Permit Bldg Repair Water Damage 571 Seaspray 2011 CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
Application Number . . . . . 11-00002861 Date 11/08/11
Property Address . . . . . . 571 SEASPRAY AVE
Application type description RESIDENTIAL ALTERATION
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 4500
----------------------------------------------------------------------------
Application desc
WATER DAMAGE REPAIRS DRYWALL AND INSULATION
----------------------------------------------------------------------------
Owner Contractor
------------------------ ------------------------
TUSCANA, DAMIJAN K. OWNER
571 SEASPRAY AVENUE
ATLANTIC BEACH FL 32233
----------------------------------------------------------------------------
Permit . . . . . . RESIDENTIAL ALT/OTHER
Additional desc . . REPAIR WATER DAMAGE
Permit Fee . . . . 75 . 00 Plan Check Fee 37 . 50
Issue Date . . . . Valuation . . . . 4500
Expiration Date - - 5/06/12
----------------------------------------------------------------------------
Special Notes and Comments
NEED RECORDED NOC PRIOR TO FIRST
INSPECTION
*2007 FLORIDA BUILDING CODE W/2009 REVISIONS
NATIONA1 ELECTRIC CODE
*REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING
DEPARTMENT IMMEDIATELY.
----------------------------------------------------------------------------
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
Permit Nu
Job Address. -z&S S�? mber:
__j
Legal Description Floor Area of 7q.Ft. Parcel# Sq Ft
Valuation of Work$ 14\,5Q�KD Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s) circle one): Commercial Residential
If an existing structure,is a fire sprin=system installed? (Circle one): Yes No N/A
Florida Product Approval #
For multiple products use product approval form
Describe in detail the type of work to
performed:
PropeewOwner Information:
Name: �� �6,4L'%� �\Vo \k-z�e Amo), Address:
City_AAZ�, c,,Ak 't C�� c,,j\ State ELZip *5*2 2-S5 Phone USS SS Ck(0
E-Mail or Fax#(Optional
Contractor Information:
Company Name: Qualifying Agent:
Address: city -State Zip
Office Phone Job Site/Co ta,LIN U111vUl #_00 --"1
State Certification/Registration -REVrENMD FOR CODE COMPLIANCE
Architect Name&Phone 0W OF AnmomeBEA-eH
Engineer's Name&Phone SEE PERMfB FEW ADDITI&114!rid�
Fee Simple Title Holder Name and Address REQUIRRILA NTSANDCONDMONS.
Bonding Company Name and Address
Mortgage Lender Name and Address REVIEWEDff, X T)ATR-
lication is hereb ma e to obtain a ermit t ed prior to the
i suance o a ermit an that all work will be t becomes null
an voi i work is not commence within six any time after
wo k is commence . I un erstan that se a flers, Heaters,
Tanks and ir onditioners,eta
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.
Ihere 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
711work will be complied with whether speci/Ted herein or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of any otherfederal,state, or local aw regulating construction or the pe�formance of construction.
Signature of Owner—D cwyrJ([gs�-= �-�o cox Signature of Contracto
....................................
Print Name 1.� Print Name
I�IEIOI
XBORAH AMANDA WHITE
Sworij t -5asubscrib e C OMMISSION#EE 057P Sworn to and subscribed befor me
&RES:May�2ftl this Day of 20
rJUHZ I"M N!!gt'UD11C U
16z i5-1p".
thi Day of
Notary Public Notary Public
/,"10 Z_ T C�l -7 Revised 0 1,26.10
CITY OF ATLANTIC BEACH
OWNER / 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 WITFIIN 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.
11. 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.
S—4 � -:t i�&�� 9
ADDRESS PHONE NUMBER
PRINT NAME
-2-0
SIGNATURE DATE
Before me thi 20/ in the county of
Duval,State of Florida,has personally appeared herin by�Iimself herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of :7T� County of
My C ISSION# 05734�
11 pqrsonally Known e-� K*j",
Produced Identifica At r,L 'Ir 1.9
EXpIFIFS.May 21,201
2%iklli` pubkirUndewn
Boded Thru 4018ry
Notary Signatuz, /11" 4_1�
F/BLDG/0�ner-BtulderAffadavit;REVISED: 4/16/2009
NOU-8-2011 11:05 FROM:CLERK OF COURTS 904 270 1512 TO:92475845 P:1/1
NOTICE OF COMMENCENENT
state of Tax Folio No.
Comity Of
To Whom It May Concern:
The undersigned hereby infbrms you that improvements will be made to ceonin real property,and in accordance with Sectiou 713 of
the Florida Statutes,the following information is stated in this NOTICE OF COMMENCEMENT.
Legal Description ofpropeTty being improved-, -
3 -7/
Address ofproperty being improved:
General,description of improvements:
Owncr: "9 177 /li,119-AJ Address:
Owner's interest in site oftbe improvemovt; 4�-)4-t�
'Fee Simple Titleholder(if other than owner):
Narne,
Contractor:
Address:
Telephone No.: Fax No:
Surety(if any)
Address: Anwunt ofBond S
Telephone No. Fwc No-
N=c and address of any p-men making a loan fbT the constucdon ofthe improvements
Namc:
Addre-s-
Phone No, Fax No;
Name of person within the State of Florida.,other than himselfi designated by owner upon whom notices or other dociurierit&may be
served: Name:
Address:
Telephone No: Fax No-
la addition to bimself, owner designates, the following person to receive a copy of ibc Lienor's Notice as provided in Section
713.06(2)(b),Florida Statues. (FW in at Owner a option)
Name:
00C#20'1 1242V'I 7,OR BK 15754 Page 24a,
NUrnber Pap". 1 flax No:
ReCorded 11/0,9/2011 at 10:21 AM.
JIM FULLER CLERK CIRCUIT COURT DUVAI,, date is one(1)year from,the date of reoording unless a diffmmt date is
COUNTY
RECORDING$10.00
;R
Date- 'XW 6�� 2-0
)6i gncd.—Z�->
Before Me this M�) day of X-vy--241t W%eCotmtyofDuvaL State
Offlorida,has Vorsonally appeared /._/AW /-U s
Notary Public at Lne4 Statc of Florida,County of Duval.
eE Wr*9
EMn 21 2016 My conunission ox.phres.
Personally Known: L 174L 9b /7/ j4Z or
Produccd ldcntification.-4"y