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
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Application desc
drain for water run off
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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
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Permit RESIDENTIAL ALT/OTHER
Additional desc . .
Permit Fee . . . . 55 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 200
Expiration Date . . 4/20/13
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Special Notes and Comments
Must install riser or other termination 101 from property
line.
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Other Fees . . . . . . . . . STATE DCA SURCHARGE 2 . 00
ENG REV PRE APP > 3 HRS 25 . 00
STATE DBPR SURCHARGE 2 . 00
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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