429 Skate Rd 2014 Roof (voided) rs'Vi, � City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by e Building Department.)
I q
800 Seminole Road -
Atlantic Beach, Florida 32233-5445
Phone (904)247-5826 - Fax(904)247-5845
E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: Z CS /��C.1 Department review required Yes No
Build in
Applicant: O��� anning &Zoning
Tree Administrator
Project: Public Works
Public Utilities
Public Safety
Fire Services
Reiew $ Dept Signature
Review or Receipt
h Age y Revie r Permit Required ona+of -.
FloM Dept. of E onmental Protection 54 rV L"t PI it S
Flori Dept. o ransportation
St. Johns RA Water Management District -r-C)-r-C)f n4 Lv l
Army VS of Engineers
Divisi of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION S'
Reviewing Department First Review: ❑Approved.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING
Reviewec
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 05/14/09
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH Lr,
800 Seminole Road, Atlantic Beach, FL 32233 L,
Office (904) 247-5826 Fax (904) 247-5845 20 14I
B
Job Address: Z Permit Numbe Y / 6
Legal Description Parcel#
Floor Area of Sq.Ft. Sq*
t
Valuation of Work$��d r 0 a 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 Residential
If an existing structure,is a fire sprinkler sy installed? (Circle on ): es No N/A ,� c
--�,• / , G
Florida Product Approval# L !Q Z J
For multiple products use product appr va form GG G f,("f j•ri►
Describe in detail the type of work to be performed: G
zm
Property Owner Information: O
Name: i/11 Y Addres Z re 'P,.-4
City State ip one
E-Mail or Fax#(Op tonal)
Contractor Information:
Company Name: Qualifying A ent:
Address: City State Zip
Office Phone Job Sit 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. 1 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 six6)months at any time after
work is commenced. I understand that separate permits must be secured for Electrical Work, Plumbing, Signs, Wells, Pools, urnaces,Boilers, Renters,
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.
1 here b certify that I have read and examined this a plication and know the same to be true and correct. All provisions of laws and ordinances governing this
type o7Mrk will be complied with whether speci ied 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 local law regulating construction or the performance of construction.
nature of Owner Signature of Contractor
Q �lrl� ✓ Print Name
.........................................................................................................................................
int
Name 1.......... .
Before me
Be
thiso a of e 20 / ` this Day of - 20
is State of Florida
Notary Pu is st►irley L GrahamNotaryP lic
Commi»ioe FF 086990
i
xpins OSI14t2018 Revised 10.24.12
C �
Ii.
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.
Zq cwt /9 �&
ADDRES PHONE NUMBER
Dn&r /9) ill
g 4-
7
T NAME
SI ATURE /� I DATE
Before me this /3 day of/ C/I►` ,20/ i e county of
Duval,State of Florida,has personally appeared peri imself/herself and�that
all statements and declarations are tr ccurate.
Notary Public at Large,State of �,County of
Xrsonally Known �/
Pduced Identi ion- (/
Notary Pudic State of Florida
Notary Signat : My Ceomg
mirion FF 088990
OF Expires 0211412018
RBLDG/Owner-Builder Affadavit REVISED: 4/6/2009