Permit Fence 1804 Sea Oats 2012 i
; 'r CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
J ' vf , °" , ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
- 401119
Application Number 12- 00000027 Date 1/18/12
Property Address 1804 SEA OATS DR
Application type description FENCE PERMIT
Property Zoning TO BE UPDATED
Application valuation . . . 1000
Application desc
FENCE - 6' WOOD PRIVACY IN SIDE YARD
Owner Contractor
BIRD PAUL DAVID LIFE ESTATE OWNER
1804 SEA OATS DRIVE
ATLANTIC BEACH FL 32233
Permit FENCE PERMIT
Additional desc . FENCE
Permit Fee . . . 35.00 Plan Check Fee . . .00
Issue Date . . . Valuation . . . . 0
Expiration Date . 7/16/12
Special Notes and Comments
Roll off container company must be on City approved list
and container cannot be placed on City right -of -way.
Other Fees STATE DCA SURCHARGE 2.00
STATE DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 35.00 35.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 39.00 39.00 .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
Job Address: / "rag 54,4 o`"�J 6.7, ve Permit Number:
Legal Description Cwt Z , 4 / Z , k /LA, ./70v41 Parcel # 661
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work $ 'roposed Work heated /cooled non - heated /cooled
Class of Work (circle one): d Addition Alteration air_ Move Demolition pool /spa window /door
Use of existing /proposed structure(s) (circle one): Commercial ' e ' I , -
If an existing structure, is a fire sprinkler system installed? (Circle one): Yes N /A
Florida Product Approval #
For multiple products use product approval form
J i
Describe in detail the type of work to be performed: �n 1 - 4 I ' / 4 C - E `� e
Property Owner Informatio n:
Name: 0 1 , ‘ " 1 : 1 / Tt / � , Address: / - q L cxvb D..,
City State tLZip 72 Z77 Phone 5 -vr-79 Z Z
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. 1 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 aperiod of six (r6) months at any time after
work is commenced. 1 understand that separate permits must be secured for Electrical Work, Plumbing, Signs, Wells, Pools, Furnaces, Bo 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.
I hereby 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
type of work will be complied with whether sppeci red 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 la ng construction or the performance of construction.
Signature of Owner -- ,,- Signature of Contractor
Print Name b i - Print Name
Sworn + grd- subscribed ,• t e me Sworn to and subscribed before me
this D -y of 20 Z this Day of , 20
Notary Public * ';;r MY COMMISSION #EE05 Notary Public
EXPIRES: May 21, 2015
Nom Thrw Notary Public undeavalers Revised 01.26.10
«.LJ f ;,
~ , 1:"_, CITY OF ATLANTIC BEACH
®WNER / BUILDER AFFIDAVIT
";tl % `
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.
/6 f-e, col-4. A 9c/v -5YX 79zt
ADDRESS k / PHONE NUMBER
D alLiti
PRINT NAME
-- sr —!�� —�
SIGNATIE Ai./ D ATE
Before me this 914—day of 20 the county of
Duval, State of Florida, has per n ly appeared h in by himself / herself and affirms that
all statements and declaration true and accu te.
Notary Public at Large, State of le .2 * --- , County of AMANDA WRIT 4 .
/' / "J 6 d 6 / / c ,• . ON # EE 2015
❑ Personally Known PI b c ) ,I� iE 2., 2015
�duce Identification - __,I',1 = EXPIRES: May
/ � - Public Undelw „Ip' onded
4 :16ta'lf-4,. > �l �q , 4 P ( BN otary Notary Signature: C.� . �`�
F./BLDG/Owner-Budder Affadavit, REVISED: 4/16/2009
MAP SHLI WING BOUNDARY SURVEY OF:
k LOT 2, BLOCK 2, SELVA MARINA UNIT NO. 9, AS RECORDED IN PLAT BOOK 36,
PAGE 20 OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY. FLORIDA.
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•
NOTES :
BEARINGS ARE BASED ON THE WESTERLY RIGHT -Of -WAY 1
LINE OF SEA OATS DRIVE AS BEING $.00'0?'4i'E OY PLAT. • % I
7 HERE MAY aE RESTRICTION L OR EASEMENTS THAT
AFFECT TOM PROPERTY Oy 20NLNG OR RECORDED LN THE.
f iy\; r City of Atlantic Beach RECEIVED APPLICATION NUMBER
l s, Building Department
t (To be assigned by the Building Department.)
r . 800 Seminole Road JAN O 9 2012
1J Atlantic Beach, Florida 32233 -544• / --..2 1
■ Phone (904) 247 -5826 • Fax (90 5845 _ f G� _ A-2 .. - Q „, E -mail: building- dept @coab.us — Date routed: /
City web -site: http: / /www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: / f - / 4 Department review required Yes No
Buildin•
Applicant: Di/W60 /8/X-)70 anni g & Zoning V
-e • • ministrator
Project: re.-I C'-L.— CrPubli orks V
`
C Publi6 Utilitie
Public Safety
Fire Services
Review fee $ Dept Signature / 1 " ----
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: b A pproved. EDenied.
(Circle one.) Comments: (4)/(0//:
BUILDING P• f( ' /O//:
PLANNING & ZONING Reviewed by: Date: //5
TREE ADMIN. Second Review: QApproved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: DApproved as revised. (Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
r0,:i1 City of Atlantic Beach APPLICATION NUMBER
.>cp Building Department (To be assigned by the Building Department.)
. n- S i 800 Seminole Road /al- ' 7
J — , Atlantic Beach, Florida 32233 -5445
• Phone (904) 247 -5826 • Fax (904) 247 -5845 �_ 4.2_ E -mail: building- dept @coab.us Date routed:
City web -site: http: / /www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: / J (2 -/, Department review required Yes No
Buildin
Dere /f� anni g & Zonin '
Applicant e Admi in strator
Project: r`"e�"-2G'-e...._- (bli orl<
[Public Uti i ie
Public Safety
Fire Services
Review fee $ Dept Signature ______(-----
Review or Receipt Date
Other Agency Review or Permit Required 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. (Denied.
(Circle one.) Comments:
G fi ING OI Reviewed by: �__..� i / Date: 1/Z
TREE ADMIN. Second Review: (Approved as revised. [1]Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: Approved as revised. [Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09 •
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247 -5826 Fax (904) 247 -5845
Job Address: / ,F 5�o -tf 4.4 e Permit Number: j .---2.,1 /
Legal Description tc Z- / 6/. c.4 Z , k / ✓
/7oih c4 Parcel # al - X 9
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work $ t ' - roposed Work heated /cooled non - heated /cooled
Class of Work (circle one): Addition Alteration ' — Move Demolition pool /spa window /door
Use of existing /proposed structures) (circle one): Commercial Re • I -
If an existing structure, is a fire sprinkler system installed? (Circle one): Yes dgC?./ N /A
Florida Product Approval #
For multiple products use product approval form work to be erfored: . `n f q If b /7 (JJ ,,
Describe in detail the type of p
Property Owner Informatio n:
Name: 6,,t6.1 / #4);07 #4);07 / , Address: fro 04/1i D...,
City 4d. State AZZip 72273 Phone 5 - Z Z
E -Mail or Fax # (Optional)
Contractor Information: N / A .
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. 1 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 work void ommenced. of I commenced nderstand that separate permits must be secured for Electrical Plumbing, Sig a Wells, Pools, Boilers, t H eat e t s,
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 BE OMERECORDING YOUR NOTICE OF
I hereby certify that I have read and examined this a placation 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 la �� %, ' ng construction or the performance of construction.
//
Signature of Owner – , Signature of Contractor
Print Name b ,.,a l Print Name
Sworn to ) g ni subscribed IV e me Sworn to and subscribed before me
this ., D•y of 1' 20 Z this Day of , 20
Notary Publi MY COMMISSION #EE057349 Notary Public
,y...si °i. 1 EXPIRES: May 21, 2015
,,• r.,nndearnN Public Undenmters Revised 01.26.10
' % CITY OF ATLANTIC BEACH
;_.
✓
J 'i 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. ,
l r 1-�... C a% 4 9'`f - s`Y1 - =79 Z Z
ADDRESS
Ol � PHONE NUMBER
/ i
PRINT NAME ' -
SIGNAT 'E / .}� DATE
Before me this , day of 20/An the county of
Duval, State of Florida, has per n ly appeared h in by himself / herself and affirms that
all statements and declaration true and accu ate.
Notary Public at Large, State of 14____
—__ , County of (G/ l-4r (1MAN DA4VHICE
v 6 tv 7/ ‘';,....4.,,iP1114) Be DEBORAH
Y c Ma # EE OF73G5 II,':-;:.:'':,..
- --/---4 ' _ El Personal) Know ; : , jy /0 d < . �� Q1, 2015
,g EPoduced Identification - f� t EXPIRES: Y
/� s. Bonded Thru Nok'vY Publir 5014 lte
Notary Signature:
F: BLDG /Owner - Builder AffadaviL REVISED: 4/16/2009
MAP SHOWING BOUNDARY SURVEY Dr:
c:
LOT 2, PAGE � 0 BLOCK
T H• E CURRENT UNIT NO. 9, AS RECORDED IN
RECORDS OF DUVAL COUNTY, FLORIDA C.
O OF H
4
le; x I L or 3, d /ocK 2 ,
�a• from ..--'1 f ur+d ' J�r►+ P ;, x '
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es 11
": -... . ' _I ___
____ _ ......_ _ _ _
... „. Line
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* ci fo w+�d h 'kw Pine 04 i iv
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•
City of Atlantic Beach 4 ..
NOTES : Pianninp and Zoning; Department
BEARINGS ARE BASED ON THE WESTERLY RIGHT-Of-WAY
complionos LINE OF SEA OATS DRIVE AS BEING 6.04.02'4 E. ev PLAT. Thte approv
iubdiv � if on an with d
THERE MA'Y DE RESTRICTION LINES OR EASEMENTS THAT development di the issuance of does toot Compliance cn,
AFFECT TINS PROPERTY • . . cry • RECORDED W THE with Florida Building Code and &l other applicable
pop/ 1!' PF/AG�1� ^� T `"' "no " •
local, State and Federal permitting requirements
must be verified by signature of the C of Atlantic
Beach Building 0 10 go • a
Building Pennit' k.�Gt..0 go. ' r
Approved By: , v• I i
Cate: r'fir�
PLANNING & ZONING DEPARTMENT �.
PLAN REVIEW CHECKLIST � ° 4
APPLICANT DAVID BIRD ~
PROJECT LOCATION 1804 SEA OATS 3+
City of Atlantic Beach
CONTRACTOR /OWNEROWNER 1 DAVID BIRD 800 Seminole Road
Atlantic Beach, FL 32233
r NEW SINGLE - FAMILY (— SIGN PERMIT (P) 904.247.5826
r NEW TWO- OR MULTI - FAMILY rX FENCE OR POOL PERMIT (F) 904.247.5845
www.coab.us
r REMODEL OR ADDITION r LANDSCAPE PLAN
r NEW COMMERCIAL r OTHER FNCE 12 00000027
Application Number
NOTES: PROPOSED FENCE ALONG NORTHERN PROPERTY LINE
COMPLIES WITH: COMPREHENSIVE PLAN DESIGNATION? __ r YES r NO RL
ZONING DISTRICT DESIGNATION? rg YES r NO PUD [RS -1]
REQUIRED SETBACKS? r YES r NO
MAXIMUM HEIGHT? rX' YES r NO 6'
MAXIMUM IMPERVIOUS AREA? r YES r NO N/A
REQUIRED PARKING? r YES r NO N/A # SPACES
SIGN PERMIT CHECKLIST
rr FREESTANDING HEIGHT OF SIGN DIMENSIONS SQUARE FOOTAGE
ILLUMINATION DISTANCE FROM PROPERTY LINE(S)
FASCIA (WALL) NUMBER OF SIGNS
ILLUMINATION METHOD OF MOUNTING
OTHER N/A
LANDSCAPE PLAN REQUIRED r- YES rX NO
REVIEWED BY: ERIKA HALL, PRINCIPAL PLANNER
?Ar-- DATE REVIEWED 01/11/2012
COMMENTS PROVIDED TO APPLICANT: E YES rX NO DATE PROVIDED
APPLICATION APPROVED rX YES r NO DATE APPROVED /11/2012
Version 2.28.2007
7 ... City of Atlantic
art Beach t
RECEIVED APPLICATION NUMBER
Jr ' ; Bu De men
�s �� Seminole g p Road
(To be assigned by the Building 7 Department.)
+� 800
� Atlantic Beach, Florida 32233-5445
JAN 0 9 2012 A2' —°2 � Phone (904) 247 -5826 • Fax (904) 247 -5845 / _ 4: 'r' :4 E -mail: building- dept @coab.us BY:_____ Date routed: / —
City web -site: http: / /www.coab.us ""
APPLICATION REVIEW AND TRACKING FORM
Property Address: /61'6 A Department review required Yes No
Buildin
t, — / ;0 /3/./C0 ann & Zon
Applicant: � 9 � V
- �
y'" e dmi in strator
Project: /`� JC -c�.- (ubliavorks'> V
C Public Uti ie `�
Public Safety
Fire Services
Review fee $ Dept Signature
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. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING & ZONING Reviewed by: Date( /1 ./
TREE ADMIN. Second Review: Approved as revised. ['Denied.
I /W OR Comments:
V i-
/
PUBLIC SA Reviewed by: Date:
FIRE SERVICES Third Review: []Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247 -5826 Fax (904) 247 -5845
a �( T:e4 04 ✓�;, f2
Job Address: � g � Permit Number:
Legal Description L;/-1' Z- , o /6 c-4 z- , Parcel # "
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work $ proposed Work heated /cooled non - heated /cooled
Class of Work (circle one): id ifO r Addition Alteration •'�� Move Demolition pool /spa window /door
Use of existing /proposed structure(s) (circle one): Commercial ' e ' • - '
If an existing structure, is a fire sprinkler system installed? (Circle one): Yes N /A
Florida Product Approval #
For multiple products use product approval form
i
Describe in detail the type of work to be performed: -TA n f q /� � ( LA:v7 �f' P�t� - � =G di.
Property Owner Information:
Name: 6,„,,) L'/1 Address: f041 a.vb Qom.
City 4d.‘ „ State "'alp 72 Z 77 Phone .S =7y Z Z
E -Mail or Fax # (Optional)
Contractor Information: 4/%4
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. 1 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 Electrical IFork, Plumbing, Signs, Wells, Pools, F urnaces, Bo 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 1 have read and examined thisplication 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
M of any other federal, state, or local t 'ng construction or the performance of construction.
� Vii`
Signature of Owner - IA`� Signature of Contractor
Print Name .. i Print Name
Sworn to subscribed otts e me Sworn to and subscribed before me
this ., D•y of ANAtailars.- 20 2-- this Day of , 20
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Notary Public ' ,,''A MY COMMISSION # EE 057349 Notary Public
!, EXPIRES: May 21, 2015
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1` 1 CITY OF ATLANTIC BEACH
J ' 'J 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.
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SIGNAT -E 4.- DATE
Before me this ' day of , 204gin the county of
Duval, State of Florida, has pe n ly appeared h in by himself / herself and affirms that
all statements and declaration true and accu ate.
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Notary Public at Large, State of _ �- -2 - '" , County of;
rf •, DE ISSION RAH NAND\ WHItE d
❑ Personally Known
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Bffication -
(pIRES: 2 2015
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F: BLDG /Owner - Builder Affadavit; REVISED: 4/16/2009