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Permit Well 405 Garden Ln 2011 CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH,FL 32233 INSPECTION PHONE LINE 247-5814 Application Number . . . . . 11-00002243 Date 7/05/11 Property Address . . . . . . 405 GARDEN LN Application type description WELL PERMIT Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 0 ---------------------------------------------------------------------------- Application desc new well ---------------------------------------------------------------------------- Owner Contractor ------------------------ ------------------------ HAMMONS OWNER 405 GARDEN LANE ATLANTIC BEACH FL 32233 ---------------------------------------------------------------------------- Permit . . . . . . WELL PERMIT Additional desc . . Permit Fee . . . . 75 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 1/01/12 ---------------------------------------------------------------------------- Special Notes and Comments Seperate permit required for electrical connection/wiring to new pumps A reduced pressure zone backflow preventer must be installed if irrigation will be provided or if there is a private well on the property. Backflow preventer must be tested by a certified tester and a copy of the results sent to Public Utilities . ---------------------------------------------------------------------------- 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 . 00 . 00 . 00 . 00 Other Fee Total 4 . 00 4 . 00 . 00 . 00 Grand Total 79 . 00 79. 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. CITY OF ATLANTIC BEACH WELL PERAUT APPLICATION Owner's Nanle;,1- —Address:— Well Address(if different than above): Well Location on Property(i.e.northeast comer,etc.) Well Installation Contractor:— 1� Contractor License No.: Phone: FAX: Cont-actor Address: Check Use of Well: Domestic Irrigation Other Estimated-Well Depth: Casing Depth: Screen Interval from to Well Diameter: Casing Material Is address currently connected to the City water system? C- Is address currently connected to the City sewer systern?_y Has a Well Permit been obtained from the City of Jacksonville? en it# rr Does the well require a permit from the St. Johns River Walter:ianagement District? (Not required for wells under 2-inches diameter installed by resident or wells under 6- inches diameter if installed by licensed well contractor). If permit is required,note Permit Number anea�ach a copy. NOTE.- WHENA WELL IS INSTALLED ON YOUR PROPERTY, YOUMUST INSTALL A REDUCED PRESSURE ZONE TYPE BACKELOWFREVENTER ON THE CITY WA7ER SERVICE. ON THE CUSTOMER'S SIDE OF TRE METER THE BACKFLOWPREVENTER MUSTBE TESTED BYA CERTIFIED TESTER AND A COPY OF TRE RESULTS SENT TO TRE PUBLIC UTILITIES DEPARTMENT. FILE COPY CITY OF ATLANTIC BEACH "I"WNER / BUILDER AFFIDAVIT 1. FLORIDA STATU TES; 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 MUNICrPAL LICENSING ORDINANCES. _j [I. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE, THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED. 111. 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(l). 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. LA�A-.I- ADDRESS PHONE NUMBER PRTITINAME eQ SrG'MA7URE \D Before me thisC�I day of 2d in the county of 3E Duval,State of Florida,has personally appeared herin by himself herself an affirms that all statements and declarations ar t d ur a. Notary Public at Large,State County of K, SHIRLEY L ft,lee'wrolly Known My COMMISSION#DD 957760 EXPIRES:February 14 2014 0 Produced Idenfificati 11 Band Thru Notary public ljn�erwow, Notary Signature: FJBLDG/0�er-Builder Affadavit;REVISED:4/16/2009 k�_ City of Atlantic Beach APPLICATION NUMBER Building Department (To be assigned by the Building Department.) 800 Seminole Road JUN 2 2oll Atlantic Beach, Florida 32233-5445- Phone(904)247-5826 - Fax(904_-7i*47-�5845 _zz Date routed: �b/& E-mail: building-dept@coab.us 4 City web-site: hftp:/Avww.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: tkn Department review required Yes No Building Applicant: 0 k)Ali Planning &Zoning Tree Administrator Project: Pulau"fork—S Public Utilities Public Safety Fire Services Al 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. F]Denied. (Circle one.) Comments: BUILDING PLANNING &ZONING Reviewed by: Date: TREE ADMIN. Second Review: []Approved as revised. FIDenied. P IC WORKS Comments: P BLIC UTILITIE TY PUBLIC AFETY Reviewed by: Date: FIRE SERVICES Third Review: []Approved as revised. FjDenied. Comments: Reviewed by: Date: Revised 07/27110