265 MAIN ST - ROOF (-- Vf: ,
j
\ CITY OF ATLANTIC BEACH
rte, .f 800 SEMINOLE ROAD
l4 a ;-)
UV ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
\0,219`
ROOF PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-ROOF-489
Job Type: ROOF PERMIT
Description: RE ROOF
Estimated Value: $6,000.00
Issue Date: 2/26/2016
Expiration Date: 8/24/2016
PROPERTY ADDRESS:
Address: 265 MAIN ST
RE Number: 170868-0500
PROPERTY OWNER:
Name: SPIEGEL, THOMAS C
Address: 265 MAIN ST
GENERAL CONTRACTOR INFORMATION:
Name: JUSTIN LARSEN CONSTRUCTION INC
Address: PO BOX 1942 LIC # BELOW 4 GERALD GOLLOBIT
Phone: 904-327-4311
FEES:
PLAN CHECK FEES $40.00
BUILDING PERMIT FEE $80.00
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $124.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904) 247-5845 I (0_ Roc(= - 48
Job Address: 265 Main Street Permit Number:
Legal Description 18-34 38-2S-29E .249 Atlantic Beach Sec H, Lot 3, 4 Parcel# BY ORD#65-88-17 BLK 103
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work$ b g Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s)(circle one): Commercial (Residential
If an existing structure, is a fire sprinkler ystem installed?(Circle one): V z 1 0 CM
Florida Product Approval # FL10124 L X73 — R. S 0 .-\, r 1
For multiple products use product ap ova form �(MF��
Describe in detail the type of work to be performed: Re-roof
Property Owner Information:
Name: Thomas Spiegel Address: 265 Main St
City Atlantic Beach State ELZip 32233 Phone
E-Mail or Fax#(Optional)
Contractor information:
Company Name: Justin Larsen Construction Qualifying Agent: Justin E. Larsen
Address:_4670 Hedgehog St City Middleburg State FL Zip 32068
Office Phone 904-241-0320 Job Site/Contact Number 904-241-0320 Fax# 904-241-0320
State Certification/Registration# CCG 1329847
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. /understand that separate permits must be secured for ElectricalpWork, 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/have read and examined thisplication and :w 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 of The granting of a permit does not presume to give authorit to violate or cancel the
provisions of any other federal,str • .r local law regulating o st ction or the performance of construction.
.s c / err.
er
Signature of Owner Signature of Contractor ••••
Print Name A 0.liarl 0, ‘--5;/iccZ Print Name Justin E. Larsen
Sworn to and subscribed b f re me Sworn to and subscribed before me
this, Day of ,fGG ,20 /Q_ this 24 Day of •���/'F , 20 /'
Notary P • •_ e _� _ Notary Pub
�,.,,,,
i'
V..) YNWAM L POPE R ..•,y'k•.•' MY COMMI AMA 1. •i 0
MY COMMISSION t+FF 242630 =•• " = EXPIRES:October 19,2019
, ober 19 "�e�?:;. EXPIRES:Oct 2019 ?• �,, r
''.4f..-N'' Bonded itwu Wry Pubic Unden niters ?;R. Bonded Thru Notary Pubic UnderwlMrs i
e •
2/25/2016 Florida Building Code Online
•
/yam�j�w.w.r«, •
FLORiOA OGPARTmWr OF / CVO/ �11
Business & Professional 'egu a ro' s (/ m }w
NWT DePR DePR DIV istoors coma
Florida Depart t°, SCIS Home Log In User Registration Hot Topics Submit Surcharge Stars&Facts Publications FBC Staff BCIS Site Map Links Search
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Professi naI ProR PcUtb11Approval
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Fec.3tefa^!,_ Product Approval Menu>Product or Application Search>Application Ust>Application Detail
1 OFFICE OF THE FL# FL10124-R17
SECRETARY
Application Type Revision
Code Version 2014
Application Status Approved
Comments
Archived
Product Manufacturer GAF
Address/Phone/Email 1 Campus Drive
Parisppany, NJ 07054
(973)872-4421
lindareith @trinityerd.com
Authorized Signature Beth McSorley
lindareith @trinityerd.com
Technical Representative Beth McSorley(current)
Address/Phone/Email 1 Campus Drive
Parsippany, NJ 07054
(973) 872-4421
bmcsorley @gaf.com
Quality Assurance Representative
Address/Phone/Email
Category Roofing
Subcategory Asphalt Shingles
Compliance Method Evaluation Report from a Florida Registered Architect or a Licensed Florida
Professional Engineer
Evaluation Report- Hardcopy Received
Florida Engineer or Architect Name who developed the Robert Nieminen
Evaluation Report
Florida License PE-59166
Quality Assurance Entity UL LLC
Quality Assurance Contract Expiration Date 05/14/2016
Validated By John W. Knezevich, PE
Validation Checklist- Hardcopy Received
Certificate of Independence FL10124 R17 COI 2015 01 COI Nieminen,Ddf
Referenced Standard and Year(of Standard) Standard Year
ASTM D1970 2009
ASTM D3161 2009
ASTM D3462 2009
ASTM D7158 2008
TAS 107 1995
Equivalence of Product Standards
Certified By
htlps://www.floridabuilding.org/pr/pr_app_dll.aspx?param=wGEVXQwtDquracBeVCbdMQNZD6Zesy3BpT6YGGOoRax64Ksl%2bsxAOQ%3d%3d 1/2
2/2571016 Florida Building Code Online
Sections from the Code
Product Approval Method Method 1 Option D
Date Submitted 12/16/2015
Date Validated 12/16/2015
Date Pending FBC Approval 12/19/2015
Date Approved 02/10/2016
Summary of Products
FL# 1 Model,Number or Name Description
•
10124.1 GAF Asphalt Roof Shingles Fiberglass reinforced 3-tab, laminated,5-tab and hip/ridge
asphalt shingles
Limits of Use Installation Instructions
Approved for use in HVHZ: No FL10124 R17 II 2015 12 FINAL ER GAF Asphalt
Approved for use outside HVHZ:Yes 5hinoles FL10124-R17,pdf
Impact Resistant: N/A Verified By: Robert Nieminen PE-59166
Design Pressure: N/A Created by Independent Third Party: Yes
Other: Refer to ER,Section 5. Evaluation Reports
fL10124 R17 AE 2015 12 FINAL ER GAF Asphalt
Shingles FL10124-R17.pdf
Created by Independent Third Party: Yes
Contact Us::1940 North Monroe Street,Tallahassee FL 32399 phone:850-487-1824
The State of Florida is an AA/EEO employer.Copyright 2007-2013 State of Florida,::privacy Statement::Accessibility Statement::Refund Statement
Under Florida law,email addresses are public records.If you do not want your e-mail address released in response to a public-records request,do not send electronic
mail to this entity.Instead,contact the office by phone or by traditional mail.If you have any questions,please contact 850.487.1395.'Pursuant to Section
455.275(1),Florida Statutes,effective October 1,2012,licensees licensed under Chapter 455,F.S.must provide the Department with an email address If they have
one.The emails provided may be used for official communication with the licensee.However email addresses are public record.If you do not wish to supply a personal
address,please provide the Department with an email address which can be made available to the public.To determine If you are a licensee under Chapter 455,F.S.,
please click here.
Product Approval Accepts:
rac■
s4.curitr sIF rKILN
Credit SAFE
https://www.floridabuilding.org/pr/pr_app_dtl.aspx?param=wGEVXQwtDquracBeVCbdMONZD6Zesy3BpT6YGGOoRax64Ksl%2bsxAOQ%3d%3d 2/2
Doc # 2016043341, OR BK 17473 Page 3, Number Pages: 1, Recorded 02/26/2016
at 09:27 AM, Ronnie Fussell CLERK CIRCUIT COURT DUVAL COUNTY RECORDING $10.00
NOTICE OF COMMENCEMENT
Permit No. Tax Folio No.
State of Florida,County of Duval
THE UNDERSIGNED hereby give notice that the improvement will be made to certain real property in accordance with
Chapter 713,Florida Statutes,the following information is provided in this Notice of Commencement.
1. Description of property(legal description of property and address if available):
265 Main St.Atlantic Beach.FL 18-34 38-2S-29E.249 ATLANTIC BEACH SEC H BY ORD#65-88-17 BLK 103
2. General Description of improvements:
Re-roof
3. Owner Information:
a)Name and Address: Thomas Spiegel-265 Main St,Atlantic Beach,FL 32233
b)Interest in property:General
Al
/- c)Name and address of simple titleholder(if other than owner):
- I 4. Contractor Information:
a)Name and Address:Justin Larsen Construction-4670 Hedgehog St Middleburg FL 32068
b)Phone Number:(904)241-0320
5. Surety Information:
a)Name and Address:
b)Phone Number:
c)Amount of Bond:$
6. Lender Information:
a)Name and Address:
b)Phone Number:
7. Person within the State of Florida designated by owner upon whom notices or other documents may be served as
provided by 713.13(IXa)7,Florida Statutes:
a)Name and Address:
b)Phone Numbers of Designated Person:
8. In addition to himself/herself,Owner designates of to receive a
copy of the Lienor's Notice as provided in Section 713.13(I)(b),Florida Statutes.
a)Name and Address:
b)Phone Number of person or entity designated by owner:
9. Expiration date of Notice of Commencement(the expiration date may not be before the completion of construction
and final payment to the contractor,but will be one(I)year from the date of recording unless a different date is
specified:
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE
NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713,PART I,
SECTION 713.13, FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND
POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING
YOUR NOTICE OF COMMENCEMENT.
Under penalty of perjury,I declare that I have read the foregoing notice of commencement and that the facts stated
therein are true to the best of my kno ge and belief.
714c.rr, C, Pifirra O W NL
Signature of Owner or O er uthorized Officer/Director/Partner/Manager Signatory's Printed Name&Title/Office
The foregoing instrument was acknowledged before me this of(a day of fe ,20 46,
by 77/erMA7 J O1 - as 43rr en for .
(Name of Person) (Type of Authority.i.e.Officer/Aaomey) (Name of PPPartyy Instrument was Executed for)
I :�"y tttuyvu;';,t;,;s NOTARY PUBLIC,STATE OP FLORIDA
1i.:.. ►n coAMSSa",s rF ,a Print Name: WI U.1 tie" L Fr,PC
>.,1 .• 19,2019
.:: uarata,,,
❑Personally Known
El Identificatiorlfype:
0
(Affix Notary Seal Above)
Revised 3/15/12