Permit Bldg Bath Remodel 1854 Seminole 2010 LA
' CITY OF ATLANTIC BEACH 0.
A
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5826
Application Number 10- 00001329 Date 11/02/10
Property Address 1854 SEMINOLE RD
Application type description RESIDENTIAL OTHER
Property Zoning TO BE UPDATED
Application valuation . . . 5000
Application desc
BATHROOM REMODEL
Owner Contractor
MCKENNA WILLIAM OWNER
1854 SEMINOLE RD
JACKSONVILLE FL 32209
Permit BUILDING PERMIT
Additional desc . BATH REMODEL
Permit Fee . . . 75.00 Plan Check Fee . . 37.50
Issue Date . . . Valuation . . . . 5000
Expiration Date . 5/01/11
Other Fees STATE DCA SURCHARGE 2.00
STATE DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 75.00 75.00 .00 .00
Plan Check Total 37.50 37.50 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 116.50 116.50 .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
.rob Address: /8',S1' �p4t //YU4 £'4I / - jiwi( FL 2 �� Permit Number: /a —
Legal Description Parcel #
Valuation of Work $ .394d, a'
Class of Work (circle one): New Addition Alteration ove Demolition pool /spa window /door
Use of existing /proposed structure(s) (circle one): Commercial ili.0041i en is
If an existing structure, is a fire sprinkler system installed? (Circle one): ' es o N /A
Florida Product Approval #
For multiple products use product approval form l
Describe in detail the type of work to be performed: ,4- 7inrozy RahvolP/ (ij&te, t /Di4 j &''' /T p'
L' C�'
Property Owner Information: / / ,? /
Name: di(/mt (1 ce„,,,a✓A /1� /•t4�tic� Address: /�' / k
City ,472;40 Rolta tL .2t State i Zip 32233 Phone C
E - Mail or Fax # (Optional)
Contractor Information:
Company Name: Qualifying Agent:
Address: City State Zip
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 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 ElectricalWork, Plumbing, Signs, Wells, Pools, Furnaces, Boilers, Heaters,
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.
1 hereby certify that I have read and examined this a plication and know the same to be true and correct. All provisions of laws and ordinances governing this
type of work will be complied with whether specified 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' / Signature of Contractor
Print Name zest , C fircee Print Name
Sworn to and subscribed before me Sworn to and subscribed before me
this ,. ad.Day of „�. ..,� , 20 /Q this Day of , 20
/,
Notary Public Notary Public
DEBORAH A. WHITE Revised 01.26.10
=:R �•� MY COMMISSION # DD 634126
EXPIRES: May 21 2011
'404 ''' Bonded Thrn Nctary Pubic Underwriters
i ',- f 1 �. � r / CITY OF ATLANTIC BEACH
®WNER / 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
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; 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.
/dsy , Par /,vr, AA/ /40 ` Afte fL V a 4'/ 6 " - /PC -
ADDRESS 1, y � PHONE NUMBER
Ui /l /A t`r R :4
PRINT i�: ^�`X'/ 4..--- l VUr`'"t Z, Ze/ D
SIGNATURE DATE
<-7 /
Before me this £2 day of > 2C0 in the county of
Duval, State of Florida, has personally appeared herin by himself / herself and affirms that
all statements and declarations are tr and accurate.
i
Notary Public at Large, State of , County of
❑ Personally Known L 7n a s --7_, 7,2 3 BEY. o/ 0 o "` DEBORAH A. WHITE
Produced Identification - :A .
.: !:� 14'
_ = 1 1 MY COMMISSION It DD 634126
/ /1_,,. ;, fi �.. - = EXPIRES: May 21, 2011
/ (�i_ J fr p •' Bonded Thru Notary Public Underwr tare
Notary Signature `� - �
F:BLDG/ Owner - Builder Affadavit; REVISED: 4/16/2009
NOTICE OF COMMENCEMENT
(PREPARE IN DUPLICATE)
Permit No. Tax Folio No.
State of County of
To whom it may concern:
The undersigned hereby Informs you that improvements will be made to certain real property, and In
accordance with Section 713 of the Florida Statutes, the following information iss stated In this NOTICE OF
COMMENCEMENT. /
Legal description of property being improved: g4/ RD 4 s� r — / f r � f - j (44r ( L� A
/ Ps r n /4la /P J??uAc 4 T 4,7Yc ,e.1r ic4 'L.. _.3123'?
Address of property being improved: /� C> ff V /fir £',Ar( ATZ4ii.7 eRIC� /--
General description of improvements: _gicR retiot 7 rct /
Owner / /i4-01 e /at 4.4/11 /j7/M1d C QP/-ki
e % Address / f' ' ' : .: !'. / C
Owner's Interest in site of the improvement
2E 1,1 p* 7;7 /it L Del'
Fee Simple Titleholder Of other than owner)
Name
Address
Contractor gun Q a `) C,(. hr) Ni&
Address
Phone No. Fax No.
Surety (if any) .
Address Amount of bond $
Phone No. Fax No.
Name and address o any person making a loan for the construction of the improvements.
Name ti
Address
Phone No. Fax No.
Name of person within the State of Florida, other than himself, designated by owner upon whom notices or other
documents may be served:
Name nionV-e
Address
Phone No. Fax No.
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided In
Section 713.08 (2) (b), Florida Statutes. (Fill in at Owner's option).
Name
Address
Phone No. Fax No.
Expiration date of Notice of Commencement (the expiration date is one (1) year from the date of recording unless a
different date is specified):
THiS SPACE FOR RECORDER'S USE ONLY /
Signed / (/ / - � 7.li_C � � DATE / / /v -
�" w 0 In the
Before me this • y of � U
Corny 9f Duval, Sletq of 1 (..... ' / appeared i illy /
W u herein by
l��j"YY'� �I'l
DEBORAH himself/ herself and affirms that all statements and declarations herein
•.,,, are true and accurate
1 , .' ,'' MY COMMISSION # DD 634126
EXPIRES: May 21, 2011
14/ "' $7: ' Thru Notary Public UndMiWrdVs
8f, � Bowled
Notary Public at Large, State of /-- , County of Z' t4.!
uoc 0 U1 UL55tD • ON UK 1 D41 D rage c34. My commission expires: / 0 (1) Number °a es' 1 Personally Known /_� L 7 0 / Z r 3 y(�
g Produced Identidcation
Recorded 11 022010 at 11 43 AM
JIM FULLER CLERK CIRCUIT COURT DUVAL
COUNTY it( J J
RECORDING $)0.00 L "" ---
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