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Withdrawn Permit App 1885 Beach 2011 BUILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Road, Atlantic Beach, FL 32233 Office(904)247-5826 Fax (904)247-5845 Job Address: < �� Legal Description Permit Number: o Valuation of Work$��'!�� r ea o Parcel#oposed Work heated/cooled t q• 4— non-heated/c &led Class of Work(circle one `d n ' Repair Mo Demolition pools ndow/door Use of existing/propose i r r (circle one): mmercial If an existing structure,i it r kle ystem ins ?(Circle one): R Florida Product Approval /A For multiple products use c pr va o Describe in detail the type of to be Proper Owner Information: Name: City .Address: tat i Ph E-Mail or Fax#(Optional) l Contractor Information- Company Name: • Address: Q ifying Agent: Office Phone1 e rte/Contact Num 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 do the work and i r s indicated. �c that no w �. nstallation has menced prior to the issuance of a permit and that all work will be rformed to meet the an o laws regulating ti3c ion in is jurisdiction. Thi permit becomes null and void f work is not commenced within six months, or if co coon or suspended or ab ora period of six(6)months at any time after work is commenced. I understand that sepa to per must b red car Work,Plumbin I W F Tanks and Air Conditioners,etc. ells, Pools, urnaces, Boilers,Heaters, WARNING TO O NER: IL O A NOTICE OF COMMENCEMENT MAY SU L PA T OR IMPROVEMENTS TO YOUR PROPERTY. IF` U ND OBTA IN ING, CONSULT WITH YOUR LENDER OR AN O Y BE RE REC G YOUR NOTICE OF C ENCEMENT. I here b certify that I have read and examined this a plication a the same to be true and correct. All provisions of laws and ordinances governing this type ojYwork will be compliedwith whet er s eci ted 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, cal w regulating construction or the performance of construction. Signature of Owner Signature of Contractor Print Nams Print Name ......................................................................................................................................... Swor i nc .�ubsc ' ed be f e n� Sworn to and subscribed before me thisDay of 20 I this Day of 20 , .. l Notary c` M MMISSION#DD 957760 Notary Public EXP RES:February 14,2014 nd>' Bon 7hru Notary Public Under wrilemm Revised 01.26.10 t-=JT CITY OF ATLANTIC BEACH Building Department 800 Seminole Road J r Atlantic Beach,Florio (904)247-580(, -45�r -�rC r►^ PLAN REVIEW COA Permit Application # 6-1/_ // •� � 5` � � �'f 1 Property Address: Applicant: Zy Project: 45 7clo5,-e Ex•;_I,'?`` 7`�)r SPa �f 0 sc,n This permit application has been: El pproved Reviewed and the following items need attention: lflP,ro a i c%'a v r' a ,� a 7L lir ch,N " G uN i 8�rn S ryC ( Forms a� G; Jla1l ow'ler- S /-0011•» 4�nc.to . 0✓e %4 )-f101a1V;1 - �-o tae_ 1-0/ ou- ' b C)r 7e own er a fav, ed C Fn�m , 3 ✓ U C a CO, 0,1f— and fere 4 ac rn--n'�r 5),a// 14 $ i 2S -e C- 1 -1 10 L EPR-C1d IhC VO4r U'la J too go PPS u c/v C f 0, /"d ua l c/vvez s 4' ")1'a/0 p s -ro o" -e d./L7r S' YO PC.T1Utn O-� E>-i 34o' Rc))l V v4 41',- +o RP vn o .-,,x whPr'e ; S, 100•T Pion Su✓ P -PftZ 4x, '0')qw, laea �ic)n o n,Pkv "er,Cf -er"ea, C,0 FiC-401 meed Re uov �� a1p 0 t . �✓� A�e� ` S' yr CC � -e . � 55—i76S Please re-submit your application when these items have been completed. Reviewed By: /'rI Date: ri- `�rl�y City of Atlantic Beach S Building Department FFDate PLICATION NUMBER } 800 Seminole Road gned b the Buildin Department.) Atlantic Beach, Florida 32233-5445 -- ` Phone(904)247-5826 • Fax(904)247-5845 r ss E-mail: building-dept@coab.us d: City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: /��, /��( Xy, nt review re uired Yes o Applicant: lanning &Zoning ree or Project: S x/�)�7 h ©V�e © Public Works Public Utilities Public Safety Fire Services m.�.➢ J Ars ks .2iI Other Agency Review or Permit Req ' ed Review r e1t Date of Permi ifie 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: QApproved. []Denied. (Circle one.) Comments: BUILDING PLANNING &ZONING Reviewed by: Date: TREE ADMIN. Second Review: []Approved as revised. ❑Denied. PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: []Approved as revised. ❑Denied. Comments: Reviewed by: Date: Revised 07/27/10 BUILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Road, Atlantic Beach, FL 32233 Office (904) 247-5826 Fax (904) 247-5845 Job Address: 1 11ps-_ el Legal Description Permit Number: d Valuation of Work$ �'®� "�' °Or rea o q t Parcel# Proposed Work heated/cooled _ t non-heated/cooled' Class of Work(circle One): New Addition Repair Move Demolition pool/spa window/door Use of existing/proposed structure(s) ((circle one : If an existing structure,is a fire s r;<nkle ) Commercial R Florida Product Approval # p Ys m installe ?(CCi,_r�e one): *es /A For multiple products use product approva orm Describe in detail the type of work to be performed:—Ge" e" 4 PCOpeI Owner Information: S Name: City � .Address: E-Mail or Fax#(Optional) State i Phone Contractor Information: Company Name:_ Address: Qualifying Ag t: Office Phone City State Certification/Registration# Job Site/Contact Number F Zip 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 installati�ns as indicated. I cert that no work or installation h issuance of a permit and that all work wall be performed to meet the standarof all laws regulating construction in this jurisdiction. This and void if work is not commenced within six(6J months, or if construction work is suspended or abandoned for at hisju d d i stx r6)wont it at any becomes ter work is comnsenced. I understand that separate permits must be secured for ElectricaC Work,Plumbing,Signs, Wells,Pools, Furnaces, Bo lers,Heaters, Tanks and Air Conditioners,etc. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEM TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT NTS YOUR LENDER OR AN ATTORNEY BEFORE .RECORDING YOUR NOTICE OF H COMMENCEMENT. 1 here b 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 ape sions k will be complied with whet er s ect aed herein or not. The granting of a permit does not presume to gave authority to violate provisions of any other federal,state, cal w regulating construction or the performance of construction. ty late or cancel the N J ignature of Owner Tint Nam Signature of Contractor ........................I............ .. Print Name ............................... worn ubsc ed be ............................................................................................................................ ii Day of 20 I Sworn to and subscribed before me this Day of 20 iota cNotary Public Nd MMISSION#DD 957760 EXP RES:February 14,2014 ~ P Bo Thru Notary Public Underwriters Revised 01.26.10 CITE'OF ATLANTIC BEACH OWNER / BULDER A-FFIDA t� I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STAT S, PART 1 "CONSTRUCTION CONTRACTING"REQUIRES OWNER/BUILDER TO ACKNO E_U ' LAW: DISCLOSURE STATEMENT FOR SECTION 489.103(7),FL A STATU S: STATE LAW REQUIRES CONSTRUCTION BE D CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDE AN Y LIC SED LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER OF Y p TION T S YOUR OWN CONTRACTOR EVEN THOUGH YOU DO THA Rte' CT AS SUPERVISE THE CONSTRUCTION YOURSELF. YOU Y BUIL I ENS E. U MUST TWO FAMILY RESIDENCE OR A FARM OUTS ING. Il�Il'RO NE-OR IMPROVE A COMMERCIAL BUILDING AT A COST O $ g, BUILD OR MUST BE FOR YOUR USE AND OCCUPANCY. IT MA R L LE, DIN IF YOU SELL OR LEASE A BUILDING YOU HAVE B T T FO ALE OR LEASE. LF AFTER THE CONSTRUCTION IS COMPLETE, THE LA O YEAR IT FOR SALE OR LEASE, WHICH IS IN VIOLATTON OF THIS AT Y BU HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR Y UR C STRUCTI T BE DONE ACCORDING TO THE BUILDING CODES AND YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE M ULATTON IT S Y V ''LASES REQUIRED BY STATE LAW AND YOU $Y C 11N R NIC ' 1 ' 1 r S9I3INANCES II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJU S TO WORKERS THEY HIRE, THE BUILDING DEPARTMENT SUGGESTS WORKER'S COM NSATION 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 EMPL ED I N ER NY 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. 00 DDRESS FVHOtf NUMBER I T NAME SIG TU DAT Before me this :�q day of 5 20in the county of Duval,State of Florida,has personally a eared herin by hyelf/herself and affirms that all statements and declarations are trurd accurate. Notary Public at Large,State of jj//�/L ,County of Pers lly Known d identlfi tion- _. . SHIRLEY L.GRAHAM :. My COMMISSION#DD 957760 Notary Signa, _ _ PIRES:February 14,2014 ;\•ci: >y on a Thru Notary Public Unden fiters F'.BLDGlOwner-Builder Affadavit;?.e,V[SED. 411612009 1 ' v Q 00 X, r %7:,fi'� /4.1.5 /� � u.�.r:-r,, f•. / lr �� , �,,�� ,� 1 t , � �' � � �. 1 (� 1 � � ,r- � r �, ���Q �n a � ��4 ���s � � ��e ���� `STC' r.,� -��� s`i� >l� ��' r �--e c� .. ' ) "—S% City of Atlantic Beach APPLICATION NUMBER :;S w Building Department ss� (To be assig ed by the Building Department.) 800 Seminole Road Atlantic Beach, Florida 32233-5445 _ Phone(904)247-5826 • Fax(904)247-5845 It ar E-mail: building-dept@coab.us Date routed: �( City web-site: http://www.coab.us APPLICATION REVIEW AND TPACKING FORM Property Address: ��e(' � int review required Yes No /� n Applicant: TZ�� Project: 6 A,/ Other Agency Review or Permit K Florida Dept. of Environmental Protection Florida Dept. of Transportation St.Johns River Water Management District Army Corps of Engineers Division of Hn+Ar- ��a ^- • Divisi Other �� • LCG�� rus Reviewing Departme r s []Denied. (Circle one.) BUILD ANNING &ZONIN( / Date: IN. ❑Denied. PUBLIC WORKS PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: Approved as revised. ❑Denied. Comments: Reviewed by: Date: Revised 07/27/10