805 Sailfish Dr (vault) CITY OF
NO SEMINOLE RQAD
ATLANTIC BEACH,FLORM4 32233-5"5
TELEMONE("d)247-SM
FAX("d)247-MS
April 27 , 1995
Ms . Ashley S. Bass
805 Sailfish Drive
Atlantic Beach, FL 32233
Dear Ms . Bass:
Our records indicate that you are the owner of the following
Property in the City of Atlantic Beach, Florida:
805 Sailfish Drive
a/k/a Lot 23, Block 6, Royal Palms #1
RE#171241-0000
Investiglation of this property discloses that I have found
and determined that a public nuisan a exists thereon so as to
constitute a violation of City of Atlantic Beach ordinance Chapter
12, Section 12-1-(7), abandoned, unregistered, inoperable motor
vehicle; and Chapter 12, Section 12-1-0) , high grass and weeds .
You are hereby notified that nless the condition above
described is remedied within ten (10) days from the date of your
receipt hereof, this case wi 11 be 1� turned over to the Code
Enforcement Board.
Under Florida Statute 162.09, the Code Enforcement Board may
impose fines Of UP to $250 .00 per day for a first violation and
$500 -00 per day for a repeat violation.
Sincerely,
Karl W. ru ewald
Code Enforcement Officer
KWG/pah
cc: City Manager
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
CITY OF ATLANTIC BEACH
COMPLAINT MANAGEMENT SYSTEM
TAKEN (date/time) : J— No:
COMPLA.I NANT:—&)A- u rLA
ADDRESS: Last Name First Name —M
CITY/STATE/ZIP:
TELEPHONE:
C014PLAINT: er
IVA�9.-J 7//F--(_ 7-&/C 7—
LOCATION: /f -c ,c"s t
REAL ESTATE #: /,17-9
PROPERTY OWNERt NAME: A.Y11A4- X A Zl! -Z
OWNERS ADDRESS:
PROPERTY OWNERS PHONE:
OCCUPANT:
DEPARTMENT FORWARDED TO:
C014PLAINT TAKEN BY: DATE/TIME:
OFFICE USE ONLY
INVESTIGATED: (date/time)
ASSIGNED DEPT./DIVISION:
INVESTIGATOR: PRIORI
CONDITIONS FOUND:
ACTION TAKEN:
COMPLIANCE:
NOTES:
CITY OF
800 SEMINOLE ROAD
ATLANTIC REACH,FLORMA 32233-5445
TELEPHONE(%4)2A7-5800
FAX(%4)247-5805
January 24, �994
Ashley S. Bass
805 Sailfish Drive
Atlantic Beach, FL 32233
Dear Mr . Bass :
Our records indicate that you ar the owner of the following
property in the City of Atlantic Beac Florida:
805 Sailfish Drive
a/k/a Lot 23, Block 6, Roya�, Palms Unit #1
RE#171241-0000 i
Investigation of this property discloses that I have found
and determined that a public nuisance exists thereon so as to
constitute a violation of City of Atlantic Beach Ordinance Chapter
12, Section 12-4-(8) (Unsafe Building) i - e, due to its collapsing,
the shed in your rear yard has become a detriment to' the health,
safety and welfare of the public aid Persons residing at 805
Sailfish Drive.
You are hereby notified that I Ln ess the condition above
described is remedied within fifteen (15) days f rom the date of
your receipt hereof , this case will :)e turned over to the Code
Enforcement Board.
Under Florida statute 162 .09 th Code Enforcement Board may
impose fines of up to $250.00 per' da for a first violation and
$500 - 00 per day for a repeat violatio. .
Sincerel y,
Karl W. unewald
Code Enf rcement Officer
KWG/pah
cc: City Manager
Don Ford
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
CITY� OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5826
�NSPECTION EMAIL REQUEST:
Puilding dept@coab.us
Application Number . . . . . 08-00000170 Date 2/06/08
Property Address . . . . . . 805 AILFISH DR
Application type description ELECRIC ONLY
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
----------------------------------------------------------------------------
Application desc
INCREASE SERVICE SIZE TO 20OA/240V
----------------------------------------------------------------------------
Owner Contractor
------------------------ ------------------------
DYER ALLAN DEES ELECTRIC
805 SAILFISH DRIVE Q/A: AUSTIN, PATRICK
ATLANTIC BEACH FL 32233 2826 LENOX AVE.
JACKSONVILLE FL 32254
(904) 338-4583
--------------------------------------- -----------------------------------
Permit . . . . . . ELECTRICAL PE IT
Additional desc
Permit Fee . . . . 70 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 8/04/08
----------------------------------------------------------------------------
Fee summary Charged P4id Credited Due
----------------- ---------- ----- ----- ---------- ----------
Permit Fee Total 70 . 00 70 . 00 . 00 . 00
Plan Check Total . 00 . 00 . 00 .00
Grand Total 70 . 00 . 00 . 00
PERMIT IS APPROVEM ONLY IN ACCORDANCE WITH ALL CITY OF AT�ANTIC REACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BI ACH,FL 32233 08
OFFICE:(904)247-5826 0 FAX NO.(904)247-5845
BUILDING-DEPT@COAE.US DUVAL COUNTY
ELECTRICAL PERMIT APPLICATION
Tv
77,77 7 111,111:
1 7 707,57_
&
j,"M ADDR
Vjd�
0 YES PERMIT
Atlantic Beach, FL 32233
A- =7777, FROPM rRMLEJ!,
5.ADDRESS IF DIFFERqNT FROM JOB ADDRESS: 6.. HONE:
4.NAME:
a
7.NAME OF ANY' B.ADDRESS.:
A11A e-, W--� S 10.CE��PHON AX NO.:
9.STATE OF FLORIDA LICENSE NO: E:-
0")1 a-3 14.
12.EMAIL ADDRESS: 13.OFFICE PHONE: 1
15.Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that all work will be performed to meet
the standards of all laws regulating construction in this jurisdiction. This perm t 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 s x(6)months at a,ny time a ork is commenced.
7/2,A
CONTRACTORS SIGW TURE:
77
4,
OWLTI FAMILY-#OF UNITS: WRESIDENTIAL
U(SINGLE FAMILY 0 TEMP SERVICE 0 COMMERCIAl.
. . .........................
7—&0,,,7;77,
,;,u J%7�1 ',"Wco
001
0 ADDITION 0 TRAILOR 19�',
[3 ALTERATION 0 SIGN [ErOLD 0 N W EV05 NATIONAL ELECTRICAL CODE
0 REPAIR OPOOL/SPA 10 REWIRE 0 OTHER:
1W 40 1
mmS � 1,-X K- I N
0 WIMMI&I
off,
UST 4W 0 UNDERGROUND UP POLE
20.TYPE OF SERVICE- 0 OVERHEAD (3 UNDERGROUND -
- -32-1660WER IS ON 0 POWER IS OFF
21.NEW SERVICE: CONDUCTORS PER PHASE: I
NT -
22.SIZE OF CONDUCTOR: — AMPACITY: �i OCOPPER 0 ALUMINUM
. AMPS: PH: W: VOLT: RACEWAY SIZE:
23.SWITCH OR BREAKER SIZE.
MpS:/100 PH: LT:
24.EXISTING SERVICE SIZE: A W: VO 2!20 RACEWAY SIZE:
#OF AMPS: #-O� AMPS:- #OF_ AMPS:
25.FEEDERS:
26.LIGHTING FIXTURES: INCANDESCENT: FLUORESCENT&M.V-:
27.FIXED APPLIANCES: 0-30 AMPS: 31-100AMPS:— OVER100AMPS:
28.FIRE ALARM: 0 YES 0 NO
DO NOT APPLY TO NEW SINGLE FAMILY,KIULTI-FAMILY AND ROOM ADDITIONS
29.SMOKE DETECTORS: NUMBER:
30.RECEPTACLES: 0-30 AMPS: 31-100 A OPS: OVER 100 AMPS:
31.SWITCHES: 0-30 AMPS: 31-100 A�41PS: OVER 100 AMPS:
-77- 0
AMPS: HEAT KW: /0
#OF UNITS: COMP. MOTOR HP RATING:
#OF UNITS: COMP. MOTOR HP RATING: AMPS: HEAT KW:—
777777,, —' -,
7,777,777,77,
77
7
NUMBER: VOLTAGE: HP: KVA:
NUMBER: VOLTAGE: HP: KVA:
7777777��,!��,��'
77, ""IL71
0,�,'m,77777 7777777
UNDER 60OV: NUMBER: KVA:
OVER 60OV: NUMBER: KVA:
�7777`-`ft**3 �,M I SC r;=1AN EQ V!f W RAI 7,17-7 77,7".
DESCRIBE IN DETAIL:
-31 a
COAB FORM BLDG02:REVISED:118/2008
CIT� OF ATLANTIC BEACH
800 SENUNOLE ROAD
ATLANT
IC BEACH,FL 32233
INSPECTION PHONE LINE 247-5826
NSPECTION EMAIL REQUEST:
Muilding-dentQcoab.us
Application Number . . . . . 08-00000157 Date 2/05/08
Property Address . . . . . . 805 (',AILFISH DR
Application type description MECH)�NICAL ONLY
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
-----------------------------------------------------------------------------
Application desc
INSTALL 1 CU & 1 AHU
---------------------------------------- -----------------------------------
Owner contractor
------------------------ ------------------------
DYER DONS AIR CONDITIONING INC
805 SAILFISH DRIVE P.O. BOX 10206
ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32247
(904) 398-4972
-- -------------------------------------- ------------------------------------
Permit . . . . . . MECHANICAL PER�IT
Additional desc . .
Permit Fee . . . . 79 . 00 Plan Check Fee . 00
Issue Date . . . .
Valuation . . . . 0
Expiration Date 8/03/08
----------------------------------------------------------------------------
Fee summary Charged P id Credited Due
----------------- ---------- ---- ----- ---------- ----------
Permit Fee Total 79 . 00 79 . 00 . 00 . 00
Plan Check Total . 00 . 00 . 00 . 00
Grand Total 79 . 00 79 . 00 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF A LANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
CITY OF ATLANTIC ACH
800 SEMINOLE ROAD,ATLANTIC B CH,FL32233 08-
OFFICE:(904)247-5826 0 FAX NO 904)247-5845
BUILDING-DEPT@COA US
MECHANICAL PERMIT PPLI ATION DUVAL COUNTY
,<NO
)T9J,
it 13 YES PERMIT*
C ri-silantic Beach, F 32233
F'7--
77
4.NAME, 5.ADDRESS IF DIFFER T FROM JOB ADDRESS: 6.PHONE:
W, -_,�M H
7.NAMI�OF COMPANY: 8,ADDRESS.p 0
tc� 47
9.STATE OF FLORIDA LICENSE NO: 10.CELL PHONE- 11.FAXI.
Cf -:4 13
34 � q3IW7 07?-6
12.EMAIL ADDRESS: 13,OFFICE PHONE: 14.
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify 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.
CONTRACTORS SIGNA:URE:
$
16. RRE101 =E*�,i,l
OF 17.3F
111777777
-CIA VOM,
Z NEW INSTALLATION 0 NEW X-RESIDENTIAL X06 FLORIDA BUILDING CODE-
•REPLACEMENT OF EXISTING SYSTEM JdEXISTING 0 COMMERCIAL MECHANICAL
•ALTERATION/ADDITION TO EXIST SYSTEM
13 REPAIR 0 OTHER
-*EPH -,EQUWM Ti:W ----"-77777_7T 1`6i
119 4K�,
7 7777777777777 �i!!:l 1, ik NiM 0"" ""To r
�� Cc
A,
`19.HEAT- 0 SPACE 0 RECESSED ENTRAL 0 FLOOR BURNERS:
20.AIR CONDITIONING: 0 ROOM PICENTRAL
211.DUCT SYSTEM: MATERIAL: F Lgg THI�KNESS: MAXCAPACITY: r0O(_--_cf`m
22.REFRIGERATION: MAX CAPACITY: Cfm
23.COOLING TOWER: ICAPACITY: CIDITI
24. FIRE SPRINKLER: NUMBER OF HEADS:
25.LIFT SYSTEM: ELEVATOR: MANLIFT: ESCALATOR: AUTOLIFT:
26.COMMERCIAL HOOD NUMBER:
27.FIREPLACE: PREFABRICATED: MASONRY:
28.IRRIGATION: 0 PUMP 0 WELL 0 P PING
29.GAS PIPING: #OF OUTLETS: 0 GAq AHU: 0 GAS WATER HEATER:
30.OTHER-SPECIFY:
SOLAR HEATING, BOILERS,UNFIRED
PRESSURE VESSEL,HEAT EXCHANGER
OR COIL IN DUCTS ETC. IVALUE FOR OTHER ITEMS:
��OQ, 40
''llie ii!i��M 4
p,
�$1� III
NUMBER APPROVING
OF UNITS DESCRIPTION MODEL# MANUFACTURER TONS AGENCY
P(A M P SOM I tL F-C-6 V—) 2. L
3 lv� 0
"A
EN 0
'R,
2.:HE
'RARDL,
ON 'M
T$l l
ll
W OIL
NUMBF-R APPKOVIN(3
OF UNITS DESCRIPTION MODEL# MANUFACTURER BTU AGENCY
/a 0 �f3 a '36 00 0
Nil
All$!:
APPRUVINU
NUMBER GALLONS C MANUFACTURER SERIAL# AGENCY
COAB FORM BLDG04:REVISED:118/2008
CITYOF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
------- �NSPECTION PHONE LINE 247-5826
Dill!)
Application Number . . . . . 09-0'0000551 Date 4/22/09
Property Address . . . . . . 805 SAILFISH DR
Application type description ROOF PERMIT
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 735
----------------------------------------------------------------------------
Application desc
REROOF FL9792 . 1
---------------------------------------- --------- ---------------------------
Owner Contractor
------------------------ --------- ---------------
BASS OWNER
805 SAILFISH DRIVE
ATLANTIC BEACH FL 32233
------------------------------
Permit . . . . . . ROOF-PERMIT--- -----------------------------------
Additional desc . .
Permit Fee . . . . 35 . 00 Plan Check Fee . 00
Issue Date . . . . --- Valuation . . . . 735
Expiration Date . . 10/19/09
------------------------------------- -----------------------------------
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 35 . 00 . 00 . 00
Plan Check Total . 00
. 00 . 00 . 00
Grand Total 35 . 00 � 35 . 00 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF AT�ANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
re
0., CITY OF ATLANTIC B CH
800 SEMINOLE ROAD,ATLANTIC B 09-
CH.FL 32233
OFFICE:(904)247-5826 0 FAX NO.::: 4)247-51345
BUILDING-DEPT@COAB. S
BUILDING PERMIT AP LICATION DUVAL COUNTY
B
,-,,��J.jo ADPRESS:,,',
Z VALUA
/I L ae4zk 0
�4.,LEOALDESCRIPTIOW i-�
5.CLASS 1�FWORK�
6.USE,OF STRUCTURE,
13 NEW B JILDING 11 DEMOLITION IZRESIDENTLAL
LOT BLOCK_SUBDIVISION 0 ADDITI)N 13 CONVERTING USE 0 COMMERCIAL
7�QESCRIPTION OF WORk'.'��',L*,.,�,��'.-�,,��,.,-,�', ',�777777777777 El ALTER kTION 11 ACCESSORY BLDG. 8.FIRE SPMNKLER.�-V',-,'�
6REPAIR EIPOOL/SPA El YES 13 N/A
144 q-W 5411.]� 13 MOVE 0 OTHER I IN NO
C'
04
S
0 0
R, 77777777
CONTR RCHITECTIENGIN
PROPERTY OWNER'
0
9.NAME: OMPANY NAME: 23.COMPANY
Irl 7-A- �1 C 19 f� . NAME,
D'� -'�'ffl 2 t L'�
16.NAME: 24.LICENSEE NAME:
10.ADDRESS,/ 17.STATE OF FLORIDA LICENSE 7NO.: 25.STATE OF FLORIDA LICENSE NO.:
1"'ADDRESS: 26.ADDRESS:
f4kWiL -SeaelL F1 322-33
11.OFFICE PHONE: 112.FAX NO.: 19.OFFICE PHONE: --7FAX NO: 27.OFFICE PHONE: 28.FAX NO.:
qr�-j--Z_W--0r7 ?oj fj L,_
13.CELL PHONE: 21.CELL PHONE: 29.CELL PHONE:
14.EMAIL ADDRESS: 22.EMAIL ADDRESS: 30.EMAIL ADDRESS:
SIMPLE.JITLE HOLDER'
DING COMPARw-',� ORtIGA
6
-- `'t- ", 6E ILENDER--.��
i F
31.NAME: 33.NAME: 35.NAME:
AJ(be 00
32.ADDRESS: 34.ADDRESS: j3F1 DRESS:
P4/4K 7A
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed t)meet the standards of all laws regulating construction in this
jurisdiction. This permit becomes null and void if work is not commenced with In 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 commence J. I understand that separate permits must be secured for
Electrical Work,Plumbing,Signs,Wells,Pools,Furnaces,Boilers,Heaters,Tanks, Air Conditionem,etc.
OWNEITS AFFIDAVIT-I certify that all the foregoing information is accurate a d that all work will be done in compliance with all applicable
laws regulating construction and zoning. I will not occupy or use the referenced 4'uilding or any part therof,until all inspections are finaled and
prior to obtaining a certificate of occupancy or completion issued by the building�fflcjal,as required by law.
WARNING TO OW YER:
YOUR FAILURE TO RECORD A NOTICE OF COMMED CEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POST ---D ON THE JOB SITE BEFORE THE
FIRST INSPECTION. IF YOU INTEND TO OBTAIN FIN NCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
�01
OWNER' AGENT`�*�-,' CONTRACTOR
Agenq etter Requi
14�4 L ��:� ( �oa er nly)?.:
Power of Attorney
Signed:)( 4,4,.ta: Signed: Date:
Before me this_day 2009 in the county of Before me:his day of 2009 in the county of
Duval,State of Florida,has personally appeared IlDuval,Stat 3 of Florida,has personally appeared
harin by himself/herself and affirms that all statements and declarations are herin by hir iself/herself and affirms that all statements and declarations are
true and accurate. true and ac mrate.
Notary Public at Large,State of FZ- County of Notary Pub ic at Large,State of_,County of
:01 P.p-Tally Known 11 Personal V Known
Wroduced Identificatiole illl� r2b In /1 11 Producec Identificafion-
Notary Signature: "I-J) .Il. I ( —f Notary Sigr ature:
SHI Ey
L. G HA
Notary Public-
State of F a
�My COmmission ExPires Feb 14,2o 10
BLDG01 PemiiiAp i �nv go V1 ED:q2ffft'"Q')n#DD 518533
gonded BY National Notary Assn.
�;x CITY OF ATLANTIC!BEACH
A/' OWNER / BUILDER,kFFIDAVIT
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART I "CONSTRUCTION
CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNCWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.103(7).FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCT11 TO BE DONE BY LICENSED
CONTRACTORS. YOU HAVE APPLIED FOR A PERM T UNDER AN EXEMPTION TO THAT
LAW. THE EXEMPTION ALLOWS YOU,AS THE OWIN ER OF YOUR PROPERTY,TO ACT AS
YOUR OWN CONTRACTOR EVEN TIiOUGH YOU DO NOT HAVE A LICENSE. YOU MUST
SUPERVISE THE CONSTRUCTION YOURSELF. YOU NAY BUILD ORIMPROVE 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 BI JILT YOURSELF WITHIN ONE YEAR
AFTER THE CONSTRUCTION IS COMPLETE, THE LAI V WILL PRESUME THAT YOU BUILT
IT FOR SALE OR LEASE, WHICH IS IN VIOLATION 0, THIS EXEMPTION. YOU MAY NOT
HIRE AN UNLICENSED PERSON AS YOUR CONTRA(TOR. YOUR CONSTRUCTION MUST
BE DONE ACCORDING TO THE BUILDING CODES .kND ZONING REGULATIONS. IT IS
YOUR RESPONSIBILITY TO MAKE SURE THAT P--_OPLE EMPLOYED BY YOU HAVE
LICENSES REQUIRED BY STATE LAW AND BY CQLNTY OR MUNICIPAL LICENSING
ORDINANCES.
L
11. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT REQUIRES WORKEF'S COMPENSATION INSURANCE BE
PURCHASED UNDER THE HOMEOWNERS INSURANCE POLICY TO CLEARLY PROTECT THE
OWNER.
III. IRS WITHHOLDING; OWNERS HIRING WORKERS BEPOME EMPLOYERS AND SHOULD ALSO
OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 R�EQUIREMENTS ON THE WORKERS THEY
EMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENALTY; UNLICENSED CONTRACTORS CA� OT BE EMPLOYED UNDER ANY
�N
I
CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 ENALTY UNDER FLORIDA STATUTE NO.
455-228(l). AN-OCCUPATIONAL LICENSE- IS NOT ADE ATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENC OR THE FLORIDA "CONTRACTORS
S1
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LItCESED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826) IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THA�T I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
J)R t Ue, -30
ADDRESS HONE NUMBER
A/IftVIL" _;Re1qC_/1
PRINT NAME
4,�'VlfEg 15
SIGNATURE ' DATE
Before me this —day of .20 in the county of
Duval,State of Florida,has personally appeared herin by t�imself/herself and a rms that
all statements and declarations are true and accurate.
Notary Public at Large,State of oe__ County of]Diva
11 Personally Known
L-F,oduced ld
Notary Public-State of Florida
Feb 14,2010
o
41
tM commission Expifes
Y
Notary Signa t #D 518533
Bonded By National Notary Assn.
F/BLDGIO—er- wi—,