615 SELVA LAKES CIR - WINDOW �' 3 ls, CITY OF ATLANTIC BEACH
. J 800 SEMINOLE ROAD
j "� ;�si
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
WINDOW AND/OR DOOR PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 15-WIND-2267
Job Type: WINDOW AND/OR DOOR
Description: window replacement
Estimated Value: $350.00
Issue Date: 10/1/2015
Expiration Date: 3/29/2016
PROPERTY ADDRESS:
Address: 615 SELVA LAKES CIR
RE Number: 172027-5550
PROPERTY OWNER:
Name: TINNEY, JAN A
Address: 615 SELVA LAKES CIR
PERMIT INFORMATION:
FEES:
BUILDING PERMIT FEE $55.00
STATE DCA SURCHARGE $2.00
PLAN CHECK FEES $27.50
STATE DBPR SURCHARGE $2.00
Total Payments: $86.50
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
iyvy; City of Atlantic Beach APPLICATION NUMBER
�S Building Department
" „� (To be assigned by the Building Department.)
A 800 Seminole Road l
Atlantic Beach, Florida 32233-5445
/ ?l/f A ” 2 l4 7
Phone(904)247-5826 • Fax(904)247-5845
J;3 >a E-mail: building-dept@coab.us Date routed: I l9 l
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 6/c. .J t!ire,, Kt.5 C14 De aliment review required Yes No
6 �/ uilding
Applicant: 6 I v pi nning &Zoning
Tree Administrator
Project: I Piw o gtpipeutii -r Public Works
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature f
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: proved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING c�-
Reviewed by: Date: g 30"/,l
TREE ADMIN. Second Review: roved as revised.
['Approved ❑Denie .
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
f
BUILDING PERMIT APPLICATION
r.
CITY OF ATLANTIC BEACH OFFICE COPY
800 Seminole Road,Atlantic Beach, FL 32233
Office (904)247-5826 Fax (904)247-5845
Job Address: 615 IV rl dos th Permit Number: /,5--w/No --ddc
Legal Description 143-// / /- 2S 2 jv y'at
4&el# ...0/- 7 7
Valuation of Work$ �Q so Poor Area of Sq.ft. q,rt
3 Proposed Work heated/cooled 16-8 7' non-heated/cooled Aoa
Class of Work(circle one): New Addition Alteratio Rep" Move Demolition pool/spa indo� ooi•
Use of existing/proposed structure(s)(circle one):. Commercial ��esidenti�
If an existing structure,is a fire sprinkler system installed?(Circle one :1Tes No ;
Florida Product Approval# F'3� / 7(, b ( K tt�al-
For multiple products use produc approval form
Describe in detail the type of work to be performed: �e v e 4- f ike_ce &I-/5/- y7 V I ii6 o iS
Property I • ner Information:
Name: a l n"e Address: 6(5 6/144, is b r
City A5 tate 'ip ?3213?Phone YDY Sg/_4L 8-3
E-Mail or Fax#(Optional)
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 that no work or installation has commenced prior to the
aissuance oid(work istnot commenced
within lsix performed or f construactionror of all is suspended r abandoned for ape jurisdiction.o o 6)months at abecomes im a after
work is commenced. I understand that separate permits must be secured for Electrical-Work,Plumbing,Signs, Wells,Pools, Furnaces,Boilers,Heaters,
Tanks and Air Conditioners,etc.
F
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 placation and know the same to be true and correct. All provisions of laws and ordinances governing this
type ofwork 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
'rovisions of any other federal,state,or local law regulating construction or the performance of construction.
iigi ature of Owner Signature of Contractor
Tint Name \761 .4,7e Print Name
iefore rile
its 0781 Day of ,pte aeg. ,20 l5' this me
Day of
1 ,20
fotary ub c Notary ublic
0vy.,• DAYNAH.WIWAMS y
•
flo�'• MY COMMISSION Y FF 217841
t- EXPIRES:August 7,2019 Revised 01.26.10
"4;:on Bonded Thu Notary Pubic Underwriters
3(i. 4o
!4-'i -
- : A CITY OF ATLANTIC BEACH OFFICE COPY
' s IJ%WNER / BUILDER AFFIDAVIT
I. FLORIDA STATUTES; CHAPTER 489, FLORID 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 PI?RMIT UNDER AN EXEMPTION TO THAT
LAW. THE EXEMPTION ALLOWS YOU,AS THE DWNER OF YOUR PROPERTY,TO ACT AS
YOUR OWN CONTRACTOR EVEN THOUGH YOL r DO NOT HAVE A LICENSE. YOU MUST
SUPERVISE THE CONSTRUCTION YOURSELF. Y JU MAY BUILD OR IMPROVE A ONE—OR
TWO FAMILY RESIDENCE OR A FARM OUTPUILDING. 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, WHICI-i IS IN VIOLATION OF TI-IIS 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 NCT 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.
615 S1vit L cps 6'(_ go V i liCs 3
ADDRESS PHONE NUMBER
;,m✓ A 7-/frney
tze T NAME
SI 7URE DATE
fore me this ts2q9day of
5e
2 ,l in the county of
Duval,State of Florida,has personally peared herin by imc.elf/herself and affirms that
all statements and declarations are and accurate. "
Notary Public at Large,State of iL ,County of':/W
❑Personally Known
❑Produced Identifi ...efrfre
c :: Notary Public State of Shirley L Graham< My Commission FF 0888Notary Signature: ! , Expires 0f1419818
FIBLDD'Owner-Builder Affidavit;REVISED:4116t2009