325 COUNTRY CLUB LN - DEMO CITY OF ATLANTIC BEACH
j 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
4J;319�
DEMOLITION PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-DEMO-1317
Job Type: DEMOLITION
Description: DEMO HOUSE
Estimated Value: $1,000.00
Issue Date: 6/20/2016
Expiration Date: 12/17/2016
PROPERTY ADDRESS:
Address: 325 COUNTRY CLUB LN
RE Number: 171962-0000
PROPERTY OWNER:
Name: GROVER JR, WILLIAM HOWE
Address: 325 COUNTRY CLUB LN
PERMIT INFORMATION: PUBLIC WORKS:
Slab and driveway to be fully removed.
Full erosion control measures must be installed and approved prior to beginning any earth disturbing
activities. Contact Public Works(247-5834)for Erosion and Sediment Control Inspection prior to start
of construction.
All silt must remain on-site during construction.
Roll off container company must be on City approved list and container cannot be placed on City Right-
of-Way. (Approved: Advanced Disposal, Realco, Republic Services, Shapell's,Sunshine Recycling and
Waste Pro).
Full right-of-way restoration, including sod, is required.
Full site to be grassed after demolition.
Lot elevation cannot be raised.
FEES:
paTinVIRAfz8e 100.00
i �I�.0 O\1,1' 1\ ACCOKD:1V('F; 1'11'11 ALL CI I'1' OF A"1 1,:1N"1"IC 13G:1C11 ORDINANCES AND THF. FLORIDA
B( ILUINC,CODES.
. , S r\-1`1:r
4t ; `'r J S 1 CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $104.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
s-An,. City of Atlantic Beach
��' APPLICATION NUMBER
e,� � Building Department (To be assigned by the Building Department.)
800 Seminole Road Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)24RECE1E
4
�UN 09 2016 1,(0 -p cmo - 13 (7
\011!9',- E-mail: building-dept@coab.us Date routed: :)/C5 ii
City web-site: http://www.coab.us BY;
APPLICATION REVIEW AND TRACKING FORM
7
Property Address: 3 ZS Coo Iv 1 CLbp- Department review required Yes No
YBuilding
Applicant: O wfLDfrL — C21R,CAT .. Planning &Zoning
Tree Administrator
Project: 11111 PAM ' • S CPublic Works
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt
of Permit Verified By Date
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: IVlApproved. ODenied.
(Circle one.) Comments: s-'( yl i j /� /_
BUILDING /T �jj�' (�
PLANNING &ZONING / �
Reviewed by: L Date: l
TREE ADMIN. Second Review: DApproved as revised. DD-,ed.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: DApproved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
I
„S /X- , BUILDING PERMIT APPLICATION
A , t' CITY OF ATLANTIC BEACH
v
800 Seminole Road,Atlantic Beach FL 32233
“rirt19r Office: (904)247-5826 • Fax: (904)247-5845
! (0 -DEMO - X317
Job Address: "3Z COvt,}p C�,,13 1A--Ne Number:
Legal Description CSG/ 3 g& c �^)2- RE#
Valuation of Work(Replacement Cost) $ Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): . New Addition Alteration Repair Move De u d Pool Window/Door
• Use of existing/proposed structure(s) (Circle one): Commercial R tttia)
• If an existing structure, is a fire sprinkler system installed?(Circle one): Yes No /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:/
VSO4uS� /or-clew-4
9/"1 or-cle 42`oh /4 4e c 1'�/'v4. b.�l -
Florida Product Approval #_ for multiple products use product approval form
Property Owner Information
Name: Mcc'4 gekey geovL,71-- Address: 3ZC 6 vAir Cd us L.�,,.c-
City 4-/I ct, �,.y et-A-c k. o
E-Mailtte4...Zip 3 2233 Phone 2 Z- —�)I U
��,�vsrL ®�Aviv()
Owner or Agent (If Agent,Power of Attorney or Agency Letter Required)
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF OMMENCEMENT 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: Qualifyin t - gent:
Address: City State Zip
Office Phone Job Site/Cont, . umber
State Certification/Registration# E-Mail
Architect Name &Phone#
Engineer's Name & Phone#
Worker's Compensation
Exempt / Insurer / Lease Employees / Expiration Date
J Application is hereby made to obtain a p: rt to do the work and installations as indicated. 1 certify that no work or installation has commenced
prior to the issuance of a permit and drat all work will _work
to meet the standards of a!!laws regulating construction in this jiiris�' ion.
Phis permit becomes null and void if work is not commenced within six(6 months, or if constriction or work rs suspended or aban ' ed for a
period of six(6 months at any time after work is comme ced. I understand that separate permits must be secured for Electrical Wor ,Plumbing,
Signs, Wells,Pools,Furnaces,Boilers,Heaters, Ta and Air Conditioners,etc.
Signature of Prope Owner: Signature of Contractor:
Befor e
•this 3 Day of a. '' ( — , ;•,:z.---- --;tit, . I ,y
•IP” , :4:4:8e....!..,:sMYCOMMISSION0 FF 924951
Notary Public: /_ '.}a :October 6,2019
,41
I hereby certify that I have read and examined this a.-'. cation and know the same to be true and correct. All provisions of laws and
ordinances governing this type of work will be comp ed 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
�,,, TREE & VEGETATION AFFIDAVIT
r3 WI City of Atlantic Beach
s) Department of Community Development
07,iir)
-5 Planning&Zoning Division
800 Seminole Road Atlantic Beach,FL 32233
(P)904 247-5800 (F)904 247-5845 PERMIT#
SECTION I-APPLICANT INFORMATION Owner(s) r Legal Authorized Agent*
NAME OF APPLICANT /1' % €-
NAME
OF COMPANY /V- 5i--
ADDRESS OF COMPANY
PHONE 2 '2- 31144/0 CELL 5(4i-- a EMAIL 7,123 /24,1,-,1_, VAd.CG',,✓L r
CONTRACTOR CERTIFICATION NUMBER
ATLBCH BUSINESS TAX RECEIPT NUMBER
SECTION II-SITE INFORMATION
STREET ADDRESS OF PROPERTY ' zr.— 7v . M p,{1 G � (�,4,✓-r
If an address has not been assigned too this property,contact the AB Building Department of(904)247-5826 to request an address.
LEGAL DESCRIPTION
LOT 3 BLOCK SUBDIVISION _ A1iN-/--
REAL ESTATE NUMBER LOT OR PARCEL SIZE: /7 24S SQ FT AC
RESIDENTIAL V-1 COMMERCIAL OTHER(SPECIFY)
I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation"of the Municipal Code of
Ordinances for the City of Atlantic Beach,FL and/or 1 have participated in a pre-application meeting with the Administrator of those
regulations. Subsequent) , I affirm that no regulated trees and no regulated vegetation will be damaged,destroyed and/or removed
from thea ove- scrib r adjacent properties in conjunction with this project.
SIGNATURE OF OWNER SIGNATURE OF OWNER .
Signed and sworn before me on this Siay of " () n0,....,201(oby State of
/� p q County of �vqa
Identification verified: C tO t 8- -*7 z -� ( q -
Oath sworn: r Yes E
TONI GINDLESPERGER (�
��. MY COMMISSION t FF 924951 Q
t.'. r ` EXPIRES:October 6,2019 Notary ignature ,
•?„p„a: Bonded Thru Notary Pubic undeneiters
REV A v10.12 My Commission expires:
-SL14-,
�� CITY OF ATLANTIC BEACH
J WNER/ BUILDER AFFIDAVIT
-4,af9..
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 WITHIN 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
HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. IT IS
YOUR RES1'ONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE
LICENSES REQUIRED 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.
12r 4 7 aka L 202''3 •-.LLt
ADDRESS PHONE NUMBER
M .elwv
PRINT NAME
'74.,---(Aiz----- G,p--Z a/4
SIGNATURE DATE
{
Before me this day ofd(,n`✓/� 2L the county of
Duval,State of Flon a,has personally appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large State of f ( .County of_112/4a--
❑Personally Known I /.t, 1^Q
�I Produced IdentificaOr
+ I �� —� /f
11111piiiak
TONIGINDIESPERGER•
MYCOMMISSIONKFF92495119
Notary Signature. (1,..:_,*;i:T.,:;) EXPIRES:OCPobtuc Undue
Bonded Thru Notary rs
F/BLDG/Owner-Builder Affadavit,REVISED: 4/16/2009 ,
41.
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