770 TRITON RD SHED 2014 CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
J
- r ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
SHED PERMIT
JOB INFORMATION:
Job ID: 14-SHED-165
Job Type: SHED PERMIT
Description: 10 x 12 shed
Estimated Value: $2,779.00
Issue Date: 10/14/2014
Expiration Date: 4/12/2015
PROPERTY ADDRESS:
Address: 770 TRITON RD
RE Number: 171333-0000
PROPERTY OWNER:
Name: ROCKWOOD, DAVID A
Address: 1790 MAYPORT RD
PERMIT INFORMATION:
FEES:
BUILDING PERMIT FEE $63.90
STATE DCA SURCHARGE $2.00
PLAN CHECK FEES $31.95
STATE DBPR SURCHARGE $2.00
Total Payments: $9985
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
APPLICATI
BUILDING PERMIT ON
BEACH
FILE
C CITY OF ATLANTICD M
800 Seminole Road, Atlantic Beach, FL 32233 IJ
Office (904) 247-5826 Fax (904) 247-5845
n�
Job Address: Permit Nimber:
Parcel# By ----
Legal Description t
Floor ea o q• t• Sq
'Ft
of Work$ 2��q C1•D Proposed Work heated/cooled non-heated/cooled 12-6
Class of Work(circle one): Ne 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 system installed? (Circle one): es o N/A
Florida Product Approval#
For multiple products use product approval orm
Describe in detail the type of work to be performed: S G�
Property Owner Information:
Loc_I<< ic,Cj C Address:
Name: y cS State�Z1 3 zZ3 3 Phone 6 E4-94 V - 3 S8 &
City (�+lc-�-�;c- �-c4 p
E-Mail or Fax#(Optional) 2-
Contractor Information:
Company Name: Qualifying Agent:
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
that
work
mmenced
rior
isPualnceionis a permit hereby nd that obtain
w111 belt to do the performethe
d toork and installations as meet the standards of all laws tror work is suionpegulating construction inothpis�urrisa canon This perm it becomesonull
and work void if
rework is not
tI ommenced within six understand that separate permits must or be seeuconstructred for Electrical Work,Plumbing,Sigended or ns,aWells,Poeriod ols,
urnaces,Boilers,tHeaters,
Tanks and Air Conditioners,etc.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT TEND O OBTAIN FINANCING, CON IMPROVEMENTS
LT WITH
UR PAYING TWICE FOR TO YOUR PROPERTY. IF YOU IN
YOUR LENDER OR AN ATTORNEY BECOMMEOR RECORDINGMENTYOUR NOTICE OF
I reythis
know t
esame to be tand
le10vaws nordtnances governing t1
hpeowork w will be complied with whetheriiedheren or not. The granting of o permit does not presume to give authority toviolate or cancel he
provisions of any other federal,state, or local law regulating construction or the performance of construction.
Signature of Owner c r`—'�-7 Signature of Contractor
Print Name Print Name
! ........ ........ ..C..... ............ .��.................
BeforVfle Before me 20
this Day 20 this Day of
Notary Public ' Shirley L Graham Notary Public
y My Commission FF 086990 Revised 10.24.12
of Expires 02/14/2018
s�I y:1TJ j% �„sew^,•,�a:,�r�,yrss�a;,+�a.�.r«�p wr
CITY OF ATLANTIC BEACH
7_7 FILE
COPY
ER / 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.
111. 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.
ADDRESS !� PHONE NUMBER
PRINT NAME
SIGNATURE j� (� DATE
Before me this�day of �/ 20 �n the county of
Duval,State of Florida,has personally appeared herin by hi se f/herself and affirms that
all statements and declarations are tru d))accurate.
Notary P blic at Large,State of 'County of
Personally Known
D Produced Identification-
Notary Signature:
el,oz/Vwzo••,ld><q
0669903:1 uolsslwwo0 FW Olt)
wetyeJO�491JIyg F:BLDG/Owner-Builder Aft'adavit;REVIS /16/2009 spoolj)o a3erg ollgnd/uei°N
Ht E PY
Eye Anchor Kit Instructionsa
Do-it-Yourself protection for most outdoor structures or possessions.
Includes: 3011 Anchors,
Wire Clamps
& 60 ft Cable
Part #59075
0
1. Install ground anchors as close to the building as possible at all four corners.
A. Install anchors using a straight rod to turn (screw) anchor into the ground.
B. A starter hole,up to 1/3 of the anchor length can be used to start anchor into the ground. Once the anchor
eye is level with the ground, backfill the soil and pack area around the anchor eye.
C. Anchor eye should be just above soil level.
2. Cable can be secured to the building using the following methods.
A. Attach one end of the cable to an anchor using the wire rope clip. Cable goes thru the anchor eye and is
clamped together using the wire clips (2). Place the cable over the roof to the opposite anchor, loop cable
thru anchor eye. Cut cable to have enough to attach to the anchor. Pull cable tight, attach 2 wire rope clips,
tighten nuts. Repeat for other side.
B. Attach cable to the side wall studs.Additional hardware required,bolts, washers nuts and wire rope clips.
All available at your local hardware supply.
NOTE:
These instructions are for suggested attachment to small shed not located in high wind areas. For more
detailed anchor requirements, see the wind zone charts for your area.You may need additional anchors,
cable,wire clamps or other forms of anchor attachments to the shed to meet local or state requirements.
Twelve(12) Month Limited Warranty
All tie down anchors,when installed in accordance with the manufacturers recommendations
and when used within the suggested capacities are guaranteed for 12 months from date of
purchase against defects in material or workmanship.
If returned prepaid to the factory.TIE DOWN ENGINEERING will replace without charge the
defective part.Labor delays or damage are not covered by this warranty and while this warranty
gives you specific legal rights,you may also have other rights with vary from state to state.
O
Instruction#08091
TIE • • Drive
www.tiedown.com (404) 344-0000 • • ,
Statesman
w _ I Tall gable with built-in functionality.
p � • 7ft.tall side walls
1 1 • Extra-wide 64in.double doors with decorative
strap hinges
• Includes complete floor
7ft.
- Vents
Q
Window
- Loft
•
shelves
Do-It-Yourself Installed
✓ Size/Category Item= Model# Base Item# Base Add Paint At
10 x Sft. S 437 ?' 183553 $1499 437575 $2299 $340
Statesman
x Oft. M -572 183560 $1699 437576 $2599 $425 s
s, loft.x 12ft. , :371 191305 -$1799 85205 $2799 $510 -
.
Shown with
11 1Oft.xl6ft. L_- 223874 191404 299 325264 99 680
❑ 12ft.x 12ft. L E0832 192654—$2199 91031 $3299 $612 optional
CI 12ft.x16ft. L 80972 192708 X$2849 91254 $3799 $816
ro -up door
❑ 12ft.x 21)ft_ L 81391 192753 $3349 92703 $4299 $1020_
❑ 12ft.x 24ft_ L _ 81392 _ 192807 $3849.92947 $4799 $1224
See full specifications on page 13 A
s
Gentry
Distinctive style with country charm.
• 7ft. tall side walls
• Extra-wide 64in.double doors with
decorative strap hinges
• Includes complete floor
f�r
- Vents
- Window
, Shutters
- Loft
Workbench
- Shelf
Pegboard
Do-it-yourself Installed
✓ Si Category Item= '.'odel# Base Item# Base Add Paint
ft.x 10ft. M 319 r 2'i0o $1899 83287 $2899 $510
12ft.x 12ft L 83367 S2549 92983 $3499 $612
——' -' —"-- Some models shown with optional accessories.
See s_e_ rs en page 13 See page 13 for more details.All stated sizes are nominal.
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Eye Anchor Kit Instructions =
Do-it-Yourself protection for most outdoor structures or possessions.
Includes: 3011 Anchors,
Wire Clamps
& 60 ft Cable
Part #59075
1,V a° �
0
1. Install ground anchors as close to the building as possible at all four corners.
A. Install anchors using a straight rod to turn (screw) anchor into the ground.
B. A starter hole, up to 1/3 of the anchor length can be used to start anchor into the ground. Once the anchor
eye is level with the ground, backfill the soil and pack area around the anchor eye.
C. Anchor eye should be just above soil level.
2. Cable can be secured to the building using the following methods.
A. Attach one end of the cable to an anchor using the wire rope clip. Cable goes thru the anchor eye and is
clamped together using the wire clips (2). Place the cable over the roof to the opposite anchor, loop cable
thru anchor eye. Cut cable to have enough to attach to the anchor. Pull cable tight,attach 2 wire rope clips,
tighten nuts. Repeat for other side.
B. Attach cable to the side wall studs.Additional hardware required,bolts, washers nuts and wire rope clips.
All available at your local hardware supply.
NOTE:
These instructions are for suggested attachment to small shed not located in high wind areas. For more
detailed anchor requirements,see the wind zone charts for your area.You may need additional anchors,
cable,wire clamps or other forms of anchor attachments to the shed to meet local or state requirements.
Twelve(12)Month Limited Warranty
All tie down anchors,when installed in accordance with the manufacturers recommendations
and when used within the suggested capacities are guaranteed for 12 months from date of
purchase against defects in material or workmanship.
If returned prepaid to the factory.TIE DOWN ENGINEERING will replace without charge the
defective part.Labor delays or damage are not covered by this warranty and while this warranty
gives you specific legal rights,you may also have other rights with vary from state to state.
ti
C;
Instruction#08091
Atlanta,TIE DOWN ENGINEERING 255 Villanova Drive SW 349-0401
/ o
• • • / 344-0000 i / i i • / • / !1
TIE DOWN ENGINEERING, INC.
~ 'Alind Zone 1 Anchor Description 112"x 30"Eye Anchor wl 4"helix
W Model Number: 59055
Building Building Length(ft.)
O Width
[ft.) 5 6 S 10 12 14 16 18 20 22 24 26 1 28 = 32
A 5 2 2 . _ 2 2 2 2 _ 2 2 2_. 2 3 3 —3_. _3
g 2 2 2. --2 2 2 2 _. 2. 2 _3_- 3
2 2 _2 _2 2_ 3_._ 3 3 3 3
_2. _2 2 2 2 2 3 3 3- _ --3 3 _
102 2 2 ? 2 —?- -2 3 3 3 3 3
-_ - 2 2 2 2 _ 2._- 3 3. 3 3 3 4
L114
- - - _
2 2 2 3 3 3 3 3 44- - _
__.---- -- -_..z_ 3 _ 3 ._3 __ .3_ 3 4 4 _ �.
-- -_ 3 4 4 4 4
wmd Zone_ 2 Anchor Description: 112"x 30"Eye Anchor wl 4"Helix
Model Number: 59055
My
W Building Building Length(ft.)
Width
8 10 12 14 16 18 20 22 24 26 J 28 30 32
N 5 ? 2 3 4 4 5 6 6 — 71 8__ _ 9 _ 9 10_ 11
3 4_ 5 5 6 6 7. 7-- $_ 9 9 10
- 3 3 4 4 5... __5 8_ 6 7 7 .- g
A -- 8 -- 3 _3. 4 4 5. 5 6 6 7 _ 7 _ _ 8 8 e
10 3 3 4 __4 5 5 6_ -- 6 7__ _.?_ _ 8 - ' 8
12.. _ ___ _ 3 4J 4. 5 _3 8 6 7
L
8 8
Iwo 14 _. _-_ _ 5 5 6 6 77 a8" 66 -... 9 9
18 - - - -
Wind Zone: 3 Anchor Description: 1/2"x 30"Eye Anchor wl 4"HOY
�y Model Number 59055
�y
W Building Building Length ft )
Width
O [tt} 56 8 10 12 14 16 18 20 22 24 1 26 28 30 32
5 2 3 4 4 5 6 7 7 8 9 10 10 11 2 13_
6 -- _.4 5... 5 6 7 7 _. 8 9 9 - 30 11 12
7 ____ - 3 4 --4 - 5 B 6 7
A _ 3 4 4 4 5 5 6 7
10 7 8 i3 9 14 10
_ .. 3 .4 _5 5 6 6 7 $ 8 _ 9 9 10
- ----
__12 -4. 5 5 6 6 7 8 8 8 9 1U
_ .
- 5 5 6 7 7 8 8 9 10 10
14 _ _ - -
= _ _ 6 fi 7 8 8 9 9 10 11
16 ; S 9 g 10 11 11
1$
Notes:
1) Maximum 102"building height. LLJ
AD
2) One anchor shall be placed at each corner of building. =:w r�
3) Any required anchors between corners shall be spaced equidistant 0 r" r. 5�4;; i
apart from each other.
4) Number of anchors required per side shall be determined by finding P.WITHERINGTON
quantities listed in columns.
- 1
Calculation Chart Instructions
Example: Note*
Wind Zone 11 chart shows 12' x 18' building: ,-'K - - - - - - - - - -
f
�� - 1 - - - - - - - -
1. Looking in 12' column - Use lowest value In the 12 column for the
number of anchors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 o
40
2. Looking in 18' column -find the corresponding width of 12'to ' ' Wind Zone II
obtain the number of anchors for the 18' side . . . . . . . . . . . . . . . . . . 5 ; 12' x 18' Shed
(if building width exceeds the widths shown in the Building Width ,
column, use the lowest number of anchors in the corresponding
Building Width column)
I
' `
*NOTE: Anchors at the corners shall be counted only once in
!� the quantity required for each side or face of building. ,)
- - - - - - - - - - - - - - - - - - - -
3. Total Anchors needed per 12' x 18' shed in Wind Zone 11. . . . . . . . . . . . .12
$uiiding $uild,rg Leng'h{f'.
width -
(ft} , 6 9 tb `.2 14 16 t z0 n 24 26 28 30 32
s z a a a 6 6 7 s $ $
6 2 _3. 3 �o »
- - - -
4 8
7 -- - - 3 _ 3 -4 4 5 5 -6 6 7 7 8_ �8.. 9
8 3 3 4 4 5 5 6 6 7 _
9 3 z a` 4 _ 6 6 7 78 E
12 _-4 4 5 2 6 T 7 7 _ B _. _. $
---
4 55 6 714
1 6 6 _ 7 7 8 -_8- $
1 6_ 6 7. 7
.. N
e m
Basic Wind Zone Map
ww nND �•2 ; "s Ad
yr
ott ? I EA MA}
�.
:A 16 xl
a OH:ns
l !. Inv (:T ` co
KS 1d0 / XVCA
J vA �ti
`
UK TN NC cu
j' AZ
,... to Mf )AL e�GA
- --' TX 1 !
7�ne n
AK 7
X
as
All Q
Zone III HI
I NOTE: See Section 32W.305(c)(2)for areas included in each Wind Zone.
111 0"
I I • I I
Eye Anchor Kit Instructions
Do-it-Yourself protection for most outdoor structures or possessions.
Includes. 3011 Anchors,
Wire Clamps
& 60 ft Cable
Part #59075
i4U oQ ��
0
oQ �
1. Install ground anchors as close to the building as possible at all four corners.
A. Install anchors using a straight rod to turn (screw) anchor into the ground.
B. A starter hole, up to 1/3 of the anchor length can be used to start anchor into the ground. Once the anchor
eye is level with the ground, backfill the soil and pack area around the anchor eye.
C. Anchor eye should be just above soil level.
2. Cable can be secured to the building using the following methods.
A. Attach one end of the cable to an anchor using the wire rope clip. Cable goes thru the anchor eye and is
clamped together using the wire clips (2). Place the cable over the roof to the opposite anchor, loop cable
thru anchor eye. Cut cable to have enough to attach to the anchor. Pull cable tight,attach 2 wire rope clips,
tighten nuts. Repeat for other side.
B. Attach cable to the side wall studs.Additional hardware required,bolts,washers nuts and wire rope clips.
All available at your local hardware supply.
NOTE:
These instructions are for suggested attachment to small shed not located in high wind areas. For more
detailed anchor requirements,see the wind zone charts for your area.You may need additional anchors,
cable,wire clamps or other forms of anchor attachments to the shed to meet local or state requirements.
Twelve(12) Month Limited Warranty
All tie down anchors,when installed in accordance with the manufacturers recommendations
and when used within the suggested capacities are guaranteed for 12 months from date of
purchase against defects in material or workmanship.
If returned prepaid to the factory.TIE DOWN ENGINEERING will replace without charge the
defective part.Labor delays or damage are not covered by this warranty and while this warranty r�
gives you specific legal rights,you may also have other rights with vary from state to state. p
O
Instruction#08091
TIE DOWN o
va Drive SIM - Atlanta, GA 30336 .
www.tiedown.com (404) 344-0000 I349-0401 l /
CITY OF ATLANTIC BEACH
r 1s)k
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.
111. 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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR: TELEPHONE THE
BUILDING DEPARTMENT(247-5826)IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
-7-70 4C),(- (Nq- 3 S g�
ADDRESS !-� PHONE NUMBER
PRINT NAME If
V.
�IIGNATU�REDATE
Before me this L day of O 2014 the county of
Duval,State of Florida,has personally appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of FL County of
IX.,:nally Known
roduced Identification-
PungO$tiU at Ftotid�
�r► N®tffY ananr
Shirit'!y L Gf 086990
mt1 ,
Notary Signature: My Com14n r
p
E�PI�s•.2
F:BLDG/Owner-Builder Affidavit.REVI :1) -YI612009
City of Atlantic Bear-,h APPLICATION NUMBER
�s S Building Departmet— (To be assig ed by the Building De artment.)
800 Seminole Road ���D _ 7&
Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845
City web-site: http://www.coab.us Date routed:
APPLICATION REVIEW AND TRAC 'ING FORM
Property Address: -770 Depar int review required Yes No
p Y uildin
Applicant: O /�-� nin &Zonin
rnistrator
Project: X �Jn �.J Public W ks
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
CONTRACTOR EMAIL ADDRESS
CONTRACTOR CONTACT #
APPLICATION STATUS
Reviewing Department First Review Approved. ❑Derned.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by:�-+s.. � /`�— Date: °/►/!y
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. ❑Denie.
Comments:
Reviewed by: Date:
REVISED 09252014
APPLICATION NUMBER
(To be assig ed by the Building D/ (a m
Building Departme
City of Atlantic Beath //(/!,
J3 � ���D0,5
,•, 800 Seminole Road
r� Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845 Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
✓ / ) n Department review required Yes No
Property Address: �7O ✓ , uildin
p ning &Zonin
Administrator
Applicant:
ge� X /�
Project: 000, ,' J Public Works
D Public Utilities
Public Safety
Fire Services
Review fee$_-
Dept Signature
CONTRACTOR EMAIL ADDRESS
CONTRACTOR CONTACT #
APPLICATION STATUS
Reviewing Department First Review:
Approved. ❑Denied.
(Circle one.) Comments: 906-
UILDI
Date: O ��--/
e
PLANNING &ZONING Reviewed by:
TREE ADMIN. Second Review: ❑Approved as revised. ❑Den'
PUBLIC WORKS
Comments:
PUBLIC UTILITIES Date:
Reviewed by:
PUBLIC SAFETY
FIRE SERVICES Third Review. []Approved as revised. ❑Denied.
Comments:
Date:
Reviewed by:
REVISED 09252014
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