374 4TH ST - SIDING J J�, *
CITY OF ATLANTIC BEACH
( 800 SEMINOLE ROAD
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_ ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL ALT/OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-RAAR-993
Job Type: RESIDENTIAL ALTERATION
Description: SIDING REPAIRS
Estimated Value: $2,100.00
Issue Date: 4/28/2016
Expiration Date: 10/25/2016
PROPERTY ADDRESS:
Address: 374 4TH ST
RE Number: 169824-0050
PROPERTY OWNER:
Name: RICHARDS, R S
Address: 374 4TH ST
PERMIT INFORMATION:
FEES:
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
BUILDING PERMIT FEE $60.50
Total Payments: $64.50
I
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
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�_ BUILDING PERMIT APPLICATION
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CITY OF ATLANTIC BEACH
�.. 800 Seminole Road,Atlantic Beach FL 32233
��o:tlw Office: 9 4
( 0 )247-5826 • Fax: (904)247-5845 f.CO —RI)-RR- 3
3Z233 Job Address: 3 -7 y 7- i , / �� �L � c�t
Permit Number:
Legal Description RE#
Valuation of Work(Replacement Cost) $4/dd , Ocileated/Cooled SF 07 OS0 Non-Heated/Cooled
• Class of Work(Circle one): New Addition Alteration Re ai Mov- I- "o Pool Window/Door
• Use of existing/proposed structure(s)(Circle one): Commercial d4 lentia
• If an existing structure, is a fire sprinkler system installed?(Circle one): eV 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: o ;,� S : ZAA-1
Florida Product Approval# .8 " C-C-C_v ..`0, c t 0.3`4 for multiple products use product approval form
Property Owner Information
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N ame: {► Address: ( �1: c - C ( .
City --j o—e. E, ig 12 CLc State FiZip 3 2 733 Phi ne '0 — ' ' I - , /,' ,
E-Mail •
caner e r 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 & P•• e#
Worker's Comp• ation
Exempt / Insurer / Lease Employees / 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 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, ells,Pools,Furnaces,Boilers Ifpaters, ks and Air Conditioners,etc.
-, Signature of Prop-• Ow r: �t//.� ' ,�.�� /.. Signature of Contractor:
Bef
.) this ay of I�fl 1`, _ w t Before me this Day of
Notary Publ. _ T 'iW ice►
��_ .���!!��I� Notary P • c:
' R 7 gentled m Notary Pubic Under*Mers I ;
I hereby certif •0 r an examined this app'cation and know the s:me to be true and correct. All provisions of laws and
ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not
presume to give authority to violate or cancel the provisions of any other federal, state, or local law regulating construction or the
performance of construction.
Rev. 3/14/16
?AJl'r
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 SEI.I. OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR
AFTER TIIE CONSTRUCTION IS COMPLETE, TITS LAW WILL PRESUME TIIAT YOU L31111,'
IT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY NOT
HIRE AN UNLICEN PEROON 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 I,AW 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.
3 7 '7 y rS7L f/4_. 7 4 c €.e o_c% ' y/ - v '7 o
ADDRESS (� /,, .2 3 3 PHONE NUMBER
4ev:64e /1 /'l CVc 02 - S
PRINT N
R DATE
Before me this Zciay of ,2kn the county of
Duval,State of Florida,has personal) ppeared herin by himself/herself and affirms that
all statements and declarations are true and accurate. `p 1/`(
Notary Public at Large,State of V L ,County of L7 a—
❑Personally Known • Z 3 —1 7 _s .50?
produced Identificati• J l �
MY COMMISSION 11 FP 924951
EXPIRES:October 6,2019
Notary Signatur-.� AR& 4111 14: Bonded Thru Notary Public Underwriters
E:AOLDG/Owner-Builder Affadavir;REVISED:4/16/2009