1595 Beach Ave 2013 sewer/water pipe replmnt CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
Application Number 13-00002397 Date 3/29/13
Property Address . . . . . . 1595 BEACH AVE
Application type description PLUMBING ONLY
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
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Application desc
REPLCE SML PIECE OF WATER AND SEWER LINE
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Owner Contractor
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BLACKARD WILLIAM R JR. OWNER
3531 HEDRICK ST
JACKSONVILLE FL 322059406
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Permit . . . . . . PLUMBING PERMIT
Additional desc . .
Permit Fee . . . . 69 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0:
Expiration Date . . 9/25/13
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Other Fees . . . . . . . . . STATE PLBG DCA SURCHARGE 2 . 00
STATE PLBG DBPR SURCHARGE 2 . 00
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Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 69 . 00 69 . 00 . 00 . 00
Plan Check Total . 00 . 00 . 00 . 00
Other Fee Total 4 . 00 4 . 00 . 00 . 00
Grand Total 73 . 00 73 . 00 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
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
OWNER OF YOUR PROPERTY�TO ACT AS
LAW. TBE EXEMPTION ALLOWS YOU,AS TTIE
YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST
SUPERVISE THE CONSTRUCTI YOURSELF. yOUMAyBUMDORIMPROVEAONE-OR
YOU MAY ALSO BUILD OR
TWO FAMILY RESIDENCE OR A FARM OUTBUILDING-
IMPROVE A COMMERCIAL BUILDING AT A COST OF$25�000-00 OR LESS. THE BUILDING
ST 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
SUME THAT YOU BUILT
AFTER THE CONSTRUCUON IS COMPLETE,THE IAW WILL PRE
YOU MAY NOT
IT FOR SALE OR LEASE. WHICH IS IN VIOLATION OF T`HIS EXEMPTION'
HIRE AN UNLIC SED PERSON.AS YOUR CONTRACTO 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 STA E LAW AND.BY COUNTY.OR MUNICIP , LICENSING
ORDINANC S.
11. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED.
Ill. IRS V41THHOLDING;'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 UND_ERANY
CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA.5 IATUTE No.
455-228(j). 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.
PHONE NUMBER
ADDRESS
&
P NT NA E
7/41
18tGOATU
A20 n the county of
Before me thi day of
Duval,State of Florida,has personally appeared h.rin b� I herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of County of
pyermally Known
Ev-duced Identificatio
SrrIRLE�!. GRAI-1k,'.
Glojl,*,,��!C,�J(`,N--i)P 7.
.�z EXPIRES:Fo�,;*U�,�,,,14
Notary Sign.
dedlhri,Nota�ryPutd
FIBLDG/0�w-Builder Affadavit; 4/16/2009
PLUMBING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd Atlantic Beach, FL 32233
Ph(9 4) 247-5826 Fax (904)247-5845
PERmrr
JOB ADDRESS:
NEW OR REPLACEMENT INSTALLATION: Project Value
QTY TYPE OF FIXTURE QTY
TYPE OF FIXTURE
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
Water Connected Appliances
Laundry Tray
Water Heater
Lavatory Water Treating System
Other Fixtures
RE-PIPE:
TYPE OF FixTuRE QTY TYPE OF FIXTURE QTY
Septic Tank&Pit
Bathtub Shower
Clothes Washer Shower Pan
Dishwasher Slop Sink
Drinking Fountain Three Compartment Sink
Floor Drain Toilet
Floor Sink Urinal
Hose Bibs Vacuum Breakers
Kitchen Sink
Laundry Tray Water Connected Appliances
Lavatory Water Hea"ter
Other Fixtures Water Treating System
MISCELLANEOUS:
_t1i (Trap) gallons(Requires 3 sets of plans)
o Sewer Replacement Ei Back Flow reventer o Grease Interceptor
Ei Lawn Sprinkler System-Number of Heads ci Well
SJRWD Well Completion Form. Complete&-forin to be submitted to tfie-Building Department for final inspection.�
coi Other
ence within a six month period or work is suspended or abandoned for six months.I certify that I have mad
Permit becomes void if wodkdoes not comm ances governing this work will be complied with whether specified
this application and know the same to be true and correct. All provisions of laws and ordin
nstruction or the performance of construction.
give author to violate the provi on of any other state or to I law regulation co
or not. The permit does not
Property Owners Name Phone Number
O�
ff
1 Fax
Plumbing Company office Phone
Co. Address: city State_Zip
License Holder(Print): State Certification/Re ation#
Notarized Signature of License Holder
Before me this day of 20
1_
Signature of Notary PPXubl*
S TOP WORK
CITY OF ATLANTIC BEACH
BUILDING AND ZONING DEPARTMENT
NT
, e
NOTICE
This building has been inspected and:
0-V
F� General Construction F� Mechanical
Concrete and Masonry R Electrical
Plumbing R Gas Piping
IS NOT ACCEPTED
CORRECT AS NOTED BELOW� BEFORE ANY FURTHER WORK
Pa I r �o S�e A-/- i? Z-ot
vA-T 19-e f-rv,,,,
I
DO NOT REMOVE TMS NOTICE
Inspector: -12� Date: 3
Failure to respond to t is Notice within 10 days will result in this violation being forwarded
to the
CODE ENFORCEMENT BOARD.
The posting of this Placard by its contents shall serve as due notice.