389 12TH ST 2015 SHEETROCK DRYWALL r SSS
CITY OF
v A TL4NTIC BEA
�JJ31� 800 SEHINO CH
INSPECTION
BEAC LE ROAD
CTION PHONE LINE 247-5814 33
- RESIDENTIAL MUST CAL
308, N Won IATION:---- --�-BY 4PM FOR NEXT DAY NSPER
�• E--- 247-5814
Job T _-------
YPe: AAR_ --
5-R 1594 -- ---- --
Description. RESIDENTIAL --_-- -- ---_
Estimated
ALTERATION
Issue --
Value: $2 500 ROCK/DRywALL
Date:
Expiration Date: 7/2/2015
PROPERry ADD � 2/29/2015
RESS:
AddreSs: _
389 1 ------
RE Number; 2TH ST ---
PROPERTY OWNER: ------171921-0000 --------- --
Name:
Address: LIGGEROn, ROBERT R
389 12TH ST --
PERMIT INFORMATION:
FEES:
BUILDING PERMIT FEE —
$62.50
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE %00
Total Payments: $66.50
App�w�`l pN�l ,N ACCORDANCE WITH L CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
Pl',1tM�T 15
1�UILDING CODS•
S' r
^J
St>
y CITY OF ATLANTIC BEACH
OWNER / BUILDER AFFIDAVIT
VIT
L FLORIDA STATUTES; CHAPTER 489, FLORIDA
CONTRACTING"REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW_
STATUTES, PART 1 "CONSTRUCTION
DISCLOSURE STATEMENT FOR SECTION 489.103(7),FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO
CONTRACTORS. YOU HAVE APPLIED FOR A PE
LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER BE DONE BY LICENSED
PERMIT UNDER R EXEMPTION TO THAT
YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. yp
SUPERVISE THE CONSTRUCTION YOURSELF. YOU AY BUILU MUST
D R PROPERTY,TO ACT AS
TWO FAMILY RESIDENCE OR A FA OR IMPROVE A pN
IMPROVE A COMMERCIAL BUILDING AT AOCOST OF$25,000.00 OR LESS. I
MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE YOU BUILT FOR ALSO BUILD OR
IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHINNE BUILDING
AFTER THE CONSTRUCTION IS COMPLETE, THE LAW WILL PRESUME THAT ypULEASE.
IT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAYYEAR
HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION BUILT
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS NOT
YOUR RESPONSIBILITY TO MUST
LICENSES RE UIRED By MAKE SURE THAT PEOPLE EMPLOYED By ITIS
pRDI- STATE LAW AND BY COUNTY ORM YOU HAVE
UNICIPAL LICENSING
II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WOR
THE BUILDING DEPARTMENT SUGGESTS WORKER'S
PURCHASED. COMPENSATION IINSURANCEERS THEY HI BE
III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AN
EMPLOY ON THEIR IMPROVEMENT TRADES. D SHOULD ALSO
OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE
IV. PENALTY; WORKERS THEY
UNLICENSED CONTACTORSR
CIRCUMSTANCES. OWNERS BEING SUBJECT TO CANNOT
455-2281 BE EMPLOYED UNDER ANY
)• AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
$5,000 PENALTY UNDER FLORIDA STATUTE NO.
SEE THE COUNTY "CERTIFICATE OF
CERTIFICATE" TO ASCERTAIN IF A PERSON ISS ATL LENSED CONTRACTOR. TE SICALLY
BUILDING DEPARTMENT RTAIN826) IF IN DOUBT. OR THE FLORIDA "CONTRACTORS
V.ACKNOWLEDGEMENT; THEREBY ACKNOWLEDGE THAT I HAVE READ T TELEPHONE THE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OWNER-BUILDER PERMIT. HE ABOVE DISCLOSURE
OF AN
ADDRESS Z
c) q-eI leI� 14ONE NUMBER
NAME C t 4 C
SIGNA URE
T1 .I DATE_
Before me this day of �l l` CC-�
Duval,State of Florida,has per a 20ij in the county of
all statements and declarations:)T
appear d herin by himself/herself and affirms that
urate.
Notarypubl Sta of
County of
0Known
uced I tifi ion-
�psY°oic^ Notary Public State of Florida
Notary Signa Shirley L Graham
My Commission FF 086990
F;BLDCil Or A¢p Expires 02/14/2016
Owner-Builder Affadavit;REVtS
4/16/2009
BUILDING PE�,IIT
C'ITI, APPLICATION
800 SeminoleOFAT L`NTIC
Office (904 Road, Atlantic BEACII
Job Address: )247-5826 Fax (904)
FL 32233
Legal Descri ��. (904)247-5845
Description
Valuation of Work S SZ�
oor permit Number:
ea o
Class of Work(circle Prop°Sed Work heated/cool Parcel#
Use one): Ne ed q t
Ifa °f existing/ ro w Addition �� non-he
n existin posed structures Alteration ated/cooled
Florida p g structure,is a fire (.) circle one): Repair
roduct A ( Move
For►nulti le pprovaI# sprinkler one): Commercial emolition poo]/s
p products use product a m installed?(Circle pa windo
Describe ' one): esid w/dooi-
ln detail the t Ppr°va orm es
type Of work to be ° N/A
Pro performed:
er OWner Infor
matiou;
Jame:
1ail
or Fax# � 2
(Optional) Address: 33 '
)ntractor v `Zl ;Z
Infor CX phone a ,
matron;
'lnpany Name: COI\tT CTO R E
'dress: MAS'ADDRESS:
"ice Phone Quali
to Certificatio Job Site/Contact City ing Agent:
hitect N 'Registration# Number
ame&Phone# State
ineer's Name&phone# Fax# Zip_
Simple Title Holder Name and Address
ling Company Name and Address
gage Lender Name and Address
'ration is hereby made to obtain a permit to do the work
ce of a permit and that all work will be er ormed to and installations as indicated
'id if work is not commenced within six(6)months, of if
the standards of
all Commenced. t const all laws re 1 certI that no York 1 understand that separate permits f ruction or work is sats gulat, k or installation has commencedprior to the
and Air Conditioners,etc. P p mist be secured p g construction in this jurisdiction. This
Or Electrical e re,01 abandoned fora��period o
Plumbing,Si ns fsix 6 Permit becomes null
WARNING TO OWNER:YO g ' ►T'ells,Pools, maces,nths 60 a rs time after
WMENCEMENT MAY RESU_T IN yp PAYING O RECORD
D YOUR PROPERTY. IF YOU_' Y TO ODT TWICE FOR IMPROVEMENTS OF
YOUR LENDER OR AN ATTORNEY BEFORE
AIN FINANCING, CONSULT WITH
COMMENCEME CORDING YOUR NOTICE OF
F
vorcertify that l have read and examined this cied here,7 or not. The tpplicatin and know the same to be true and correct. All rovisions of laws and ordinances
is of
t complied with whether saw flat n construction or pe granting of man e ofconstratcttonYe presume to give authority to violate governing
this
1s o an other Jed tate, or local{� does
el the
tlll'e of Owner Signature of Contractor
,C f�i°e-.......... .P�egu
. ....................... Print Name
Name ....................... . ........................................................................................................................................
21� Before me
this Day of 20
Day f
10444�NouNp°e�G�Florida Notary Public
$ � 5Mv ey m�.e�v,,assso
Revised 01.26.10
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