Permit Plbg Repipe 548 Pelican Key 2011 t - s CITY OF ATLANTIC BEACH
a 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
'"1 0;31 a1'
Application Number 11- 00002015 Date 4/29/11
Property Address 548 PELICAN KEY
Application type description PLUMBING ONLY
Property Zoning TO BE UPDATED
Application valuation . . 0
Application desc
REPIPE 16 FIXTURES
Owner Contractor
MIGNONE PETER AND WENDY OWNER
548 PELICAN KEY
ATLANTIC BEACH FL 32233
Permit PLUMBING PERMIT
Additional desc . REPIPE 16 FIXTURES
Permit Fee . . . 167.00 Plan Check Fee . . .00
Issue Date . . Valuation . . . . 0
Expiration Date . . 10/26/11
Other Fees STATE PLBG DCA SURCHARGE 2.51
STATE PLBG DBPR SURCHARGE 2.51
Fee summary Charged Paid Credited Due
Permit Fee Total 167.00 167.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 5.02 5.02 .00 .00
Grand Total 172.02 172.02 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
PLUMBING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd Atlantic Beach, FL 32233
Ph (904) 247 -5826 Fax (904) 247 -5845
JOB ADDRESS: J� `��3 f�1.. V.e...A., 1�-1 - l& �C -et- 2-233 PERMIT # // /j
NEW OR REPLACEMENT INSTALLATION: Project Value $ p��
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank & Pit
Clothes Washer Shower
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Water Heater
Other Fixtures Water Treating System
RE -PIPE:
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub A/ Septic Tank & Pit
Clothes Washer / Shower /
Dishwasher / Shower Pan
Drinking Fountain Slop Sink /
Floor Drain Three Compartment Sink
Floor Sink Toilet 3
Hose Bibs / Urinal
Kitchen Sink / Vacuum Breakers
Laundry Tray f Water Connected Appliances /
Lavatory 3 Water Heater /
Other Fixtures Water Treating System
MISCELLANEOUS:
❑ Sewer Replacement ❑ Back Flow Preventer ❑ Grease Interceptor (Trap) gallons (Requires 3 sets of plans)
❑ Lawn Sprinkler System - Number of Heads ❑ Well * *
** SJRWD Well Completion Form. Completed form to be submitted to the Building Department for final inspection. **
❑ Other
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have read
this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified
or not. Thy permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction.
Property Owners Name r (%. il- c W Ak... t Phone Number % I-1 $ 3- 6 (/ 3
Plumbing Company f ice Phone Fax
Co. Address: City State Zip
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uv �- n h .tate Certification istration #
License Holder (Print): A. • � g
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Notariz • •_ _ _: ;,.?;',1 . , , •. old ° • L ,
''Y ' My conoss os # *1 20 . li
*; 'i :; EXPIRES.MPub�ndden+rit and re m
d subscribed befg '� d.y of • 20
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Signature of Notary Public eft ,/ ` 41Pre
Nta &ga 7S7 0 / o
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., CITY OF ATLANTIC BEACH
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WNER / BUILDER AFFIDAVIT
1. 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 REOUIRED 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.
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DDRESS PHONE NUMBER
(A) I ■ 641 5 v, YLL
PR .t T NAME J
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SIGNATURE ,, ` DATE
1 / 4410
Before me this t' day of "AlaL 20 in the county of
Duval, State of Florida, has perso r appeared herin by imself / herself and affirms that
all statements and declarations a rtru nd accurate.
Notary Public at Large, State of , County of
r sonally Known pt �-/(— J / `] IIIYYY o Ap7S e y 7 l 6 O r 0 duced Identificatlon -
Notary Signature/ /�
�� D EBORAH A. WHITE
4126
'4 ,.�=
MY C OMMISSION #DD
F :/BL.DG /Owner - Builder Affadavit; REVISED: 4/16/2009 ' *: f -I0 c
s. .• y �: bi EXPIRES: Ma n
May 21, 2011 Yrters