225 Sherry Dr 2013 fence CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
n ATLANTIC BEACH, FL 32233
Application Number . . . . . 13-00002328 Date 4/01/13
Property Address . . . . . . 225 SHERRY DR
Application type description FENCE PERMIT
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
----------------------------------------------------------------------------
Application desc
replace fence
----------------------------------------------------------------------------
Owner Contractor
------------------------ ------------------------
TANCRETO CHRISTINA M LIFE OWNER
ESTATE
225 SHERRY DR
ATLANTIC BEACH FL 322335237
----------------------------------------------------------------------------
Permit . . . . . . FENCE PERMIT
Additional desc . .
Permit Fee . . . . 35 . 00 Plan Check Fee . 00'
Issue Date . . . . Valuation . . . . 0'
Expiration Date . . 9/28/13
----------------------------------------------------------------------------
Special Notes and Comments
Avoid damage to underground water/sewer utilities . Verify
vertical and horizontal location of utilities . Hand dig if
necessary. If field coordination is needed, call 247-5834 .
----------------------------------------------------------------------------
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 35 . 00 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 ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
MAP SHoNNG BOUNDARY , SUR .OF
LOT 'S BLOC
I
K ASS SHOWN ;ON SAP OF
tom. t rz r ` t-to,•�•.+r s SgF-S'
AS RECgPgEp NN P,LA-T BooK ?-;1 pAGES 3$ OF THE PUBL,tC RECORDS OF DUVAL COUNTY, FLORIDA
CERf7p, D FOR: l o p
'�7 - �/,-,e- Np-� rJI= 1z.S
Ton n hl pproval ve iea cjompllance with applidable
g, subdivision sand other local; land
dev lopment regulationo.,.but does not-constitute
app VW for the issuance of permits. Compliance
with lorida Building.Code and all other applicable
loca State and Federail permitting requirementsGj�el
mus be verified by s!' nature of the Citof Atlantic
Bea4h Building Offici 1 prior to the Issuance of.a
Building Permit, a
Appr�ved By: `� N
Date
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1IOT VALID UNLESS aIBDSS D Nl1N SEAL Of IJIE dlNDoERSIMED. _BEARIOAt�S.&ALS't73 OYY__F— 'J -UNE-AS SNOW
THE PROPERTY SHO*N, HEREON APPS.RS To I/F w MIAI F►nnn UA7APn WWr 7L- �AC cue i c,r; rn v. n'iw,
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 WELL 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.
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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE' IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA 'CONTRACTORS
CERTIFICATE' TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826)IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
A DRE/SSS ^ PHONE NUMBER
PRINT E
SIGNA E DATE
Before me this day of 20/3he county of
Duval,State of orida,has personally appeared herin by himself/herself and affirms that
all statements and declarations are tru and accurate.
Notary Public at Large,State of County of
P ally Known
roduced Iden• 'on- SHIRLEY L.GRAHAM
„`- MY COMMISSION#DD 957760
EXPIRES:February 14,2014
NotarySigna ''.F'° °' Bonded Thru Notary Public Underwriters
F:BIDG/Owner-Builder Affadavit;REVIS 16/2009
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904) 247-5845
Job Address: �v� �� �14 F 121 0 /7 Permit Number:
Legal Description Parcel#
Floor Area of Sq.Ft. Sq'
t
Valuation of Work$ Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s) circle one):installed?
Residential
If an existing structure,is a fire sprinkler system nstalled? (Circle one): Yes No N/A
Florida Product Approval#
For multiple products use product approva orm
t _
Describe in detail the type of work to be performed: -eo_,�
Property Owner Information: Ile
/ ,
Name:
,� _� u�/L � Address: y0 P+4�U I be►1J A4 ties-
City Stater-(Zip ?L2.?3 Phone 6 2 r---On„b,1
E-Mail or Fax#(Optional)
Contractor Information:
Company Name: Qualifying Ag t:
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 th 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 perform d to meet the standards of all laws regulating construction in this jurisdiction. This permit becomes n 1l
and void tf work is not commenced within six(6)mont or if construction or work is suspended or abandoned for a_period of srx6)months at any time afer
work is commenced. I understand that separate permits must be secured for Electrical Work,Plumbing,Signs, Wells,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 I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this
type cowork will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of any other federal,state, or ocal law regulating construction or the performance of construction.
Signature of Owner Signature of Contractor
Print Name Print Name .......
BeforBefore me
th' ! Day 20 this Day of 20
No c i,nry 14,2014 No Public
otary-tvic Unaarwriters
Revised 10.24.12
RECFIV �
rs� City of Atlantic Beach MAR 18 2013 APPLICATION NUMBER
J� „! Building Department (To be assigned by the Building Department.)
800 Seminole Road BY. _ Z
Atlantic Beach, Florida 32233-5445 _..�
Phone(904)247-5826 - Fax(904)247-5845
.,�s �• ' E-mail: building-dept@coab.us Date routed: SA013
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 76-
Department review required Yes No
Applicant: ,n VE4 anning &Zoning
ree mmistrator
Project: Q
u '
Public Safety
Fire Services
Review fee $ # Depf.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 STATUS
Reviewing Department First Review: Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: Date:
TREE ADMIN.
Second Review: ❑Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
RE MET VED
City of Atlantic Beach MAR 18 2013 APPLICATION NUMBER
�s Building Department (To be assigned by the Building Department)
s3 800 Seminole Road �$ 31-3Z9
j Atlantic Beach, Florida 32233-5445 -
Phone(904)247-5826 • Fax(904)247-5845 l
E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address rVDepartment review required Yes No
Bui�nn�ing &
Applicant: �OIVE74 aZoning
1 ree Oministrator
Project: Q
Pu is afety
Fire Services
;be t Si nature
Review fee $ x p ... g ;. .
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
i
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: PApproved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: Date: 2
TREE DMIN. Second Review: QApproved as revised. ❑Denied.
P WORKS Comments:
P C UTI
�Ty Reviewed b Date:
PUBLIC SAFETY Y'
FIRE SERVICES Third Review: ❑Approved as revised. []Denied.
Comments:
Reviewed by: Date:
Revised 07127110
i� !f City of Atlantic Beach APPLICATION NUMBER
�s Building Department (To be assigned by the Building Department.)
800 Seminole Road .3 3 z 8
Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845
E-mail: building-dept@coab.us t coab.us Date routed: ` I
9-de P
s
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: Z Department review required Yes No
' Buil
Applicant: aGC1
re e mirnstrator
Project: Awd.o�'
U
Public Safety
Fire Services
Reviewfee $—. ' _ : .Dept Signature' s
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 STATUS
Reviewing Department First Review: Approved. ❑
Denied.
(Circle one.) Comments:
BUILDING
03
LANNING &ZONI Reviewed by: Date: 11?
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: []Approved as revised. [-]Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
� y
�j y lJv�
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
±) ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
Application Number . . . . . 13-00003290 Date 8/29/13
Property Address . . . . . . 225 SHERRY DR
Application type description FENCE PERMIT
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
----------------------------------------------------------------------------
Application desc
6FT FENCE REPLACEMENT
----------------------------------------------------------------------------
Owner Contractor
------------------------ ------------------------
TANCRETO CHRISTINA M LIFE OWNER
ESTATE
225 SHERRY DR
ATLANTIC BEACH FL 322335237
----------------------------------------------------------------------------
Permit . . . . . . FENCE PERMIT
Additional desc . .
Permit Fee . . . . 35 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 2/25/14
----------------------------------------------------------------------------
Special Notes and Comments
Avoid damage to underground water/sewer utilities . Verify
vertical and horizontal location of utilities . Hand dig if
necessary. If field coordination is needed, call 247-5834 .
-------------------------------------------------------------------------
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 35 . 00 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 ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
MAP SMINNCCS BO SWr^0�'_
LOT `� 0 l _.S SAHM10— ON MAP OF
:AS RECORDED !N R xT sqw .]' . PAGES -..dry THE PIyHUC RECORPS OF DUVAL COMM,, FLORIDA
CER11F& FOR. e- . / ,� .0 . GoMyr,p: h/EA T'f/ L4,1/
1 'A -
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INE P �ERTY SNOi{A1 H4REON APPEARS TO UE.W7MN FLAQp HA�ZAI�D Z q x AS SC�IL[iD FRg4/ FLOW
INS{lk CE RATF:ALAP' FOR MF, CATV Dim[S in i.( G-H.,FLQRIL A. P TQD-,-:T i 7 yT. AND
MSV A$ A ¢1 N. SY gNLY ANDi L?QE,S,NOTi C1E�1I�Si<ITUTE A CER 1fTON OF - c
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Cotte,A 'SCALE}
ACM4=AV RAD
;DATEL 4-
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,_
City of Atlantic Beach AUG 2 1 2013 APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road
- r�r Atlantic Beach, Florida 32233-5445
�.
Phone(904)247-5826 Fax(904)247-5845 Q d
.^ J IT E-mail: building-dept@coab.us Date routed: d
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: ���� �� r ry Department review required Yes No
I ing
Applicant: 60 Planning &Zoning
ree rniistrator
Project: -77 < Public Works
Ic tilities
• afety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit RequiredFReview or Receipt Date
rmit Verified By
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 STATUS
Reviewing Department First Review: ]Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: Date: ✓ /
TREE ADMIN. Second Review: QApproved as revised. ❑Denied.
�L1lOR- Comments: a,
P BLIC
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: QApproved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
sm
riy�,�r�JCity of Atlantic Beach
AUG6 12013 APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road
o Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845 O
E-mail: building-dept@coab.us Date routed: o
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORD
Property Address: � gyri Department review required Yes No
I ing
Applicant: 1A) Planning &Zoning
ree ministrator
Project: 7— -;�) d Public Works
is tilities
afety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
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 STATUS
Reviewing Department First Review: [ pproved. ❑Denied.
(Circle one.) Comments: �\
BUILDING
PLANNING &ZONING Reviewed by: V3 Z
y Date.
TREE ADMIN. Second Review: QApproved as revised. ❑Denied.
PUBLIC WORKS Comments: 2 a
PUBLIC UTILITIES 3
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: QApproved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
City of Atlantic Beach APPLICATION NUMBER
' � Building Department (To be assigned by the Building Department.)
.i� : s 800 Seminole Road
Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845
E-mail: building-dept@coab.us Date routed: o�d
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: C2rry Department review required Yes No
ing
Applicant: lN_/1"1�C Planning &Zoning
ree ministrator
Project: 4 7— 01 Pu I' Works
-Ptrblic Utilities
afety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
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 STATUS
Reviewing Department First Review: ❑Approved. enied.
(Circle one.) Comments: for (=orhew t0�S on ,1i9Ae o( w �vJdei fla�� So`, mss 5 41/ :Wert
BUILDING be C-1v5er tti►ar, IS ' 40w► 'fie_ edye �� s�✓ie �cvrwiu,l� Please /-e_s-E»,
rrnd 5hor v � 12,9_ *W,-- -411 k i or'e P��:-� s` �o�►�+ j.� 54vv-Q*-
PLANNING &ZONING Reviewed by: 4�� Date: ��►
TREE ADMIN. Second Review: Approved as revised. ❑Denied.
PUBLIC WORKS Comments:,A°P nvet4ter ere aoz rirProA l i,,, kC F(a a�
PUBLIC UTILITIES p f"A� I
PUBLIC SAFETY Reviewed by: < �� Date: 001
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
BUILDING PERMIT APPLICATION (�
CITY OF ATLANTIC BEACH C d
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904) 247-5845 AU 0 2013
Job Address: �2,2 Y Sh&z 91-,11'e- Permit N
Legal Description Parcel#
Floor Area of Sq.Ft Sq. t
Valuation of Work S Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s) (circle one): Commercial esiden
If an existing structure,is a fire sprinkler system installed? (Circle one): es No N/A
Florida Product Approval #
For multiple products use product approval form
Describe in detail the type of work to be performed: 9,o,D/oC e, ipor fi o r, a ex)Ceo Mel f /S
Q GtQi ve 7-0 9� Coaf, tion 7— e4-
Property Owner Information:
Name: Gla Address: aaS
Citya77aa 7,, e ,f46-19 State/-7-Zip 3�33 Phone
E-Mail or Fax# (Optional)
Contractor Information: CONT OR EMAIL ADDRESS:
l n
Company Name: (?rr 6+T v e D 1 SC' i QuGali g Agent: /ver/ fe�T
Address: of -r 0/- 6.) Ci ,Tic State GL Zip 3zz33
Office Phone 90 - v Job e/Contact Num o -6 ,1—o o.- Fax#
State Certification/Registr ion#
Architect Name&Pho #
Engineer's Name& one#
Fee Simple Title older Name and ddress
Bonding Com ny Name and A ress
Mortgage Lender Name and dress
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 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. I understand that separate permits must be secured for Electrical Work, Plumbing,Signs, Wells, Pools, Furnaces,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 I have read and examined this a plication and know the same to be trite and correct. All provisions of laws and ordina ices governing this
type o7Mrk will be complied with whether spect ied herein or not. The granting of a permit does not presume to give authority to tolate or cancel the
provisions of any other federal,state, or local law regulating construction or the performance of construction.
Signature of Owner i'yt ���� Signature of Contractor
Print Name ,t/ .P eTo Print Name
/',h��
........................... ... .................................................................... .............................. .......................................................................................................
Bef e �2 Before me
t ' ay f 201 this Day of 20
Pub
Nota � EXP E5•Feb Notary n
t Af!yd c` Bon hru Not u enytjters v/
Revised 01.26.10
CITY OF ATLANTIC BEACH
OWNER / BU LDER AFFIDAVIT
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION
CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.1.03(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.
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(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.
0a3- Sher& )Dr-ut,
ADDRESS PHONE NUMBER
L119011-
PRINT AME
13
SI A URE DATE
Before me thiy,�::a day of —20 i the county of
Duval.State of Florida,has personally ap ed herin by himself/herself and a�that
all statements and declarations are true an ccura,e.
Notary Public at Large,State of County of �1
❑Per Wally Known
roduced Identification-
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k OMM
Bondrd Thru Notary Public underwr er
— 09