2343 W OCEANFOREST DR - PLUMBING : s f CITY OF ATLANTIC BEACH
A 0 800 SEMINOLE ROAD
� ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
PLUMBING PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 15-PLBG-1834
Job Type: PLUMBING ONLY
Description: WATER HEATER
Estimated Value:
Issue Date: 7/30/2015
Expiration Date: 1/26/2016
PROPERTY ADDRESS:
Address: 2343 W OCEAN FOREST DR
RE Number: 169463-1568
PROPERTY OWNER:
Name: TROST. THOMAS J
Address: 2343 OCEANFOREST DR
FEES:
State PLMG DBPR Surcharge $2.00
State PLMG DCA Surcharge $2.00
Plumbing Fixtures $7.00
Trade Permit Base Fee $55.00
Total Payments: $66.00
1 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
i
PLUMBING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd Atlantic Beach, FL 32233
Ph(904)247-5826 Fax(904) 247-5845
JOB ADDRESS: 2 q3 b c_A....4 „7-G 0(--.. PERMIT#
NEW OR REPLACEMENT INSTALLATION: Project Value$
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank&Pit
Clothes Washer Shower
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Water Heater ---1
Other Fixtures Water Treating System
RE-PIPE:
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank&Pit
Clothes Washer Shower
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Water Heater
Other Fixtures Water Treating System
MISCELLANEOUS:
❑ Sewer Replacement ❑ Back Flow Preventer ❑ Grease Interceptor(Trap) gallons(Requires 3 sets of plans)
❑ Lawn Sprinkler System-Number of Heads ❑ Well **
**SJRWD Well Completion Form. Completed form to be submitted to the Building Department for final inspection.**
❑ Other
Permit becomes void if work does not commence within a six month period or w is suspended or abandoned for six months.I hereby certify that I have read
this application and know the same to be true and correct. All provisions of I s and ordinances governing this work will be complied with whether specified
or not. The permit does not give authority to violate the provisions of an er state or local law regulation construction or the performance of construction.IT-
Property Owners Name 67-1A•- Phone Number
Plumbing Company ,� (Office Phone Fax
_ '
Co. Address: A I City . . 'S .to Zip
License Holder(Print): : . . -i'fiic.• 'egistration#
Notarized Signature of License Holder
efore m- is_ . , , /20 /S
f Notary Public State of Florida
<
41 My Commission FF 086990 : -�� •
Shirley l Graham • afore of Notary P
"ler A.e Expires 02/14/2018 ,/
II
S 1.tLY j
" `. t° CITY OF ATLANTIC BEACH
'''' _.1 } ®WNER / 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 TTIOUGII YOU DO NOT HAVE A LICENSE. YOU MUST
SUPERVISE TI IE 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. TI IF, 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, WHICII IS IN VIOLATION OF TIIIS EXEMPTION. YOU MAY NOT
IIIRE 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 EMPLOYEE) 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.
3�i C Ct ,A,1 corn--.\. Wr. 0 ci 0`1 --1---`t(4,-- 0 Dli
ADDRESS PHONE NUMBER
r-,,,,,,.. (, 1.sz-D S\r-
PRINT NAME
SIGNATURE DATE
Before me this G/ v day o 1 . ,20bin the county of
Duval,State of Florida,has personally appealed herin by himself/herself and affirms that
all statements and declarations are true nd accurate.
Notary Public at Large,State of � ,County of V c
❑Personally Known i L 1
1 uced Identification- l�
' 7 �yyir PUQ Notarblic State of Floflda
c ShirlGraham Notary Signature:__ _, ion 9
'20,09 Expires 02/14/2018
F BI.DG/Owncr-Builder Afiadavit;REVISED:4/16/2009