354 Sargo Rd interior remodel 2013 CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
Application Number . . . . . 13-00003204 Date 8/06/13
Property Address . . . . . . 354 SARGO RD
Application type description RESIDENTIAL ALTERATION
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 500 ---------------------
-------------------------------------------------------
Application desc
DEN INTERIOR REMODEL
-----------------------------------------------------
Owner Contractor
------------------------
------------------------
SCHIFFMAN STEVEN D. OWNER
354 SARGO ROAD
ATLANTIC BEACH FL 32233
--- Structure Information 000 000 REMODEL DEN
occupancy Type . . . . . . RESIDENTIAL ------
---------------------------------------------------------------------
Permit . . . . . . RESIDENTIAL ALT/OTHER
Additional desc - -
Permit Fee . . . . 55 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 500
Expiration Date . . 2/02/14
--------------------------------------------------------------------- ------
Other Fees . . . . . . . . . STATE DCA SURCHARGE 2 . 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 4 . 00 4 * 00 . 00 . 00
Grand Total 59 . 00 59 . 00 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLOR DA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach,FL 32233
Office (904) 247-5826 Fax (904) 247-5845
?
Job Address: 31f �o x7a t�4 /ov"9"�,F/C_ Permit Number:
Legal Description I""'' Parcel#
Uloor Area Y. I'', 11Ft.
Valuation of Work$ Proposed Work heated/cooled non-heated/cooled
— c
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Residential
Use of existing/proposed structure(s)(circle one): Commercial
If an existing structure,is a fire sprinkler system installed? (Circle.one): Yes No N/A
Florida Product Approvat#
For multiple products use�_roduct approval form
ed: &7
Describe in detail the t pe of work to be perform
I-,'
4f: 1
Property owner Informotion:
Name: Address:
2 7
ip YA233 ?hone Lf
city egii WL/Re 6z&,# Stat Ii-Z. --ZA23 -1
E-Mail or Fax#(optional)— !z F c
Contractor Informationt
Company Name: Qu ing Agent: State Zip
Address:
Office Phone Job Site/Contact N er 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
4ppication is hereby made to btain a ermit t o the work and installat o as indicated I certify that no work or installation has commencedprior to the
issuance o a permit and that ail work will be rmed to meet the standards of all laws regulating construction in thisjurisdiction. Thispermit becomes null
months, or if construction or work is suspended or abandonedfor eriod ofsixfi months at any time after
I i I r eaters,
and void i work is not commenced within s* (6 1 lie V,us,Poo s, urnaces,Boi e s,H
work is commenced I understand that s arate permits must be secured for E ec ar Work,Plumbing, Si ns,
Tanks and Air Conditioners,etc.
CE OF
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTI
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 YOUk NOTICE OF
COMMENCEMENT.
examined this application and know the same to be true and correct. Allprovisions of laws and ordinances governing this
I hereby cer ify that I have read and or cancel the
type oj work will be complied with whether specified herein or not. The granting of a permit does not presume to give au to violate
provisions of any otherjederai�state, or local law regulating co ction or the peFformance of construction.
ignature of Contractor
Signature of Owner
Print Name
............................ ...................................... ................................................................
Print Name .........................................................................................................
Befor me Before me
#DD 95n60 2013 this —Day of 20
this
P ftic U erwftn
rmd WIC U
Notary Public
N i;t- ic
Revised 10.24.12
DO NOT WRITE BELOW- OFFICE USE ONLY
Applicable Codes: 2010 �ORIDA BUMD-77VU CODE
Review Result�(circle one):
Approved Disapproved Approved w/ Conditions
Review Initials/Date:
Developmen
Habitable Space Non-Habitable
Impervious area
Miscellaneous:,Information
Occupancy Group
Type of Constr i uction
Number of Stories
Zoning District
Max. Occupan!cy Load
Fire Sprinklers Required
Flood Zone
Conditions/Comments:
CITY OF ATLANTIC BEACH
OWNER / BUILDER AFFIDAVIT
PART I "CONSTRUCTION
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES,
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.�� TBE EXEMPTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY
YOUR OWN CO-VM ACTOR F-VPM T1401 JQ.14 U DO NOT HAVE A LICENSE.
YOU MAY BUILD OR IMPROVE ONE-OR
I
I—RIVENCE OR A FARM kBUILDING. YOU MAY ALSO BUILD OR
IMPROVE A COMNIERCIAL BUILDING AT QOqT OF$25.000.00 OR LESS-=BUFUJIUla-1
MUST BE FOR YOUR USE AND OCCUPANC:Y.
IF YO SELL OR LEASE A BUILDING YOU wITH-E777M YEATF
AFTER TBE CONSTRUCTION IS COMPLETE, THE LAW WELL PRESUME' THAT YOU
YOU
THAT
IT FOR SALE OR LEASE. WIHCH IS IN VIQ-LA11QhLQL.=S EXEMPTIO:=
[ T
YOUR CONS R
:i
—1-FING TO TBE BUIL _jjU 70NING REGULATIONS.
_p (�WiOQ ARM
w
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.
40.
$ , 0"Op
CUPATIONAL LICENSE".IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE 1 COUNTY "CERTIFICATE OF COMPETENCY' OR THE FLORIDA "CONTRACTORS
i NTRACTOR. TELEPHONE THE
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CO
BUILDING DEPARTMENT(247-5826) IF IN DOUBT.
V.ACKNOVVLEDGEMENT; 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-BU�ILDER PERMIT.
-5'
3PY
ADDRESS T—HONE NUMBER
PRIN NAME
SlGRATURE DATE
Before me this day of 20Lain the county of
Duval,state of Florida,has personally app re a n by himself/herself aqd affirms that
all statements a nd declarations are true d acc te.
Notary Public a�Large,state of un of
[I Personally Knclwn
OProduced I a ti
SHIRLEYLGRAHAM
-.*s .,IY uummlb510N#DD 957760]
Note na 01
ebruary 14,2014
t:X IRESA
.4nn&d Thru Wary Pulft Underwrthn
FIBLDG/0—er-B ilder Affaclavit;I SED: 4/16/2 A-