1155 Ocean Blvd - Electric 4,1_,--;,..s\ CITY OF ATLANTIC BEACH
r s) 800 SEMINOLE ROAD
legiir)
j fan : _ ;", ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
JF3lt
ELECTRICAL PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-ELEC-1185
Job Type: ELECTRIC ONLY
Description: ELECTRIC - 27 FIXTURES
Estimated Value:
Issue Date: 5/23/2016
Expiration Date: 11/19/2016
PROPERTY ADDRESS:
Address: 1155 OCEAN BLVD
RE Number: 170276-0000
11 PROPERTY OWNER:
Name: ANDREWS, MARK LEE
Address: 1155 OCEAN BLVD
FEES:
State Elec DBPR Surcharge $2.00
State Elec DCA Surcharge $2.00
Electrical Repairs $35.00
Trade Permit Base Fee $55.00
Total Payments: $94.00
PERNIIT IS APPROVED ONLY IN ACCORDANCE WITII ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
'WILDING CODES.
4
ELECTRICAL PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd, Atlantic Beach, FL 32233 -
Ph (904) 247-5826 Fax (904) 247-5845 1 //V _C L E.C'- I ( 6 S
JOB ADDRESS: /•/ S) C CSP-G:(l ) 67Z-l/, PERMIT#
JEA INFORMATION REQUIRED ON ALL PERMITS d,, AMPS 2_2,0 VOLTS 5/r 4HASE
l/
VALUE OF WORK$
NEW SERVICE ❑ Overhead n Underground J Underground up Pole
Residential(Main) Service
0-100 amps i 101-150amps 0151-200amps -] amps #of Meters
:Commercial(Main)Service
00-100 amps I :101-150amps 0151-200amps 1 amps I :CT Service amps
Conductor Type Size
UMulti-Family(Main)Service
00-100 amps I 1101-150amps I 1151-200amps amps #of Unit Meters
I 'Temporary Pole I amps
SERVICE UPGRADE amps CCT Service amps
NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES,ETC.)
1100 amps Li 150amps ]200amps amps I CT Service amps
ADDITIONS, REMODELS REPAIRS,BUILD-OUTS,ACCESSORY STRUCTURES,ETC.
Outlets/Switches: 0-30amps 31-100amps 101-200amps
Appliances: )-- 0-30amps 31-100amps 101-200amps
A/C Circuits: / 0-60amps 61-100amps
Heat Circuits: f # circuits @_S' kw
Number of Lighting Outlets, Including Fixtures: 2
OTHER ELECTRICAL PROJECTS •
! :Swimming Pool IL Sign Smoke Detectors Qty 1Transformers KVA :"Motors hp
FIRE ALARM SYSTEM (Requires 3 sets of plans)
Qty volts/amps VALUE OF WORK$
REPAIRS/MISCELLANEOUS
[Replace Burnt/Damaged Meter Can I :Safety Inspection I I Panel Change ;JOH to UG
Other:
'ermit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have
ead this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether
pecified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of
:onstruction.
D 0
'roperty Owners Name P)frit 44Lv & Jc UC Phone Nul r 10 y 3 93 V2 2 6,
'electrical Company ili )4. K l4,t Y i .4v.V 5 Office Phone Fax
;o. Address: /( 5T e e pt L. V / d City ,1 State( Zip 2 -2,q3,icense Holder (Print): N\. r Le,e . to ---1 State Certification/:egistration :
Jotarized Si 'd
- - --- / /NT GINDLESPE' —�I .ssION#Fg.924 1 /�re .e this Z'-(' day • 'ns:Octoberbru NotaN Pubrrc Undenm ers WIN.
a _.re of Notary Public #
A
rs \7%•
CITY OF ATLANTIC BEACH
'Ill- —'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 WITI-IIN 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
!MIRE 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 REOUIRI.I) BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING
ORDINANCI S.
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.
1 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.
jis5a 6 vve '7° Y77yz7---C
ADDRESS PHONE NUMBER
a „ k
PRIN • E
,RI� SI23 / �
SIGNA RE /II DATE
Before me this�� day of 2( it le county of
Duval,State of Florida,has personally ap d erin by himself/herself and affirms that
all statements and declarations ar-true and ur te. /
Notary Public at Large,State• l .County of 1J(--7 V Qi
Personally Known • _`;r'+ TONI GINDI.ESPERGER
❑Pr d Identification- - A 'iii, =
wail ,; ,:� MY COMMISSION i FF 924951
W i EXPIRES:October 6,2019
'•'? A goaded Thru Notary Public Underwriters
Notary Signature: " — '',.5,-..
F:/BLDG/Owner-Builder Affidavit;REVISED:4/16/2009
I