702 KESTNER RD - WINDOW / DOOR r y\J,,,/
�S
\� CITY OF ATLANTIC BEAC
800 SEMINOLE ROAD
;y ATLANTIC BEACH,FL 32233
_ INSPECTION PHONE LINE 247-5814
`r/J.31 `-
WINDOW AND/OR DOOR PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
7OB INFORMATION:
Job ID: 15-WIND-2188
Job Type: WINDOW AND/OR DOOR
Description: WINDOW / DOOR
Estimated Value: $7.500.00
Issue Date: 9/18/2015
Expiration Date: 3/16/2016
PROPERTY ADDRESS:
Address: 702 KESTNER RD
RE Number: 172382-0000
PROPERTY OWNER:
Name: TWARDZIK. JONATHAN,
Address:
PERMIT INFORMATION:
FEES:
PLAN CHECK FEES $43.75
BUILDING PERMIT FEE $87.50
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2 00
Total Payments: $135.25
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
iLAn-, City of Atlantic Beach APPLICATION NUMBER
fac
Building Department (To be assigned by the Building Department.)
- 800 Seminole Road
u v Atlantic Beach, Florida 32233-5445 5— I>J» t 8 g
Phone(904)247-5826 • Fax(904)247-5845 it
��(i;31y�' E-mail: building-dept @coab.us Date routed: 9 / ( (p City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 702 ki.ST SE(Z RC) paxtent review required Yes o
0 w N Ei2 Building
Applicant: �01AmptTl-1 AN -1-vv A.RpZIK • Zoning
/ ^ Tree Administrator
Project: \i1/4-11 �S c p w / 1�pp S. Public Works
/ Public Utilities
Public Safety
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:
1
APPLICATION STATUS
Reviewing Department First Review: Approved. ['Denied.
(Circle one.) Comments:
BUILDING
PLANNING & ZONING
Reviewed by: Date: 7./7•/5-
'/7'/3
TREE ADMIN. Second Review: ['Approved as revised. ❑Den d.
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
•
BUILDING PERMIT APPLICATION EL:
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach,FL 32233
Office (904)247-5826 Fax(904)247-5845
Job Address: 7'2 /(. .S7h/ten___ ed, Permit Number: /5 —toil/6-Aft
Legal Description Parcel#
�
,, oor • ea o q. t. q. t
77
Valuation of Work$ �• Proposed Work heated/cooled t7�-O non-heated/cooled
Class of Work(circle one): New Additio' Alteration_ Repair Move Demolition pool/spa ndow/doo
~
Use of existing/proposed structure(s) (circle on• . ommercial Residential ,
If an existing structure ,is a fire sprinkler system installed?(Circle one): Yes No N/A
Florida Product Approval# EL. l49 L 1 . Z�, FL L S Z 5 5 . 1 3
For multiple products use product approval form I
Describe in detail the type of work to be nerformed: > _ - -
s•- ,Att,k--,,,i -E-- ,a$0,,D,,,, .v vi,.A.,„..),
- i
,
Property Owner Information:
Name roV sr l M ) 4 41-0-0 L1 f-- Address: --7P2-- S'i'ne- -Z) .
City P L . Stater Zi. Phone '?1 '� - ,5'19 -M �
E-Mail or Fax#(Optional) WV Y P :% 6 ��1i , (-1:74-01
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 cert fy 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 sus ended 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 ElectricalpWork,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 cert5 that I have read and examined thisplication 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 speci red herein or not. The granting of a permit does not presume to give authority to violate or cancel the
vrovisions of any other federal,state, or local law re t. .Ling construction or the performance of construction.
signature of Ow ��a�
�' Signature of Contractor
'rint Name (3--A,„ • - T ' ,\Q.p'Z-ic.— Print Name
3eformie Before me
his 1 Day of ' ,.. be L20 1-S this Day of
,20
AL N IVO"?'',,,, DONNA LBAFME
rotary 'ublic : ` -•� '.• MY COMMISSION#FF018392 Notary Public
11,,...,,,E :8: EXPIRES:May 14,2017
I'Z'f:, o?/ Rnnded TAm NnInn,Pi hlir tindanerifort •
,`/t Tf r ,i (�
Y - �, CITY OF ATLANTIC BEACH COPY
Vis)
y 'J WNER / BUILDER AFFIDAVIT
u ��
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 TIIOUGI-I YOU DO NOT I-fAVE 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 WITI-IIN 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 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.7A T" —7N 7 -- 1y -VI 1,�
PHONE NUMBER
141J PS'SWVJ \• 'T fv-t?.—P —1 )C____
PRINT NAME
i
URE
D E
I St -0-bet- county Before me this day of 20��in the coun of
Duval,State of Florida,has persona y appeared herin by himself/herself and affirms that
all statements and declarations are tr ue and accurate. {�
Notary Public at Large,State of FL- ✓,County of 'l_V j• 1
❑�€rsonally Known �L/ L �� �~�`]� � /X/ 0
Zg °Y4;: DONNA L�fl�-E roduced Identification-
=.. AI irS MY COMMISSION I FF 018392
...r-,, EXPIRES:May 14,2017
,,r.���n^, ,, ri�� /����;;JJ %:±uf�'1;' Bonded ThruNotary Public Underwriters
Notary Signature: 0''4 t.��'(,/ �� '
FjBLDG/Owner-Builder Affadavil;REVISED:4/16/2009
■