2025 SEMINOLE RD #103 - GARAGE DOOR CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
7.4 ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
r4 J111>1-
WINDOW AND/OR DOOR PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-WIND-1742
Job Type: WINDOW AND/OR DOOR
Description: replace single garage door
Estimated Value: $1 ,000.00
Issue Date: 8/8/2016
Expiration Date: 2/4/2017
PROPERTY ADDRESS:
Address: 2025 SEMINOLE RD 103
RE Number: 169723-0206
PROPERTY OWNER:
Name: DECKER, NANCY K
Address: 2025 SEMINOLE RD APT 103
PERMIT INFORMATION:
FEES:
PLAN CHECK FEES $27.50
BUILDING PERMIT FEE $55.00
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $86.50
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
c1:�.,p;yCity of Atlantic Beach APPLICATION NUMBER
#..+ " Building Department (To be assigned by the Building Department.)
, � 800 Seminole Roadn _- f? Atlantic Beach, Florida 32233-5445 110—ha N I I'ya
• Phone(904)247-5826 • Fax(904)247-5845
' 0;; 9Y• E-mail: building-dept@coab.us Date routed: 0% (O a-` I kp
City web-site: http:/lwww.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: a Oas SLf O L ea *1o3 Department review required Yes No
(Building V
Applicant: Oaf1(A.( ti-a4 Planning &Zoning
Tree Administrator
Project: (Q,p\W..L St n6k L q(,t,' y � (�-( 0f Public Works
v Q Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
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:
APPLI ATION STATUS
Reviewing Department First Review: I Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: Ph J ' a Date: / /6
TREE ADMIN. Second Review: QApproved as revised. ['Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ['Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09 I
I
i
1".
r'11��, BUILDING PERMIT APPLICATION
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t CITY OF ATLANTIC BEACH OFFICE COPY
800 Seminole Road,Atlantic Beach FL 32233
.,.I0%alar Office:(904)247-5826 • Fax:(904)247-5845
Job Address: 4 o a 5 Jet t A o e., Q\d, } (Anj i t o 3 Permit Number: Ito–vo.Ngo- l'*La
Legal DescriptionThe.>,61 a t'i•Z of t_ te5'c,,,,r1 40,11\1,rkl, kk,�} ,4, RE#_
Valuation of Work(Replacement Cost)$ /0 06 t oo Heated/Cooled SF Non- Heated/Cooled
• Class of Work(Circle one): New Addition Alteration Repair Move Demo Poo Window/Door
• Use of existing/proposed structure(s)(Circle one): Commercial ( esidentrap
• If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No 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:
l�Pltic� 5�v\ge, 3cx,-Q.3e, .Aooe-
Florida Product Approval# F L I 5o1 44-- (Z 5 ,0 1 for multiple products use product approval form
Property Owner Information
Name: tia,r\e-1 K, Vec /e✓ Address: aoR.5 2 i,,lc kKA• urs,A- - 109
City 1k1 avOk c I�3ert,eln State4,13-3 Zip g Phone (9 0 -9 ri o g– 97•4 7
E-Mail n decger 0 y t' c , c--00-)
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 •C 'te/Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name &Phone#
Worker's Compensation
Exempt / Insurer / Lease Employees / Expiration
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 ofsix(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 Property Owner: a✓7 t%l 1 Signature of Contractor:
Befors me ray -
this C— Day of ? .i q Before ii- %ay of
W *',' TONI GINDLESPERGER I'
=, ,� �t • MSN�FF 924951
Notary Public: ___ 1, f'� _ . .1 a :_" • - . 44. =6: . 4
1'1. t1 4 : . l4
1447 Bonded Thru Notary Pubic U. :rwcters
I hereby certib,that I have read and examin . applica a- an' ow t e same to be true and correct. All provisions of laws and
ordinances governing this type ofwork will be complied with whether specified herein or not. The granting of a permit does not
presume to give authority to violte or cancel the provisions of any other federal, state, or local law regulating construction or the
performance of construction.
Rev. 3/14/16
CITY OF ATLANTIC BEACH OFFICE COPY
. IJ%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 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 TIIIS EXEMPTION. YOU MAY NOT
HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONS"IRUCTION 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.
64tc U.ri (0-5 (9‘4) 901-- 1747ADDRESS CnPHONE NUMBER
1 a ,,i • VeG4<e'r
PRINT NAME )1
SIGNATURE!
G/ DATE
Before me this day of 20.the county of
Duval,State of Florida,has persona ly a ea ed herin by himself/herself and affirms that
all statements and declarations are true anccurate.
Notary Public at Large,State of r( ,County of VCi—k
El Personally Known / se, 3 1 4 Z-1`
0
L• /Produced Identification- LQ
L �.� / TONT GINL'IESPERG'—
i ' + MY COMMISSION t FF 924951
Notary Signature: �� d�� EXPIRES:October 6,2019
Bonded Thru No!a y Pub iic Undenwiters
F:/BLDG/Owner-Builder Affidavit;REVISED:4/16/2009