671 Amberjack Ln 2015 Roof 11 CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
Dim
ROOF PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 15-ROOF-808
Job Type: ROOF PERMIT
Description: REROOF
Estimated Value: $2,364.00
Issue Date: 4/8/2015
Expiration Date: 10/5/2015
PROPERTY ADDRESS:
Address: 671 AMBERJACK LN
RE Number: 171190-0000
PROPERTY OWNER:
Name: KING, ADAM J
Address: 671 AMBERJACK LN
FEES:
BUILDING PERMIT FEE $61.82
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $65.82
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax(904) 247-5845
Job Address: (, 71 44yjak- G., _ />fbl. Act,. zc/ Permit Number:
Legal Description &,26. 9—t Parcel#
Floor Area of Sa.Ft. Sq.F't
Valuation of Work$ Z1-1 Proposed Work heated/cooled Mo 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# L
For multiple products use product approval form
Describe in detail the type of work to be performed:_ {cJ�ac�
Property Owner Information:
Name: /�► ., ki•+._ Address: 67/ A Sc/,cck 1-,
City^*I, jgk State/H Zip k) Phone
E-Mail or Fax#(Optionalge..,40 eve l.so. c.,-%
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 permit 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 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 six(6)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,Heaters,
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.
I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this
type o1 work 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,st or local law regulating construction or the performance of construction.
Signature of Owner__J y Signature of Contractor
Print Name �RC ...".../`-.^... ........................................................................ Print Name
Be a Before me
th Da 20 this Day of 20
Notary Pu ate of Florida
1 ommi i FF 086990 Notary Public
dor n Expims 0 /14/ 18
Revised 01.26.10
CITY OF ATLANTIC BEACH
OWNER / BUILDER DER _ '1FW WTl
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 'I "CONSTRUCTION
CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 439.103(7),FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED
CON'l-RACTOP.S. YOU FLAVE APPLIED FOR A PERNIIT UNDER AN EXEMPTION TO THAT
LAW. THE E`{ENIPTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY,TO ACT AS
YOUR OWN CONTRACTOR EVEN TROUGH YOU DO NOT HAVE A LICENSE. 1'OU MUST
SUPERVISE THE CONS FRACTION YOURSELF. YOU NLAY BUILD OR IMPROVE A ONE—OR
fWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD OR
I III2PROVE A COMMERCIAL BUILDING AT A COST OF$25.000.00 OR LESS. THE BUILDING
IIrIUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEAS['.,
IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR
AFTER TIS CONSTRUCTION IS CONIPLETE, THE LAW WILL PRESUNLE THAT YOU BUILT
IT FOR SALE OR LEAS- VIT1IICH IS IN VIOLATION OF THIS E3M1.VIPTION. YOU MAl'NO_I_
HIRE AN UNLICL=:NS1=_1;. i'ERSON AS YOUR CONTRACTOR YOUR CONSTRUCTION MUST
BE DONE ACCORDINO TO THE BUILDING CODES AND ZONING REGULATIONS. I f I
YOUR R1=.S11ONSIBILIII' -1-0 MAKE SURE THAT PEOPLE EMPLOYED BY YOU RAVL
LICENSES REQUIRED „Y STATE LAW AND BY COUNTY OR MUNICIPAL LICENSINt,
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
III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO
j OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY
EMPLOY ON THEIR IMPROVEMENT TRADES.
W. PENALTY; UNLICENSLU CONTRACTORS CANNOT BE EMPLOYED UNDER ANY
CIRCUMSTANCES. OWNERS NEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUA T E_ 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
STAT EME�dT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER—BUILDER PERMIT.
ADDRESS PHONE NUMBER
AOr-- k/
PRINT NAME
SIGNATURE DATE
Beforeme this day of 20-- in the county of
Duval,State of Florida,has personally ;ppe-.i ed herin by elf/herself and affirms that
all statements and declarations are'u ncf;calrate.
Notary Public a4 Large, !__,County
of
Personal) own
❑Produc Ideniifi tion- —. Notary Public State of Florida
Shirley L Graham
My Commission FF 086990
Notary Sign _ — .__-_. oFpo Expires 02/14/2018
F:/iiLUG/Owner-L'uilder Affadnvir;HnVItiEU; 9/1 -19