258 Pine St - Transfer Job from Contractor . \J
I _ 41110`< " `� CITY OF ATLANTIC BEACH
- , .' 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
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RESIDENTIAL ALT /OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247 -5814
JOB INFORMATION:
Job ID: 16 -RAAR -394
Job Type: RESIDENTIAL ALTERATION
Description: TRANSFER - TO FINISH JOB FROM CONTRACTOR
Estimated Value: $1,000.00
Issue Date: 2/16/2016
Expiration Date: 8/14/2016
PROPERTY ADDRESS:
Address: 258 PINE ST
RE Number: 170553 -0000
PROPERTY OWNER:
Name: DEL GALLOWAY, CHARLES
Address: 912 NW F ST APT 700
PERMIT INFORMATION:
FEES:
BUILDING PERMIT FEE $55.00
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $59.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
ir
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247 -5826 Fax (904) 247 -5845 1 ,_- R'nR -
Job Address: r j _ Fe/ 7 er:
4 ILA, i.._ .4, P rmit Numbe :
Legal Description .► L_ rer., I Parcel #
Valuation of Work $ OC Floor Area off' ? t. Ft
1 Proposed Work heated /cooled n o n - heated /cooled
Class of Work (circle one): New Addition Alteratio Repair Move Demolition pool /spa window /door
Use of existing /proposed structure(s) (circle one): Commercial e ' ti
If an existing structure, is a fire sprinkler system installed? (Circle one): No N /A
Florida Product Approval #
For multiple products use product approval form
Describe in detail the type of work to be performed:
T - aLG
Pro . e 1 ner I I formation:
• ,
• Name: /tf ' ir- - pi • -3( , , f .
A ddress: J
Cit :ii i G M" S ater Z'. _,3a hone _ 6 _��. 1 ` OA AP
E -Mail or ' . # (Optional)
Contractor Informafon: CONTRA • OR EMAIL A4 DRESS:
Company Name: • "' . • vim% ` y al , • / e'Q in
Address: Qualifying g A gent:
Office Phone City tate Zip
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 certi6, 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 YOUR NOTICE OF
COMMENCEMENT.
I hereby certiji that I have read and exami d this a plication and know me to be true and correct. All provisions of laws and ordinances governing this
type of work will be complied wi h wh- '-r rifled d herein .r no . 7 , , .ranting of a permit does not presume to gi authority to violate or cancel the
provisions of any other federal, s te, • .cal regulati . .n u t .'• the performance of construction.
Signature of Ow r 111 .... Signature of Contractor
?rint Name �E / . 8 Q
f — Print Name
3efoj me Before me
his l `I
�A It of /k 21 Day of 20
1111� / r " TONIGINDI.ESPERGER
11. -_ . „ *MMISSION # FF924951
dotary ''e is ' oa ''' " f - - s October s, 209 N jai Pt. s is
Iliill • ' Bonded Thru Notary Public Unden nt� y
Revised 01.26.10
tn
CITY OF ATLANTIC BEACH
WNER / BUILDER AFFIDAVIT
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.
gili Warr
ADD'tSS • 6- O.
P ••EN
/w..4,,
PRIN
SI •A 4RE Ftworato
IVY / 6
DATE
Before me this 6 day of A2' e county of
Duval, State of Florida, has personally appeare. • rrin b i y him • -If / herself and affirms that
all statements and declarations arLr.u4, d acc ate.
Notary Public at Large, State of 1 � , County of
❑ Personally Known e /IJ
X roduced Identification - u ( -J1 d'
'' \\
N ., " ;- TONI GINDLESPERGER
MY COMMISSION t FF 924951
EXPIRES: October 6, 2019
Notary Signature
,r' Bonded
� Thru Notary Public Underwriters
ow
FIBLDG/Owner- Builder Affadavit; REVISED: 4/16/2009
•
February 12 2016
Dan Arlington
Chief Building Official - --
Atlantic Beach Building Department
800 Seminole Rd. C
Atlantic Beach, FL 32233 n1
RE: DEL GALLOWAY
258 PINE ST. O r -.
ATLANTIC BEACH
.,_ 0.----,<„
Dear Mr. Arlington: N k
lam the owner of the property at 258 Pine St., Atlantic Beach. The
contractor I hired, FLA. Design Build, Inc., has abandoned the project and refused
to finish the job. I would like the building permit transferred into my name to
complete the construction. I have hired a licensed contractor, Jeff Harrison, to
complete the project. I would like to appoint him as my agent, and authorize Mr.
Harrison to coordinate the final inspection, and complete any items required by
the building department. Mr. Harrison will take care of any financial
requirements related to the transfer.
I appreciate your assistance with this matter. I can be reached at 202 -360-
0279 if you need to speak with me or need any additional information.
Sincerely,
STATE OF FLORIDA
OUNTY OF OVAL
b c Sworn to (or affirmed) and subscribed before me this 4 _ day of
rN3,'.w►igi , 20 l(e t, RRut'y zei,L G.ttiowl -
�.1 � (Notary Stamp
Signa of Notary
Personally known or Produced identification
Type of identification produced Fi (�
.4 DAYNA H. MAW
W
, A ., r . _ _
,=„: •, MY COMMISSION # FF 217841
r' EXPIRES: August 7, 2019
'):tif: y° Bonded Thru Notary Public lMdeiwriten
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