1055 OCEAN BLVD - ROOF f,S
\s\ CITY OF ATLANTIC BEACH
- f 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
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ROOF PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 15-ROOF-2716
Job Type: ROOF PERMIT
Description: ROOF
Estimated Value: $4,500.00
Issue Date: 11/19/2015
Expiration Date: 5/17/2016
PROPERTY ADDRESS:
Address: 1055 OCEAN BLVD
RE Number: 170254-0000
PROPERTY OWNER:
Name: HAHN, VICTORIA L
Address: 1055 OCEAN BLVD
FEES:
BUILDING PERMIT FEE $72.50
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $76.50
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
•
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach, FL 32233
Office (904) 247-5826 Fax(904)247-5845
Job Address: /O5,S (9c.c'A.l) /?41/0 Permit Number:
Legal Description Parcel#
Floor Area of Sq.Ft. 5 Ft
Valuation of Work$ 7 O0 Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New Addition Alteration 111113, Move Demolition pool/spa window/door
Use of existing/proposed structure(s)(circle one): Commercial 'Residential)an existing structure,is a fire sprinkler system installed? (Circle one): Yes No
Florida Product Approval# _ f tS
For multiple products use product approval form
Describe in detail the type of work to be performed: STAI P oL A S/ks,Gi-s R th) ►ZE.P�.fk E c✓�s��„cA�Z
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Property Owner Information:
Name:( A G 5,��Lr y Address: /055 Oc A.r/ i3 Li/6
City f4 3 State Zip ' Phone 1 yt -9 516
E-Mail or Fax#(Optional) C2Ai G S Lary •g Mg. wM
Contractor Information: CONTRACTOR EMAIL ADDRESS: 4//4
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 certifir 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 aperrod 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 YOUR NOTICE OF
COMMENCEMENT.
I hereby certifir that I have read and examined this application 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, tate, or local law regulating construction or the performance of construction.
Signature of Owner %_ i Signature of Contractor
Print Name rat G `e .
W .l . Print Name
Before e J ., V
Before me
his IS, Da • ∎,r_ 1!,_=�mosok 20 this Day of ,20
OI"'" �,r� CADAMS
Jota� Pub`Y'� ``u
II. ,
' •' MY COMMISSION *FF182128 votary Public•
EXPIRES December 9,2011
' ^ Revised 01.26.10
(407)398-0153 FloridallotaryService.com
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• a' CITY OF ATLANTIC BEACH
WNER / BUILDER AFFIDAVIT
r•U;tl�V
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 I-LAVE BUILT YOURSELF WITHIN ONE YEAR
AFTER THE CONSTRUCTION IS COMPLETE, THE LAW WILL PRESUME THAT YOU BUILT
IT FOR SALE OR LEASE, WIIICH 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.
/ox a• g )4-) Z
ADDR SS PHONE NUMBER
PRIJJ�NAME /
[SIGGNATURE ///(/20J
��� DATE
Before me this lZ) day of Mr ,201S in 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 go 4(A&>.County of \�yucA,..
❑Personally Known C .��j;r ry;•+..,
ducedIdentification- l- ��� •:. NICOLE MCADAMS
MY COMMISSION#FF182128
foe, EXPIRES December 9,2018
Notary Signatu - (407)396-0153 FloridallotaryService.com
11111WF
F/BLDG/Owner-Buil.. I . •,• VISED.4/4/. r