1937 SEMINOLE RD - REPLACE FIREPLACE , ALTERATION - PERMIT 16-RAAR-330 o' .'; CITY OF ATLANTIC BEACH
' " 800 SEMINOLE ROAD
+ Z ATLANTIC BEACH, FL 32233
\ INSPECTION PHONE LINE 247-5814
\JF1I>`'
RESIDENTIAL ALT/OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-RAAR-330
Job Type: RESIDENTIAL ALTERATION
Description: REPLACE EXISTING FIREPLACE
Estimated Value: $5,200.00
Issue Date: 2/23/2016
Expiration Date: 8/21/2016
PROPERTY ADDRESS:
Address: 1937 SEMINOLE RD
RE Number: 169542-0522
PROPERTY OWNER:
Name: FRANKEL TRUST, MURIEL
Address: 1937 SEMINOLE RD
PERMIT INFORMATION:
FEES:
PLAN CHECK FEES $38.00
BUILDING PERMIT FEE $76.00
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $118.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
1
II
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OFFICE COPY
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233 ;�
Office(904) 247-5826 Fax (904)247-5845 , G -. RNA R 33 c
Job Address: _ 1937 Seminole Road Permit Number: __
Legal Description Replace existing fireplace that has rusted firebox Parcel #
Valuation of Work S 5,200 Proposed Work heated/cooled non-heated/cooled •
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Class of Work(circle one): New Addition `Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s)(circle one): Commercial v_Recidential.i
If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No N/A
Florida Product Approval#
For multiple products use pro pct approve ortli
Describe in detail the type of work to be performed: Remove and replace existing firebox and flute
Property Owner Information:
Name: Barbara Haasis Address: 1937 Seminole Road
City Atlantic Beach State FL Zip_ 223 l'hone 904 249-02 _fiG� �Q! L_q ,8-2,„
I E-Mail or Fax#(Optional)
Contractor Information:
Company Name:._---_----------__.-.-- Qualifying Agent: -----------__-_-- __-.
Address:___^...-- City�_— State Zip
Office Phone Job Site/Contact Number Fax#
State Certification/Registration
Architect Name&Phone 4 -
Engineer's Name&Phone# 1('C� C-IBC= E A S se,_RV 1e-'
Fee Simple Title ifolder Name and Address 4Q7 = 5 - `77-7 - cam -
Bonding Company Name and Address 3 I Ca 07
Mortgage Lender Name and Address N r ► e o�e CXl-4-Co l
Applicalion is hereby made to obtain a perm«to du the work and installations as Indicated. I certi/v that no stork or installation has commenced prior to the
ivmunce of a permit mid that u11 work gill be performed inert the standards of lams reguhumi constntction in this jurisdiction. This permit become.%Judi
and void quark is not commenced within sir(4)months or if construction or nark is suspended or ulxrmdoe:ed for a period of sit-(G)months at(lily!line«lien
stork is commencer!. I understand that Separate permi+ most be scarred for Electrical Work, Plumbing,Signs, Wells, Pools, Furnaces, Boilers,Healers,
Tanks and Air Conditioners,etc.
WARNING TO OWNE ' : YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RE` LT IN YOUR PAYING TWICE FOR IMPROVEMENTS
TO YOUR PROPERTY. IF Y I■ INTEND TO OBTAIN FINANCING CONSULT WITH
YOUR LENDER OR AN AT ORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
1 herein,certif,drat 1 have read and examined this cvpli, lion and know the-same to he true and correct. All provisions()flaws and ordinances governing this
type of work will be complied with whether specified h•rein or not. .The grantink cif a permit doe. not presume to give aaarhaite to violate or cancel he
provisions giant,other f•dctol.stun•.or local law reett! tug construction or the performance of cottsavction.
Signature of Owner Sri/- _ d ,r / Signature of Contractor
Print Name -tit-12.6 .__. #4-AS _ Pht 4a��=i — —
,a%���r�.,, CYNTHIA.4 �pQQlye�ir
Swon�o an subscribed a me _._._... 1 �� '��p`v ° t +' �CrtweicN't(611dot'c
this a of ‘10/& Y My .Iii xpims-Mv}29,2418
Y 0
.pc Commission#EE 187878
f�, —gsraAp�Tluough-National Notary Assn.
Nora y lm I c
ll...d.....1 Ai 11. In
OFFICE COPY
oeTm 7 _ ,F I(, *fit* - 330
PERMIT AUTHORIZATION
I eh r Is n/L°/)/P'\1/& hereby authorize
(License Holder)-PLEASE PRINT
&_r_-__b_r_o_ ik ,-( ___.______ to obtain a permit(s) on my behalf, under my
(Authorized Person)-PLEASE PRINT
license#______,, io D '7 for the job(s) described below. I understand as the
license holder I am required to sign the permit application.
PERMIT TYPE DESCRIPTION
Building Owner Name___7 g r b r A //i 5 Y
Electrical Site Address 71,_?7 3_,S VJ n of c C�
4i-frn, c- erA elk
Plumbing
HVAC -----
Roofing --_
Pool
Other _
-� (License Holder)
4Jo0C1 /5Qr-/)_r/14 rye p 1cq' a-/ � . /.
,/1.fh2 Date
•
State of Florida County of Orkr1 -c_ —"� �
Affirmed and subscribed before me this._ day of_�__�- f e='
X_._._.204'by e4,-,:y /7 .f�' /
who is •ersonally known to or who has produced_ (type of ID)as id ntification.
. i ..dik' (7-e1-1.4-t4-eg---L-r-7 Sig ature of Note Public State of Florida �'rint.Type or Stamp Name of Notary
40.,454„, yCYNTHIA J.DOW
i: ., Notary Public-State of Florida
• 5 My Comm.Expires May 29.2016
.- -,1- �; Commission#EE 187878
", % mod',,, Bonded Through National Nola(y Assn. 1 01/28/15
OFFICE COPY
•
�s ' 3!3hr,a
CITY OF ATLANTIC BEACH
fit: „r
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 RE•UIRED 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.
/`l37 LA-,ele dooR� 1�D y9��aa
ADDRESS
PHONE NUMBER
' � SAS ca 903 A.3 f/6
INT NAME
IGNATUR�
DATE
Before me this / day of t✓ /r
Duval,State of Florida,has personally appeared 2him a herself and of
P y and a cc herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of I C._County of (I r Q�
❑Personally Known •--7 !-/�
❑Produced Identification- ��-r►7 Z ` - �C�3
•� , Nsr"!; TONI GINDLESPERGER
Notary Signature: , !!'
MY COMMISSION FF 924951
x•��.'�= EXPIRES:October 6,2019
'�R P Bonded Thtu Wotary Public Underwriters
F:/BLDG/Owngr-Builder Affadavit;REVISED:4/16!1009
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I
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Installation Manual FILE COPY
Installation and Fireplace Setup
INSTALLER: Leave this manual with party responsible for use and operation.
OWNER: Retain this manual for future reference.
NOTICE: DO NOT discard this manual! A WARNING: If the information in these
instructions is not followed exactly, a fire
H EAT.G LO or explosion may result causing property
No one builds a better fire damage, personal injury, or death.
Model(s): • DO NOT store or use gasoline or other flam-
mable vapors and liquids in the vicinity of this
EXCLAIM-36 or any other appliance.
EXCLAIM-42 V US • DO NOT overtire. Overfiring will void your
warranty.
LISTED • Comply with all minimum clearances to com-
bustibles as specified. Failure to comply may
cause house fire.
�\\i- ; A WARNING
• \ i HOT SURFACES!
,i Glass and other surfaces are hot during
�ibi∎ operation AND cool down.
fr Hot g lass will cause burns.
DO NOT touch glass until it is cooled
.. NEVER allow children to touch glass
� I!% • Keep children away
` ~ o
• CAREFULLY SUPERVISE children in same room as
�`� / fireplace.
/ • Alert children and adults to hazards of high temperatures.
High temperatures may ignite clothing or other flammable
materials.
• Keep clothing, furniture, draperies and other flammable
WOODBURNING FIREPLACE materials away.
Installation and service of this fireplace should be A WARNING
/2Q s performed by qualified personnel. Hearth &Home Fire Risk.
Technologies recommends NFI certified profes-
a ' sionals, or technicians supervised by an For use with solid wood fuel only.
NsTITL)<4* NFI certified professional. 4=7;IL,,g Other fuels may overfire and generate
CERTIFIED
poisonous gases(i.e. carbon monoxide).
Heat& Glo • Exclaim 36/42 •4013-266 Installers Manual • Rev J • 02/02/15 1
, s--up,,, City of Atlantic Beach APPLICATION NUMBER
Y �� Building Department (To be assigned by the Building Department.)
-,:.'iw 800 Seminole Road
��10 . .-r Atlantic Beach, Florida 32233-5445 — �� R -3 Phone(904)247-5826 • Fax(904)247-5845 �l
`�J;tIo. E-mail: building-dept @coab.us Date routed: -t it c
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1 9 2 I
3 " rn v • t review required Yes No
(DePar.tm)ent
Biding Applicant: 01` aLf-A l4 ct0.S t S a� Planning &Zoning
Tree Administrator
Project: Re P tae e___ 1---I`re JDo Y Public Works
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt
of Permit Verified By Date
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: PApproved. ❑Denied.
(Circle one.) Comments:
BUILDING /1/ 0 C-.—
PLANNING &ZONING
Reviewed by: Date:
TREE ADMIN.
Second Review: UApproved as revised. ❑Denied.
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