1763 E PARK TER - SIDING Cjam' , CITY OF ATLANTIC BEACH
J 800 SEMINOLE ROAD
J
;r ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5826
'-40.219r
SIDING PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 15-SIDE-2440
Job Type: SIDING PERMIT
Description: SIDING
Estimated Value: $1,500.00
Issue Date: 10/21/2015
Expiration Date: 4/18/2016
PROPERTY ADDRESS:
Address: 1763 E PARK TER
RE Number: 172020-0412
PROPERTY OWNER:
Name: Williams, Daniel
Address: 1763 Park PARK
PERMIT INFORMATION:
FEES:
PLAN CHECK FEES $28.75
BUILDING PERMIT FEE $57.50
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $90.25
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATI.ANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
I
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH OFFICE C
800 Seminole Road,Atlantic Beach, FL 32233 COPY
Office (904)247-5826 Fax (904)247-5845
Job Address: I 7({3 PG,{K re i f ce as
Permit Number: /S'S i,per -.7j/yp
Legal Description
oor rea o q t Parcel# 0 0 - Oil 1Z
Valuation of Work$ $ 11 500 Proposed Work heated/cooled t
non-heated/cooled 400
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa F window/door clou Sp
Use of existing/proposed structures)(circle one): Commercial P eside tial
If an existing structure,is a fire sprinkler system installed? (Circle one): 'es o
Florida Product Approval # 1
For multiple products use product approva orm
Describe in detail the type of work to be performed: rib et- C ern
1 ar. s,a� ow( exisiv
5/'d t% ti S/i+CL AX 7 �� 7'Cvrr S></�fJS A td le rnrrreiE 6 lore."(I If
®® o screws x �d�a.�n r�lel. �' � a s�J� 3.75 T«y��n
Property Owner Information: c( s Il rY4 # c& / �e -Cvrrr�ot s 1`r v s,i°.2 'x(/c .0i3"_,
rer we rs, daver4,rt, sfi.o= be .
Name: 4 P ' �/1�111 t 'art S 7(( � P K �',-ern r,i,, f �i.,�,.�. s Sid..
city Address: l(°r/GGPtS ndil
ty Ai la, Pc trar4 State AZip 3223? Phone gS0- C19 -24dy ,
E-Mail or Fax#(Optional) Qhjy 5 0 p 9.f-tut;l*roman
Contractor Information: CONTRACTOR EMAIL ADDRESS:
Company Name:
Address: Qualifying Agent:
Office Phone City State Zip
State Certification/Registration# Job Site/Contact Number Fax#
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 if work is not commenced within six(6)months, or if construction or work is suspended 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 Electrical Work,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 YOU-R.NOTICE OF
COMMENCEMENT.
1 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
'ype 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
7rovisions of any other federal,state, or local law regulating construction or the performance of construction.
>ignature of Owner G✓j
Signature of Contractor
print Name Pam.?/ lit/l//ra in-S- Print Name
tefe 1 e Before me
its of f ( , 20 I'S
IP..... yp, this Day of _ 20
_.f�..mo■�- • �� .am • '.-
b 7 _ ey ra am
Notary Public -- --- —
1 i.," My Commission FF 086990
4o6' Expiros 02/14/2018
Revised 01.26.10
.r
“.A.A
CITY OF ATLANTIC BEACH OFFICE COPY
"Mr-1 13-WNER / BUILDER AFFIDAVIT
ji 91'
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 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.
/76,3 Park 1 wave as-1- ?SO -S161- Z6-0
ADDRESS ) PHONE NUMBER
Daniel �i�Ii] hQ me
PRINT NAME
� W /0/ /4/ /201s-
SIGNATURE
DATE
Before me this /5--day of D 20.the county of
Duval,State of Florida,has personally appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of i'V •County of V
❑Personally Known
gooduced Identifi on- V •r /�J
alria_AT
- r°e Notary Public State of Florida
Notary Signa - ; Shirley L Graham
• m= My Commission FF 086990
40t 0.4' Expires 02/14/2018
F:/BLDG/Owner-Builder Afradavir,REVISED 4/16/2009
�,S!.r�.�JJ; City of Atlantic Beach
s APPLICATION NUMBER
Building Department
s�\ (To be assigned by the Building Department.)
800 Seminole Road
r� Atlantic Beach, Florida 32233 5445
6-S/. 14 - al 10
Phone(904)247-5826 - Fax(904)247-5845
0;3 9r E-mail: building-dept@coab.us Date routed: AO /5/
City web-site: http://www.coab.us .
APPLICATION REVIEW AND TRACKING FORM
Property Address: /74 3 /frrR Tr E Department review required Yes o
Building
Applicant: Q lt)31..z • anning &Zoning —
Tree Administrator
Project: 2)-7-11 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:
APPLICATION STATUS
Reviewing Department First Review: Approved. ❑Denied.
(Circle one.) Comments:
BUILDI •
PLANNING &ZONING Reviewed by: `% / ► r Date:JO 1?VS--
TREE ADMIN. Second Review: ❑Approved as revised. ❑Deni
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