1842 HICKORY LN - BATH ALTERATION j rL4jt1el
�� '� CITY OF ATLANTIC BEACH
A rt' V 800 SEMINOLE ROAD
O r .- ATLANTIC BEACH, FL 32233
" INSPECTION PHONE LINE 247-5814
J111>�
RESIDENTIAL ALT/OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-RAAR-728
Job Type: RESIDENTIAL ALTERATION
Description: durarock bath
Estimated Value: $500.00
Issue Date: 3/25/2016
Expiration Date: 9/21/2016
PROPERTY ADDRESS:
Address: 1842 HICKORY LN
RE Number: 172020-1452
PERMIT INFORMATION:
FEES:
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
BUILDING PERMIT FEE $55.00
Total Payments: $59.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BLJILUINC PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800
Scirilnoic Road. Atlantic Beach_
Office 004) 247-5li2(, l'aN t 0(4) 147-54.--;
,
-Job Address: ,---i-',..:. !--h C tii: ,:_. i t.L ;LA- Permit Number:
Legal Description Parcel#
s li loot-Area ill- Suit.
Valuation of Work Sr BOO Proposed Work heated/cooled non-heated/cooled-
Class of Work(circle one): Nes:. Addition Alteration : Repair Move Demolition pool:Ta IA indov.:door
Use of citing/proposed structure(s)(circle one): Commercial -Akoidential..-
Ilan existing structure.is a fire sprinkler system installed? (Circle one)' \ - L. No N \
F iori da Product Appn:
For multiple products use product-
1)escri he in detail the type of work to be pv.rformcd: Li , . _ i . , :-H,
- —
Property Owner information:
\ .,`,1 ilirt•s :
_, __
!-ainc:-i_. /in .;. .1-ii me . _
, - - -- -
. _ - --------
t:oat i-actor information:
-i. ompany !\,arri,,': __ 7 il:.. . ,,,`-. f,nialif:itiLi -Vient:
....,- e...
AddreSS: 1 1 6a 3.._ 1 yy... 6;..,6- 4.--c tc -bt,o-c. c..--, citv 73ks..v50-).‘0:I(.R :-.1,0,.. 'rL
C,94ft
. .• . /.. - 3 aa
P
()ffiCe Phone 441)(- - _ LE 16 1-1.1oll Site"f... tact Number 1.,,, --
Stat.:.Cet-tificatiooReLlistration i•-• CJ' (...(2)(-1 w azci
Architect Name& Piton,:
Ert2icer ,-, Name& Phone
Isee Simple I itle I folder Name and Addre ,
Bonding Compaip. Name and Address
Mort.Q.a9e I ender Name and Addres:- _ _ _
11,..11;1,::a:i.:,E,h_ iiii ; I;•!.,,!rt,El ::,Ell,E t fu, -,%1;;:i,:ra-. .!;ii :i::., ic:::::,:itin,:z, ,,, ,ticou.,.::,;,,a: ,._;::r:(0i: i
znti v:;d 12 v,t,:- N nii . •111?i'ren.;(V t:;thin;.11. +.';.,En,oith, E,-ir tpn. ,,,,,,..,....i. :. .,:t4.,:. ici,a::/-a174-3:1r-onkd/to-a_pc,-;,hi w -.0;;6 i ua,iv,jr ,,- if.,
7, rom-in,-n,ad 3 undcr.,131n,i ii;,:: -:1`,:iratj 1,,,Trzi: ?7:::'4 i':• '.,-:-'rt a i-- Electrical 0 forA, Plumbing,Sins, 14 ells. Arai, Farliders. Etpiki,, neaten,
Tanioi and Air Condilionen,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
170IR LENDER OR \N ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
ypear..7,.............._.
'-d-innitm:.of t %ii,_,! I ' ) \--, ‘ lature.ofContraetor _ (../..J tj.....
i'vin! ‘‘;ante - tek.4.6.14"" Rk.)-'‘----,-- Print Name 't%I
,orn to and .-,..:al-ierille...' ,NA',.-ffc mi..' Sy,OM 'y .. :i ',11t71/4i:ribed belorc p
hic c2.51 Ea', of /. ' .j -- thk 0 5 ,,7. <,I 'Nrv„.rk.,
-,------A., g', : _:..v., ‘,..„-\4■-
Notary Public • Penny Jo Smith
' . .'•• NOTARY PUBLIC .-
STATE OF FLORIDA'':‘ised 01'26-
Notary Public State of Florida
"i'tcfs„ Susan T Slocum *..4 '
.41116,11,1.-":r Comm*FF9397613
ir. My Commission FF 196022
IIIMMIIMIr
cvni/e.nvanont ci '7.' 10: rvniraa 11/Iffin1t4 CI
1
fil..' (1TV'OF A IL_1!TIC BEACH
`t R / B1 11.1)x:R AFFIDAVIT
I. FLORIDA STATUTES: CHAPTER 48C., FLORIDA STATUTE S ?ART ._
:. _3NTRACTING REQUIRES OWNER/BUILDER TO ACKNOWLEDGE T iE LAW
;)!1; I)�'. , -.',`t:. i ii' - ( ( . :Y. l)i,;;) . . - -
,.i ;00., -O ;i.•c .,' op, , i' .� .11: ,,i)11, ,;. ..
()i l) ' ' 1 ,f` . :kV' i ,: .. (:(.(•. '(i! .)t i .,' .. , ' '; ,l)
;:.Lt.0 .li `i Vii!)( ._- t ;t . .l i) 2:;-„ )I, t {�; ` - ♦i7 , t;.
-,; i _: ,.'I. ) -l: . .! . ..• !' ' `(.' . • .L ,
i(
i): ; .,A`,C I
II. INJURY LIABILITY: SINCE OWNERS MA' BE LIABLE ■=OR INJUR E_:- . .`v. rt :;,.
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION NS'!Ra ,(_c
PIJRC-ASED
M. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND .
OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1090 REQUIREMENTS ON THE WORKERS - .
EMP LCY ON THEIR IMPROVEMENT TRADES
IV. PENALTY: UNLICENSED CONTRACTORS CANNOT BE EMPLOY-ED '..:ND.:::::. A ..
CIRCUMSTANCES OWNERS BEING SUBJECT TO S5 000 PENALTY UNDER FLORIDA STA NO
455-2280; AN OCCUPATIONAL LICENSE IS NOT ADEQUATE THE OWNER .SHOT '-ice ,A
SEE THE COUNTY CERTIFICATE OF COMPETENC(' OR THE FLGR;DA ..; - / _,,TRL
CERTIFICATE TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TE__E . Off+= 'r'*
BUILDING DEPARTMENT(247-5826)IF IN DOUBT
V.ACKNOWLEDGEMENT: : HEREBY ACKNOVs/LEDGE THAT r =AL' i HE A`r. ' 7. -
STATEMENT AND THAT . COMPLY" '/'JTr N.... TnE RE(.) t K . ,_
OWNER-BUILDER PERMiT
8 LL? 1 Y 614 4Tt-A c 1CS61,1 FL _` s l 311 )bo -
U00G-1/4 A`� L..7. -e.GS As j
�
.5 MAR. ?f)1 (4,. '
0Z5 0444,th /2
74 saJoNt, Notary Public State of Ronda '
Susan T Sloam
. m3+06 196022"ai Exy pre0m /20F9
aeiar,it_ 7%(?‘„,
1