.., Phone (904} 247-5826 Fax (904) 7-5845 f) ~~ ~t1~~
.~~JSt j°' E-mail: building-dept@coab.us ~•~,~,
City web-site: httpa/www.coab.us °'~----.: -..
property A¢~dress: ~ ~' .~ /a f'~ .~7f
4ppllcent: V ~~ ~-~
Project: lp / % ,,(~~~
APPLICATION NUMBER
(To be assigned by the Building Department.)
/~ - Q ~~ ~
Date routed: ~!~ 7 ~
~~~@~Id7 ~®~~
® ent review required Yes No
anning & Zon'
ministrator
ublic Wor
u lic Utiliti
Public Safety
Fire Services
aRev ew fiee~,~ ~ Dept S gnature_
Other Agency Review or Permit Required Review or Receipt
of Permit Verified ray ®ate
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/LICATION STATUS
Reviewing Department First Review: Approved. ^Denied.
(Circle one.) Comments: )/
BUILDING ~ ~ l(4~~- ~~
PLANNING & ZONING Reviewed by: G~~
TREE ADMIN. Second Review: QApproved as revised. ^Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY
FIRE SERVICES I Third Review:
Coo~arnents:
Reviewed by:
^Approved as revised. ^Denied.
Reviewed by:
Date: ~ ~ ~((~
Date:
Date:
Revised 05/14/09