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Permit Res Other Drain 1540 Main St 2012 CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 Application Number . . . . . 12-00001456 Date 10/22/12 Property Address . . . . . . 1540 MAIN ST Application type description RESIDENTIAL OTHER Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 200 ---------------------------------------------------------------------------- Application desc drain for water run off ---------------------------------------------------------------------------- Owner Contractor ------------------------ ------------------------ BIDLACK ADAM M ET AL OWNER BIDLACK, REBECCA & GORDON 1540 MAIN ST ATLANTIC BEACH FL 32233 --- Structure Information 000 000 DRAIN FOR WATER RUNOFF Occupancy Type . . . . . . RESIDENTIAL ---------------------------------------------------------------------------- Permit RESIDENTIAL ALT/OTHER Additional desc . . Permit Fee . . . . 55 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 200 Expiration Date . . 4/20/13 ---------------------------------------------------------------------------- Special Notes and Comments Must install riser or other termination 101 from property line. ---------------------------------------------------------------------------- Other Fees . . . . . . . . . STATE DCA SURCHARGE 2 . 00 ENG REV PRE APP > 3 HRS 25 . 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 29 . 00 29 . 00 . 00 . 00 Grand Total 84 . 00 84 . 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 JobAddress: Permit Number: Legal Description 114 -7 s -If -7o-5 0 A ?� 1"k I A,c� 1 14:zl Parcel# Floor Area of S q.r t Sq Ft Valuation of Work Proposed Work heated/cooled no*n-heated/cooled r1qN Class of Work(circle one): �� 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 approv-aTTo—rm Describe in detail the type of work to be performed: r tOL'(-k iv A\-,Lr r A Property Owner Information: Name: A1JkAe% 1�,; M.(, Address:-.-..1,0c, -44A �^ City_AV\-�,-,­ L-Ii z,i,(_ State&-Zip Phone r,6!j _ &:I I Ll I S-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 4 Fee Simple Title Holder Name and Address Bonding Company Name and Address Mortgage Lender Name and Address a, n " reb ade 0" a ermil 10 do he work and installations as�ndic or installation has commenced prior to the f ,pp"c c io is e mi Y md h to o't 'rk p be e 0 m'd 10_Z,the san�ads a law thisjurisdiction. This permit b�comes mill an e a ,an ' w i r r 0 is not c,_at a" 0 t w"'a p 6)months or, c _,trct, n or�ork"s a eriod ofsixp6)months at anV timeafter su P k' e ed hi 0 t,p"mi s m, t secur f or I ctrIc w n ,nc (a b ed E e id/s, Pools, lurnaces, Boileis, Heaters, d d. ta d t at"P, d'o'd 0 "'k is com_e c, s n T'n , . . t k a dAr C"di i",rs'ec- 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 FINANCING9 CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. I hereby ceriffy that I have read and examined this application and know the same to be true and correct. .411 provisions oflaws and ordin 6 governinz this ope P�work W11 be complied with whether specified herein or not. The granting of a permit does not presume to give authority to vaiolcatse or canc�l the provisions of any otherfederal.state, or local aw regulating construction or the peTformance ofconstruction. Signature of Owner A-el— Signature of Contractor Print Narne .......... .............................................................. Print Name ....................................................................................................................... lwo,nke,�_,S�_ scrib 'fore Sworn to and subscribed before nie this 0 2012- this Day of 20 Notary u ORMA 'y c, �rfAISSION P,DID 957 �o ta�ryPublic PIFES:February 14,2014 Pondeo Thru Notary Public Unlervifitors 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 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. I 11. 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(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. 3vr-z-�- fog ,a - Lj-1 S7Z- ADDRESS PHONE NUMBER A&,, Ut— PRINT NAME ......... -.:;?..................... 1,o SIGNATURE DATE I Before me this day of 10 e-7— 20_L2�nthe county of Duval,State of Florida,has personally appeared herin by himself herself and affirms that all statements and declarations are true and accurate. Notary Public at Large,State of County of 0 Personally Known "Y'nowno, ca CWroduced dentificatio tur Notary Sig ture: R HAM SHIRLEY L.G�AD ,4P 't-, :6N D D 957760 My CO�JfAISSION#DD 957760 phr,�p y FALDG/0�er-Build Affaclavit;REIM 4/16/2009�� ill" '* F 14 2014 y 14.2014 I"'j"j, -ub,., rv, Q,� i 2m,Nnjary v lie i)odervinter� City of Atlantic Beach APPLICATION NUMBER Building Department (To be assigned by the Building Department.) -P 800 Seminole Road 0 Atlantic Beach, Florida 32233-5445/,t 201, 12 - Fax(904y'2401 Phone(904)247-5826 E-mail: building-deptQcoab.us Date rotAed: Cityweb-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: Department review re uIred Yes No Building Applicant: -Planning&Zoning Tree Administrator Project: &q,7T 29�1CWo_A_s Public Utilities Public Safety Fire Services Review fee Dept Signature Other Agency Review or Permit Required Review or Receipt Date I of Permit Verified B 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 AJcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: [gApproved. E]Denied. (Circle one.) Comments: BUILDING PLANNING&ZONING Reviewed by: _.4e4 Date:Y'49 TREE ADMIN. C, Second Review: DApproved as revised. FIDenied. PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: ElApproved as revised. MDenied. Comments: Reviewed by: Date: Revised 07127110