68 W 13TH ST - ROOF ,� `s, CITY OF ATLANTIC BEACH
.„x, .s 800 SEMINOLE ROAD
\k,, 4 ATLANTIC BEACH, FL 32233
/ INSPECTION PHONE LINE 247-5814
N �
'`.4J;319
ROOF PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-ROOF-675
Job Type: ROOF PERMIT
Description: REROOF
Estimated Value: $6,500.00
Issue Date: 3/21/2016
Expiration Date: 9/17/2016
PROPERTY ADDRESS:
Address: 68 W 13TH ST
RE Number: 170805-0020
PROPERTY OWNER:
Name: SLEDGE, KATHRYN L
Address: 68 W 13TH ST
FEES:
BUILDING PERMIT FEE $82.50
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $86.50
PERMIT IS APPROVED ONLI IN ACCORD:IN(E 11'1'111 ALL CI TI' OIF ATLANTIC BEACII ORDINANCES AND TILE FLORIDA
BUILDING CODES.
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CITY OF ATLANTIC BEACH
OWNER / 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. TI-IE 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 TFIE 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, WIIICI-I 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 REOUIRED 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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN "OCCUPATIONAL LICENSE"IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826)IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
ADDRESS
PHONE NUMBER
1�SIcV cz.. 43 S .d -�
PRINT NAME
SIGNATURE
_^/ �y� VVVV DATE
Before me this F / day of 7/1 L' . 204the county of
Duval,State of lorida,has personally appeared herin by him e f/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of F L ,County of A ✓�
❑P sonally Known Poi, Notary Public State of Florida
roduceddentifl _ :Y f` Shirley L Graham
■ V .a My Commission FF 086990
ofExpires 02/14/2018 Notary Signa. J1 AfMr
F:BLDG/Owner-Builder Affidavit;REVISED:4/16/2009
soi ,
c,,,,:. �,1BUILDING PERMIT APPLICATION
�
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach FL 32233
u;tt>r Office: (904)247-5826 • Fax: (904)247-5845
Job Address: /a 9 L.) 13 . Permit Number:
Legal Description RE#
Valuation of Work(Replacement Cost)$ 6,5"o 0 Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Addition Alteration Repair Move Demo Pool Window/Door
• Use of existing/proposed structure(s)(Circle one): Commercial 'esidentia
• If an existing structure, is a fire sprinkler system installed?(Circle one): Yes o N/A
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work to be performed:
Qt.41A 6.-C_A/...A,v-t- (4', )—b-tri)
Florida Product Approval# "FL 1 t) (07 t,.,Li - it_ 1,114 4, . 1 for multiple products use r
4 p p product approval form
Property Owner Information
Name: 0,C / ./ts a o. Address: Lo 7 0 0, � �.
City QUAo.+w 6.' hA, L . State'' ip.3 3 Phone 9by_&.41_113sr
E-Mail 11N MIAA 5a_ a 0081.-0;Jr.r_6h-
Owner or Agent (If Agent,Power of Attorney or Agency Letter Required)
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.
Contractor Information:
Name of Company: Qualifying Agent:
Address: City State Zip
Office Phone Job Site/Contact Number
State Certification/Registration# E-Mail
Architect Name& Phone#
Engineer's Name & Phone#
Worker's Compensation
Exempt / Insurer / Lease Employees I Expiration Date
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 constriction 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 o(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.
Signature of Propert Owner:( la,,N-12Q AQ.S c Signature of Contractor:
Bef. :qte
this. / :- •� • �U / / C'/�--� '/ / Before me this Day .
No < P . Notary Public:
`�-''.*.v� 11.1.1 ira
, °4. Not
I hereby cert that . 1 ' •_ - RtiP lic• on and know the same to be true and correct. All provisions of laws and
ordinances governi x, , • ..t•'lied s .•ith
of any whether specified herein or not. The granting of a permit does not
presume to give aut .' . io f i : s � f Y .federal, state, or local law regulating construction or the
• performance of con-. •
•
2. -S JO 6 Rev. 3/14/16