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Permit Plumbing 1780 Park Ter E 2013 CITY OF ATLANTIC BEACH r) 800 SEMINOLE ROAD J == ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 Application Number . . 13-00001951 Date 1/07/13 Property Address . . . . 1780 E PARK TER Application type description PLUMBING ONLY Property Zoning . . . . 1, . . . TO BE UPDATED Application valuation 0 ---------------------------- ----------------------------------------------- Application desc � back flow ---------------------------- -------------------- --------------------------- Owner Contractor ----------------------- ------------------------ APP LAWRENCE OWNER 1780 PARK TERR E ATLANTIC BEACH FL ,32233 ---------------------------- ----------------------------------------------- Permit PLT BING PERMIT Additional desc . . Permit Fee . . . . 62 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 0 Expiration Date 7/06/13 ----------------------------- ----------------------------------------------- Other Fees . . . . . . . STATE PLBG DCA SURCHARGE 2 . 00 STATE PLBG DBPR SURCHARGE 2 . 00 - --------------------------- ----------------------------------------------- Fee summary Charged Paid Credited Due ----------------- ---- ----- ---------- ------ ---------- Permit Fee Total 162 . 00 62 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 Other Fee Total 4 . 00 4 . 00 . 00 . 00 Grand Total 166 . 00 66 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WI TH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. PLUMBING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd Atlantic Beach, FL 32233 Ph(904)247-5826 Fax(904)247-5845 Gj Jos ADDRESS: t783o P L j3 � PERMIT# NEW OR REPLACEMENT INSTALLATIO !: Project Value$ TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY Bathtub Septic Tank&Pit Clothes Washer Shower Dishwasher Shower Pan Drinking Fountain Slop Sink Floor Drain Three Compartment Sink Floor Sink Toilet Hose Bibs Urinal Kitchen Sink Vacuum Breakers Laundry Tray Water Connected Appliances Lavatory Water Heater Other Fixtures Water Treating System RE-PIPE: TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY Bathtub Septic Tank&Pit Clothes Washer Shower Dishwasher Shower Pan Drinking Fountain Slop Sink Floor Drain Three Compartment Sink Floor Sink Toilet Hose Bibs Urinal Kitchen Sink Vacuum Breakers Laundry Tray Water Connected Appliances Lavatory Water Heater Other Fixtures Water Treating System MISCELLANEOUS: ❑ Sewer Replacement � MISCELLANEOUS- 0 Flow Preventer ❑ Grease Interceptor(Trap) gallons(Requires 3 sets of plans) ❑ Lawn Sprinkler System-Number of Heads ❑ Well ** VRWD Well Completion Form. Completed fonn to be submitted to the Building Department for final inspection.** ❑ Other Permit becomes void if work does not commence within a six mo n1t i period or work is suspended or abandoned for six months.I hereby certify that v P y fy I ha a read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified Dr not. The permit does not give authority to violate the provisions f any other state or local law regulation construction or the performance of construction. Property Owners Name ANJ Q� t�� Phone Number r-,2 AW pq6 00,9 Plumbing Company A�_ Office Phone Fax Co. Address: LL City State Zip 1.� �(Print): UVJ Qk � State Certification/Registration# Votcarized Signature of License Holder P ,��lalaubS, bed be or e this -7 d y f 2013 'r � `t`,�P:IP�IiSSION k DG 95y760 ;IT � ' Public noml2s Th oto u lic n eM n e 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 HAVEAPPLIED 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 CONSTRUCTI N YOURSELF. YOU MAY BUILD OR IMPROVE A ONE—OR TWO FAMILY RESIDENCE 09 A FARM OUTBUILDING. YOU MAY ALSO BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS. THE BUILDING MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE. IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR AFTER THE CONSTRUCTION I$ 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. -oo82 ADDRESS PHONE N MBER �P PRINT AME 1 /off- 13 SIG ATURE ( }� DATE Before me this day of 20 n the county of Duval,State of Florida,has personally appeared erin by himself/herself and affirms that all statements and declarations are true and ac cur. te. Notary Public at Large,State of C�unty of ❑P allyKnown roduced Identification- _� SHIRLEY L.GRAHAM Notary Signatu 'I _ 1IV C,pbIMfSSICN Y DD 9577E0 -' XRF ES:February 14,2014 Bonded i hru Neta P F:BLDG/Owner-Builder Affadavit;REVISED: 6/2009 Notary Ub,IC Und9fN1rIt8rS