566 CLIPPERSHIP LN 2015 BATH REMODEL �J `S, CITY OF ATLANTIC BEACH
j 800 SEMINOLE ROAD
J ` ` ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL ALT/OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
]OB INFORMATION:
Job ID: 15-RAAR-770
Job Type: RESIDENTIAL ALTERATION
Description: BATH REMODEL
Estimated Value: $1,500.00
Issue Date: 4/2/2015
Expiration Date: 9/29/2015
PROPERTY ADDRESS:
Address: 566 CLIPPERSHIP LN
RE Number: 170703-0232
PROPERTY OWNER:
Name: SHAW, MICHAEL
Address: 566 CLIPPERSHIP LN
PERMIT INFORMATION:
FEES:
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
BUILDING PERMIT FEE $57.50
Total Payments: $61.50
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FL01111M
BUILDING CODES.
BUILDING PERMIT APPLICATION
` CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904)247-5826 Fax (904) 247-5845
Job Address: 1-77 Permit Number:
Legal Description Parcel #
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work$ 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): Commercial Residential
If an existing structure,is a fire sprinkler system installed? (Circle one): Yes No N/A
Florida Product Approval#
For multiple products use product approval form /
Describe in detail the type of work to be performed: R,--, k, L
Properly Owner Informa'ti'on-: l
Name: 9/)w Address: �� ��PJ���� �� 4AJ
City Af %. k . Stated Zip _Phone q -(�/a/ - rf Sia
E-Mail or Fax#(Optional)
Contractor Information: CONTRACTOR EMAIL ADDRESS:
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
Application is hereby made to obtain a mit 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 1 be performed to meet the standards of all laws regulating construction in this jurisdiction. This permit becomes null
and void tf work is not commenced thin six(6)months, or if construction or work is suspended or abandoned for a period of six M6 months at anytime after
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,eta
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 here, 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
,lb
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 local law regulating construction or the performance of construction.
Signature of Owner Signature of Contractor
Print Name Print Name
.................. ...................................................................................................................
Before me Before me
this Day of ,20 this Day •20
Notary Public Notary Pub c
Revised 01.26.10
CITY OF ATLANTIC BEACH
1. FLORIDA STATUTES; CHAPTER 489,, FLORIDA STATUTES, PART 1 "CONSTRUCTION
CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 459.103(7),FLORIDA STATUTES:
STATE LAW f2EQUIRES CONSTRUCTION TO BE DONE BY LICENSED
CONTRACTORS. YOU IiAVE APPLIED FOR A PEPMT UNDER AN EXEM-PT`ION TO THAT
LAW. THE EXEAIPTIONT ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY.TO ACT AS
YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST
S_UI'E:RVISE THE:CONS I RUCTION YOURSELF. YOU MAY BUILD OR IMPROVE A ONE—OR
TWO FA ULY 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
INIUSTBE 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 WITFIIN ONE YEAR
AFTER TIIE CONSTRUCTION IS COMPLETE, THE LAW 17VILL PRESUME THAT YOU BUILT
IT FOR SALE OR LEAS s_ WFUCH IS IN VIOLATION OF THIS E)[ENIPT'ION. YOU NI A1'_N(_1I;
HIIt1'. AN UNLICE:NSEI PERSON :1S YOUR CONTRACTOIC YOUR CONSTRUCTION MUST
BE DONE ACCORDING, TO THE BUILDING CODES AND ZONING REGULATIONS. I I IS
YOUR RESP()NSI.BILI I V "1-0 MAKE SURE THAT PEOPLE ENIP1_.0YED BY YOU HAVE.
LICENSES REQUIRED SY STATE LAW AND BY COUNTY OR (MUNICIPAL LICENSING
ORDINANCES.
It. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED
111. IPS 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.
II iV. PENALTY; UNLICENSI_U CONTRACTORS CANNOT BE EMPLOYED UNDER ANY
CIRCUMSTANCES. OWNERS EYEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPA T ZONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTOR'S
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.
477�I X66 C'L�PPE�c.S,�i�o �.A! 4��-
ADDRESS PHONE NUMBER
MIXT "
PRINT NAME
SIGNAT E DATE
Before me this day of 20^_ in the county of
Duval,State of Florida,has personallyappe=.led herin by himself/herself and affirms that
fall statements and declarations are true am: jccurate.
(. Notary Public at Large,State of __,County of
El Personally Knovrn
❑Produced Identification-
I
diE
lic State of Florida
Notary Sigraham _ —._____
ssion FF 086990
14/2018
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