Permit Void 600 Levy Road 2011 r1! Z'l. City of Atlantic Beach !� �! APPLICATION NUMBER
�S a Building Department (To be assigned by the Building Department.)
�; •` 800 Seminole Road
X Atlantic Beach, Florida 32233-5445
Phone (904)247-5826 • Fax(904)247-5845 I
E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
operty Address: )n Z' VV ;Eoa Department review required Yes No
"—T ui din
iplicant: (��1�/l/�z )n r iS�. r��j Planning &Zoni
Tree Administrator
Oj0Ct:
_ ublic Utilitie
llc`a Pubic Safety
Fire Services
Review fee $ Dept Signature,
Other Agency Review or Permit Required Review or Receipt Date
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 Alcoholic Beverages and Tobacco
Other:
APPLICATION NATUS
eviewing Department First Review: pro \ElDenied.
(Circle one.) Comments:
BUILDING
,LANNING &ZONING viewed by: Date:
TREE ADMIN. Seco Revie ❑Appy ed as revised. ❑Denied.
PUBLIC WORKS Com nts:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
wised 05114/09
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach, FL 32233
Office (904)247-5826 Fax (904)247-5845
Job Address: (a o o L r:v A rL• 73 Z P-x Permit Number:
Legal Description Parcel#
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work$ Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Useofexisting/proposed structures)((circle one):• coAOffrcle
Residential
If an existing structure,is a fire sprinider system installe one): Yes No N/A
Florida Product Approval#
For multiple products use product approval form
Describeindetail the type of/work to be performed: 1_t.Y (L x S Cone—Cre, lt4b Y j,.&Aes 4,CL i o row lest
�o2 y'1 06ciCr
Property Owner Information: 1
Name: 8o,yRts o25tfip &-,dreg, i--,,c- Address: (o Do L Evy RDaA
Ci 4-r6q- ,q7'je_ Z E4c.u State rZ Zip 3aa 3 3 Phone Qo(j)
-Mai r Fax#(Optional) Yo ,' ea c-q)- 4;ZJso Z, ,ne✓T
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 I 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,f work is not commenced within six(6)months, or if construction or work is suspended or abandoned fora period ofsix months at any time after
work is commenced I understand that separate permits must be secured for Electrical Rork,Plumbing,Slgns, eUs,Pools, urnaces,Boilers,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 hereb certify that 1 have read and examined this plication and know the same to be true and correct. All provisions of laws and ordinances governing this
type o?.work will be complied with whether speed herein or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of arty other federal,state, or local law regulating construction or the performance of construction.
Signature of O4rie�'Y''�C k''C� Signature of Contractor
Print Name ,74*".P....Y.!......t. ............................................................. Print Name
.........................................................................................................................................
Swor44p and subsc 'bed before me Sworn to and subscribed before me
this of,11 20 It this Day of ,20
,,,
' '_
Notary Pu is � ;,�,�# ENI Notary Public
ECxp miresJJu e 1b 2012
gppg867019 Revised 01.26.10
JS r y'i
CITY OF ATLANTIC BEACH
OWNER / 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 HONE NUMBER
S om�Z;�S E
PRINT VAME
SIGNATURE `J DAT
Before me this g day of M�'� 20 L/ in the county of
Duval,State of Florida,has personal appeared herin by himself/herself and affirms that
all statements and declarations are twe and accurate.
Notary Public at Large,State of 1 V County of
❑personally Known
ducd Identification 2Po ^i,9. _q
Notary Signature: ;tiM"eiF,: ENID V.JOHNSON
- ; �_ Commission DD 797850
-or€ Expires June 15 2012
F./BLDG/Owner-Builder Affadavit;REVISED:4/16/2009 �'%„QF W10.°�'� Bonded Thru Troy Fain Insumnoe 809-3857019