1767 W PARK TER - INTERIOR REMODEL s CITY OF ATLANTIC BEACH
s 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
JOB INFORMATION
Job ID: 15-RAAR-2094
Job Type: RESIDENTIAL ALTERATION
Description: remodel bedroom bath ..add screen porch (existing slab)
Estimated Value: $13,500.00
Issue Date: 9/16/2015
Expiration Date: 3/14/2016
PROPERTY ADDRESS:
Address: 1767 W PARK TER
RE Number: 172020-0380
PROPERTY OWNER:
Name: PACE, JOHN PARK & ELAINE, *
Address: 3380 PLAZA WAY
PERMIT INFORMATION:
- - -------- --- -----------
FEES:- - --- -
PLAN CHECK FEES $58.75
BUILDING PERMIT FEE $117.50
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $180.25
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALE CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION i
ra r' CITY OF ATLANTIC BEACH I d
i tu .vvr 1 800
Seminole Road,Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904)247-5
Job Address: /76-7 M 7i `t) Permit Number: 1145'•/2M/i-)c)c/
Legal Description Parcel#
^ �y Floor Area o ' Sq.Ft. q, t
Valuation of Work$ A.'oc Propos ork heated/cooled.2)7t2 non-heated/cooled AM
/3 S00 . cd
Class of Work(circle one): New Addition Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s)(circle one): Commercial tia
If an existing structure ,is a fire sprinkler system installed? (Circle one): No N/A
Florida Product Approval#
For multiple products use product approval form
Describe in detail the type of work to be performed: re�'13Y/� r' J C�(��/ �� A•
lvr& 4eieen Pd /6?/ /7 h. 1.r1/ c�e,ico I /eE.f /%(�4 Ov s7rtic7 Zi 4-- 1 S
J
Property Owner Information: �Q ,Q
Name:Jdh� 26 ShrihP/ C(C C.- Address: /76.j1 /, 7p
City /78 State LZip.it s3 Phone P0/-5--z/-Z S) s`
E-Mail or Fax#(OptionalLipbae e 270.5e&ma,//. (•
Contractor Information: CONTRACTOR EMAIL ADDRESS:
Company Name: CD WO eit, 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:f work is not commenced within six(6) onths, or if construction or work is suspended or abandoned for aperiod of six(6)months at any time after
work is commenced. I understand that separate permits must be secured for Electrical;York,Plumbing,Signs, Wells,Pools,Furnaces,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 cert 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 of 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,state, or local t regulating construction or the performance of construction.
Signature of Owne Signature of Contractor
Print Name Phfl C e Print Name
Befor= r e _Zr,,, Before me
thi�` !. • ` 20 / this Day of ,20
Notary Public Notary Public
Revised 01.26.10
11 11 rim f17.,rtH tRI,
.? ,
(it .it,„.., , r" - j CITY OF ATLANTIC BEACH �� W
-
'' "f 'J%WNER / BUILDER AFFIDAVIT
- jj gi?
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 REOUIRED 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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826)IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
7'67 /° Gt) R9/ 52/ ?SYS
ADDRESS PHONE NUMBER
csld/7) f'c -
PRINT NAME /
l( / ' '
9:c2-/$
SI NA U- DATE
Before me this Z day of S T .201,57he county of
Duval,State of Florida,has personally ppeared herin by himself/herself and affirms that
all statements and declarations are tru d accurate.
Notary Public at Large,State of L ,County of
lPonally Known �
iilWri
Notary Signatur-• _......1 ff
F:BLDG/Owner-Builder Affidavit;REVISED:4/1./2009
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road..Atlantic Reach_El.32233 _.--- '
Office(904)247-5826 Fax(904)247-5845 , 1 ,. I N ' 'I 1
Job Address: 1767 Park Terrace W.—__-----_- _ --Permit Number: 1 I 1)i
I Sr t-.-. --
i
Legal Description I U 'I fit LICK I'OF S11VA 4=4 A UNIT NO 8 11 AT BOOT; :-1 PAIL 4 Parcel#172020-0380 —
Fl«/r Area of `�,f t. Sq.Et
Valuation of Work S S6500 Proposed Work heated/cooled non-heat} c l�Yooled—-- �-
Class of Work(circk one) New Addition .Alteration Repair •• •molition iwwllspa window.ldooi
Use of existing/proposed structure(s)(circle one) ( mm
'ocretal r'J
If an existing structure,is a lire sprinkler system installed?(('leek one ` diNp N/A
Florida Product A provai i
For multiple products use product approval torm - --
Ii Z 1iic in detail the type of work to be performed: Remodel matter bathroom.add screened addition over existing
slab cued add outdoor sholvcr--- ---.
1
Proner(v Owner Information_
Name. 1011N AND El AINE PACT Address. 3380 P1.A7.A WAY
City SAT:1iAN)r.(-JIY_—State 1.ET Zip 84109 Phone (81)11837-2733 -----.- - -
E-Mad or Fax if(Optional) F('IIOi.AINEt MAII_COM ----1111.._--_ —..- --' -.._.------
('gntractor Information: D Q d 3 E i t't M Y'k `
C onlpan Namc 1 )VFJOY('ONSTRtICTION SERVICES.INC. Qualifying Agent: DAVIT)T I)(111GI(MAN
Address.21. I FORB S Si,• C'ity_LhSLfCS()NYJL1 F State Ft Zip 32204-- 1
office Phone (9(14L521-4179 _.—.lob Site/('(intact Number,__..DAVIT)OR 101:N fax!< J i
Stare('ertifie I.N✓Rcgistranon if CBC'12S(l 26 —. ---
—
Archked Namc&Phone if SCO•I-f I.EllTl iOl l) (904)389-5456 - —
Engineer's Name&['hone if H11.1.1 El n i TOLD(SIGNET)ANT)SFAI,EDI _._..-.
Fee Simple Tnlc I Iolder Name and
Address NA
Mauling -_---
Matding Company Name and
Address NA
Mortgage —
Mortgage Lender Name and Address
NA
irrheallettI IN hereby satrk•M!AWL!w math M.11'the wore*fall,rn.A64hIlr\,I\walnut/ I t rru(r Una no rnr+'If'w,w,1LM,4,Inc.,,wMnr,n eJ prior I..
Inc i a.ww-.4.l pelant.awl daw till wrnk will 14.prrhsnnrd a,wr.v the clarklnls of all hews r sdrim,to ubu.Ills,I,this,hai■Ins,II,Ilan
161 erAII•
by rases rw/l Anil mail I4 work u sag commented s-Illun see(GI'awaits.or II s onnrwc rwwl,N r ork is.\w lea or ohnwl.nn•rlJor is 1,-lh,fl'nnls. 4 nnnrr's.
an ten'nitr"tilt•r rusk Lt<lantOe tiii wnJer i,aI that ceps:r le pernM,,.wee h •.s an"J for Elect,kol Work.Phnwbine..Stern,
Bailers,Heaters.ranks and-fir(:owdltionen.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 B EFORE RT ORDINC 'OUR NOTICE OF
1 ltn by<coifs.law I lane oval lami e,stalospl r/u s appI4rw'.M And burn/h•WWII'to he mew rail(Wen 1/1 T..,'',+ssu of lows anti,, was es M r u,-
J![IIK trl(YI IfJ IK/ewl/N MO Ibr.tnaunr N<+permit does not Yevu.'en�,h',MIIMfIII•• 'I..l.wr'nr o r..-. r
1111V11/...n1 wont-will MI, lreknduwne/.NI,knit//Mr IV 64x,4.ewnine,non at the r ere Tennis a of a onsinn two
',neaten /1.,/ —�� /Al _ _-
Signature of(hi Signature of C'<xrtraoxol -• `
Print Name tv.Ad/P r.�'4 ..,i/Hf
I'rini Name Etra; 'v'.
Sworn to and subse:ri d helorr cpc pack_ Swo ,an crib 't' /• /
this,...L_-_Da)of 7 he:t _ 20!";r this I as of '!g
.�7ri:- : •..- --,-`)..!/l T?...-4-.c' Notary Iair
Notary -- - -.-
Nota Public
Revisc;• - 't, IQ
/ -e •' -' ; n--p4-/I ' CO n /rat-4,r-
Ivy)
(.10"-1 i 1' l •94-4-€r/ Co Peel ktor.nP®we't' 'r g 6 3
We ,ems/' 'le- -or
f'• / Sias.? pkate c.o,//n i-ac i- h'o'e_. l `'
' ►'N /►C�1►,t O W n F r /TJ Q T s k'rl S T C b T rot r �{�• �. ... Notary Public State of Fonda
• Shirley L Graham 4 9, /_/c+� My Commission FF 095990
I J ''iM Ermines 02/14/2018
i
Ile
V 4
0 0 e a 'i I~i 2 s S 2 °W 2 T •:
iiiliA. g11 .4, � }a. .,.Itt��, f� �n .�}taa5{ �Op P, ffp ry P.1-, ., y�p� �+ W pNp P �Pp ppJD V pr N V O &' W O.W 4,, V. W 1N0 A b L O .0 OOJrr P T P iC. W Oo
R a A T T m X X F X Tr i C i 7, 7, r- gI
25▪ 7. 2 O R W ZE Zi EZ Zg S 2 Z D y. A 1 .
m (2. z Gi Ci k E E p p n lAi
D9g9z _ ggA � - g $
8 m � To < a a < K
pp W 7-.0pI W7 < < < < n n Y Y Z Z irn 601
p D D D D O O �e O A n n A " rac-
w O Ei ei G1 g'i O O O T
Z Z Z P A
Z Z Z Z < < t
p p p
p
E, n n n
n n O A A A p V A A D A A A A n b A y, -
2 O g 1 (2 0 70 g 0 0 O O O O O p 0 i ��
m 1 r'�r.,. N T m N N N N N A N � ^
0 0 Roo"' 0 0 SO O O 0 0 n 1O O ^ 1
T
r • o r r C C r • • A n A A A . I t
T .= T M D D
CY p O FD p p
NN, VAI V. gV V. ININ V " c
N- ) 3
0_
c.,\ 3 ,..__ - c.›)- c n
ti \ N U N�
O
UI (,I o
o o '^ � a ' N •N I ,. ` H H c vi
$ r A C
�{
� s ro
A en CI
�
f) 3
Nk
Q t L (.1) `S
k...
w
CI 3
a
qp/
• J Jc p .Je J �yJn� iI J • J <JC J J cJc J ~ ` v i-i
N V. G N N '* C T In m * * m C T m INn S L `'♦
zz p T O p O O O r rG O O 0
z Z D Z Z y �v Z Z Z D Z t Z Z Z A A »
o O x 0 ZZ 00 0� n x p A o 0 0 x 7, t (>� T '�
✓ m T m m m r g T r /� g O SI Y `
r r � T
O O p O P A A O 0 O A P 0 A O O 0 p A `+ 1-Q Q �•
1` \
8.
s
O J J NO J Q P Q J V O J p O.' ti: V V I
wb IQw Wi wp p W WNN „
. N
Q QQQ QQ
c
City of Atlantic Beach APPLICATION NUMBER
A �� Building Department (To be assigned by,the Buil•ing De art t
800 Seminole Road
� Atlantic Beach, Florida 32233-5445 0-1(1
xl Phone(904)247-5826 • Fax(904)247-5845
oll �' E-mail: building-dept @coab.us Date routed: 3 /.6-•
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: /7 r W / 1( K / z r ent review required Ye No
/', Q/� Building
Applicant: Q W 7/1rC., ing &Zoning
_l / L ;�1I Tree Administrator
Project: Tj?i&2 p 1. i-✓ - /il c I r00 Public Works
Public Utilities n n G d _ JCI1 £I fr � Public Safty
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: EliCroved. ❑Denied.
(Circle one.) Comments:
Pp, frn•, SPf v� n o fde e" -�� c ln34' ov 1.3u,�,ns
BUILDIN f Tt)R- di rn.;SS
et, ��P1/idVT rdn rar wi
PLANNING &ZONING Idler Fry w� hVrile om-rler O��Sr.-%vS n'-'•oc
Reviewed by: / Date: Q F``1S
TREE ADMIN. Second Review: Approved as revised. ❑Denie Semi(
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10