Permit Siding 165 Pine St 2012 fj CITY OF ATLANTIC BEACH
r� ; s) 800 SEMINOLE ROAD
J V ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
01119 '�
Application Number 12- 00000363 Date 4/04/12
Property Address 165 PINE ST
Application type description SIDING PERMIT
Property Zoning TO BE UPDATED
Application valuation . . . 500
Application desc
siding
Owner Contractor
SAPIA WORLD CONSTRUCTION CO INC
165 PINE STREET 8464 MALLORY RD
ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32220
(904) 554 -1862
Permit SIDING PERMIT
Additional desc .
Permit Fee . . . 55.00 Plan Check Fee . . .00
Issue Date . . . Valuation . . . . 500
Expiration Date . 10/01/12
Other Fees STATE DCA SURCHARGE 2.00
STATE DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 55.00 55.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 59.00 59.00 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
CITY OF ATLANTIC BEACH
fl t 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.
ADDRESS PHONE NUMBER
PRIN
( P
ATUR DATE
Before me thisC J / day of /? e 20 /4+n the county of
Duval, State of Florida, has personally appeared herin by himself / herself and affirms that
all statements and declarations are true d accurate.
Notary Public at Large, State of k� , County of _a�%
ersonally Known •
❑ Produced Identificaf • - • .
• : „.4V.;;;;,„ - ' - E Y L ORAFIAM 01 / r ; .. '�” tt ray f OMM $ 8 IoNDD95776O
Notary Signature: .. .. 4.ter ∎_ FAMES; I'vtuuary 14, 2014
"'� dfib. 80:ilid NI Notary Public Underwriters
F: /BLDG/Owner-Builder Affidavit REVISED: 4/16/2009 - - —
' BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247 -5826 Fax (904) 247 -5845
Job Address: 16 7 T / " cS Permit Number:
Legal Description Parcel #
Valuation of Work $ ° d Floor Area of Sq.Ft. Sq.Ft
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 sprinkler 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 be performed: S-i 0 n 9 i pl Cc il
Property Owner Information: / ` (� `�
Name: C / Address: 7to��7 , z Iva, AGt 1' %, a , Lei
City ' G StateFl Zip 3Z
E -Mail or Fax # (Optional) 1
1
Contractor Information:
City J J,(�y� S4= t
Company Name:
C ��� Qualifying Agent: %h'!®h 7 r4.42j
Address: 3 Z ,- i ik. 6-5( State {, Zip '7ZZi k
Office Phone 90y -s- i 84.2- Job Site / Contac Number Fax #
State Certification/Registration # (�C l 5 O y g' Z._
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 conznzenced prior to the
issuance of a pernzit 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 (6) months at any time after
work is commenced. I 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 a plication and know the sane 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 fed- •. state, or local law regulating construction or the performance of construction.
O ' 4
Signature of Owne ,, , (t om`_ Signature of Contracto �__a I _
Print Name C- irC"
Print Name 6Vtai eC, 5
Sworn ,t9 and suesc • -e• before m- Sworn to and subscribed before me
this Day• • t l4. 2 0 Z this Day of , 20
Notary Pub is t o CL .` �, "' - - L. GRA,.
ry , _,: ..% •' MY COMMISSION 4 0f ; ublic
=a•�. S : February 14, 2014
P Bonded Thru EXPIRE NWary Public Underv+nters Revised 01.26.10
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