375 Seminole Rd - Ceiling Insulation AV; \S\ CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
\+J °` ATLANTIC BEACH, FL 32233
>� INSPECTION PHONE LINE 247-5814
0.219'
RESIDENTIAL ALT/OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 15-RAAR-2977
Job Type: RESIDENTIAL ALTERATION
Description: CEILING INSULATION
Estimated Value: $1,450.00
Issue Date: 12/31/2015
Expiration Date: 6/28/2016
PROPERTY ADDRESS:
Address: 375 SEMINOLE RD
RE Number: 170435-0000
PERMIT INFORMATION:
FEES:
I
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
BUILDING PERMIT FEE $57.25
Total Payments: $61.25
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach, FL 32233
c Office (904)247-5826 Fax (904)247-5845
Job Address: 5 JQ.NL( nD
OG CI Permit Number:
Legal Description '' tt Parcel#
Valuation of Work$ i 45� ,0Q Floor Area of Sq.Ft. q t
Proposed Work heated/cooled 1 I non-heated/cooled
Class of Work(circle one): New Addition Alteration k Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s) (circle one): Commercial esident.
If an existing structure,is a fire sprinkler system installed?(Circle one): es No N/A
Florida Product Approval#
For multiple products use product approva orm
Describe in detail the type of work to be performed: �-Y' ac, & 1p-or i`I oA 0E- au L(
AS-Lt(etd-i on
Property Owner Information:
Name: uNda
Address: 'a1 S S QiniCt A 0 I$ i� ad
City ` Q 1 u (tT M& Stat; Zi Phone . f •ZMIL1 1. i
E-Mail or Fax#(Optional)
Contractor Information: CONTRACTOR EMAIL ADDRESS:
Company Name: Qualifying Agent:
Address: City
Office Phone Job Site/Contact Number State Zip
State Certification/Registration# 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 certifr that no work or installation has commenced prior to the
and void�wpermit i ot commencework ithinl six performed
months, or:if construction or of is suregulating or construction b abandoned for this jurisdiction.o of si 6)This
onpermit hs t 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 certify 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 sppeci ted 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 loc law regulating construction or the performance of construction.
Signature of Owner
Signature of Contractor
'rint Name Li 'ntta cr 9 Print Name
3efore me Before me
his Day of 20 .
20
�ki Nota public State of Florida
¢ ry Gratlam
rotary Public My Corn .
c4 r.04) Expires 0n F
i'I,g ll r IC
•
Revised 01.26.10
.,'•t jJ Ij\
CITY OF ATLANTIC BEACH
OWNER / BUILDER AFFIDAVIT
-'•u,sur
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. TFIE 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 CES.REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING
ORDINAN
II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED.
HI. 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.
15 SOWAdlLQoa Uf30 ,2.3q y (�
ADDRESS
L'ti da PHONE NUMBER
PRI T NAME
SIGNATURE U
DATE
Before me this 3 day of / Z ,2c/ he county of
Duval,State of Florida,has personally appeared herin by himself/herself and affirms that
all statements and declarations a and ag, ate.
Notary Public at Large,State of { ,County of • `�
OP naffy own f
ro eed IdeKnntific. - - _
29,Nit Notary Public State of Florida
dmoroir_ $� �: Shirley L Graham
-� My Commission FF 088990
Notary Signat - for r�o Explret 02/14/2018
F:/BLDG,Owner-Builder Affadavit;REVISED:4/16/2009