871 Sherry Dr ROW pavers permit CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
RIGHT OF WAY PERMIT
MUST CALL BY 4PM FOR NE)Cr DAY INSPECTION: 247-5814
JOBINFORMATION:
Job ID: 16-ROW-1898
Job Type: RIGHT-OF-WAY PERMIT
Description: replace existing concrete driveway with pavers
Estimated Value:
Issue Date: 8126/2016
Expiration Date: 2/22/2017
PROPERTY ADDRESS:
Address: 871 SHERRY DR
RE Number: 169982-0000
PROPERTYOWNER:
Name: PALMER ET AL, CHRISTY L
Address: 871 SHERRY DR
PERMIT INFORMATION: PUBLIC WORKS: UTILITY DEPT.:
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 runoff must remain on-site during construction.
Full right-of-way restoration, including sod, is required.
Maximum driveway width within the City right-of-way is 20' (circular driveway width is 12'maximum).
Ensure all meter boxes, sewer cleanouts and valve covers are set to grade and visible.
A sewer cleanout must be installed at the property line.Cleanout must be covered with an RT1
concrete box with metal lid. Cleanout to be set to grade and visible.
FEES:
Fence/ROW $35.00
rk*UkREM*Ea%H)BWK[4(Rb@DANCE$afiaML CITY OF ATLANTIC REACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
Total Payments: $60.00
PERJAIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by1he Ruilding Department)
800 Seminole Road E-CEIVE
Atlantic Beach,Florida 32233-541, X� I f—ow—
Phone(904)247-5826 Fax(9(412 5
E-mail: building-dept@coab.us 6 22 2016 Date muted:
Cityweb-site: http:/1www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1 Shur, Department review required Yes No
Building
Applicant: kku Planning&Zoning
free Administrator
Project: L*jSN�Ah MUIA9 ublic Works
ublic Utilities
Public Safety
F Sew ces
ire 4 1 im
Review fee $ Dept Signature,
Other Agency Review or Permit Required Review
of Penmit=PBty Date
Florida Dept, of Environmental Protection
Flonda Dept.of Transportation
St.Johns River Water Management District
Amy Corps of Engineers
Division at Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: [OApproved. E]Denied.
(Circle one.) Comments:
BUILDING
PLANNING&ZONING Reviewed by: Date:
TREEADMIN. '01, ZZS7�-/
Second Review: ElApproved as revised. ElDenled.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date
FIRE SERVICES Third Review: [DApproved as revised. F]Denied.
Comments:
Reviewed by: Date:
Revised 05114109
City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road nECEIV w7j�'q'%
Atlantic Beach,Florida 3223'-5
Phone(904)247-5826 FEd:(94(0445)247-58 AUG 2 2 Date routed: aa
Of E-mail: building-dept@coab.us
City welo-site: http:/Avww.coab.us n 2016
BY:
APPLICATION REVIEW AND TRAGKING FORM
Property Address: Department review required Yes No
Building
Applicant: Planning &Zoning
Tree Administrator
Project: _i*tiucti)� Lx�s'�N emufAil Irublic Lo
U b J�t�
'e,
<2ublic Utilities D
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Revi.ew
it=P' Data
of Pe By
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Amy Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPL!GATION STATUS
Reviewing Department First Review: ETApproved. ODenied.
(Circle one.) Comments:
BUILDING
PLANNING&ZONING Reviewed by: Date:
TREEADMIN. Second Review: ElApproved as revised. [-]Denied.
C VORVS Comments:
J.t�'
'0"f_4__�
PUBVP UTILITIES
jr-7-2—I&
PUBLIC SAFETY Reviewed by: Date,
FIRE SERVICES Third Review: E]Appmved as revised. [:]Denied.
Comments:
Reviewed by: Date:—
Revised 06114109
CITY OF ATLANTIC BEACH
CONSTRUCTION PERMIT WITHIN CITY RIGHTS OF WAY AND EASEMENTS
800 Seminole Road 90�247-5800
Atlimlle Beach,Florida 32233-5"5 F. 904-247-5B45
PLEASE SUBMIT(3)COMPLETE SETS OF PLANS WITH APPLICATION.
Date I,A��4 A 0
Job BY THE Crry
=#
Address slil., `ts�Nu�'
Permitee: 2W'2y%0� P�U*A-& U,�� - Telephone
PermittmAddress: )D-qq Ay�o"Ay.,%S� 1��
Requestrig Pemnissionto Construct'. t;XMA;W1LACA-As' lvauywc. ^CAAIVS
Location: (Reference to Crom-Street) I.,c!5 P,
I Applicant declares that prior to filing this application he has ascertained the location of all existing utilities,
both aerial and underground and the accurate locations am shown on the sketches.
A Letter of Notification was mailed to the following Utilitles/Municipalitles:
Jacksonville Electric Authority Yes( ) No Date:
Bell South Telephone Company Yes( ) No Date".
Ferrell Gas Yes No Date:
Corti Yes No Date:
2. Whenever necessary for the construction, repair, improvement, maintenance, safe and efficient operation,
alteration or relocation of all, or any portion of mid street or emement as determined by the Director of Public
Works, any or all of mid poles, wires, pipes, cables or other facilitim and appurtenances authorized
hereunder, shall be immediately removed from said street or easement or restat or relocated hereon as
required by the Director of Public Works, and at the expense of the Perri unless reimbursement is
authorized.
3. All work shall meet City of Atlantic Beac='da Deparmtment,,of Transportation Standards and be
performed under the supervision L A N&*&% (Contractor's Project
Superintendent) located at lag a Telephona*
4. All materials and equipment shall be subject to inspecti6n by the Director of Public Works or his designee.
5. Ail city property shall be restored!to its original condition as far as practical, In keeping with city specificartions
and the manner satisfactory to the city.
6. A sketch of plans covering details of this installation, as well as, a Copy of a recent survey shall be made a
part of this permit. Calculations showing any Increase in impervious area on owner's lot or in the city
Rlqht of Way are to be Included with this application.
7. This permittee, shall commence actual construction in good faith with
days. If the beginning date is
mom than 60 days from date of permit approval, then permittee must review the pemit with the Director of
Public Works to make sum no changes have occurred in the area that would affect the permitted construction.
S. It is understood and agreed that the rights and privileges herein set out am granted only to the extent of the
City's right, title and interest in the land to be entered upon and used by the holder, and the Holder will, at all
times, assume all risk of and indemnify, defend, and Base harmless the City of Atlantic Beach from and
against any and all loss, damage, and cost of expenses arising in any manner of the exercise or attempted
exercises by the holder of the aforesaid rights and privileges.
9. The Director of Public Works shall be notified twenty-four (24) hours prior to starting work and again
immediately upon complati n.
OWNER
Signed: Date: MAY A.ARVIN
day
lh Notary Public,State of Florida
" , Ir . .
'rr Erly pp.. My Comm.Expires WIDrA20
=1t'.'0';F dli�',ins. . .11L M 4.4cr
NotivyPublic. Stataofflo
4,tnl Zp��
MY M1.1 nww' Pereonatty Kn�: commission No.FF994922
E, Pd.cea mentlicawn:
R.O.W.Permit Attachment—of for
R.O.W.Permit#—issued 1200 Atlantic Beach,Fl, 32213
Owner's Name: (Y\_A�- �A as&
PropertyAddress: R'71 S�-c=q L10 0�
Subdivision:
Lot#/Block
R-E.#:
REVOCABLE ENCROACHMENT PERMIT
THIS REVOCABLE ENCROACHMENT PERMT, issued on this _ day of
200, by Atlantic Beach, Florida, a municipal corporation organized and existing
under the laws of the State of Florida,hereinafter referred to as"CITY" and
of Atlantic Beach,Florida,hereinafter referred to as"USER".
NVITNESSETH:
That the CITY does hereby giant the USER permission on a revocable basis as described herein the
right to enter upon the property of the City of Atlantic Beach for the purpose w described in the City of
Atlantic Beach Right-of-Way/Easement permit numbers noted above(copies attached).
This work is generally described as:
Any facility maintained, repaired, erected, and/or installed in the exercise of the privilege granted
remains subject to relocation or removal on thirty (30) days notice by CITY to the USER, said notice to
USER shall be given by certified mail, retain receipt requested, to the following address:
The depositing of said notice of cancellation in the United States mail shall constitute the notice of
cancellation and the burden is upon USER to keep the CITY informed of USER!s proper address.
The USER shall promptly make my and all necessary repairs to any facility erected or maintained in
the exercise of the privilege herein granted and shall at all times maintain said facility in good and safe
condition.
in the event it is necessary for the CITY or the City's approved representative or other franchised
utility to enter upon the above-described property of the CITY, the USER shall replace at the USER's
sole expense, any and all material necessarily displaced during the action of maintaining, repairing,
operating,replacing,or adding to of the utilities and facilities of the CITY or franchise utility provider.
The facilities allowed by the permit shall meet the current requirements of the City Code, Building
Codes,Land Development Code,and all other land use and code requirements of the CrrY,including
City Code Section 19-7 (b) which states "Driveways that cross sidewalks: City sidewalks may not be
replaced with other materials, but must be replaced with smooth concrete left natural in color so that it
matches the existing and adjoining sidewalks."
Page I of 2
The USM prior to making any changes from the approved plans and/or method, must obtain
written approval from the City of Atlantic Beach, Public Works Department, for said change. The
USER shall, at the discretion of the CITY,be requested to submit as-built drawings showing the change
within thirty(30)days after the day of completion.
This permit shall inure to the benefit of, and be binding upon, the USER and their respective
successors and assigns.
USER shall meet the terms and conditions of this permit and to all of the applicable State and CITY
laws and/or specifications, to include utilities locate requirements and use limitations/requirements of
public rights-of-way and other public land. USER filarther agrees that the CITY and its officers and
employees shall be saved harmless by the USER from any of the work herein under the terms of this
permit and that all of said liabilities are hereby assumed by the USER.
DATED and SIGNED this IfffNdayof As�av,,� 20P0
100�- —
Property Owner
(to be signed in presence of the Notary)
STATE OF FLOREDA
COUNTY(!MDUVAL 2 If
On this I'X' day of 001 perso��y appeared before me, a Notary
Public in and for said Col and- State, ��1 �r the property owner of
-A-1 I Z4-ps-'-A I Atlami each, Fl�� known to me to be me person(s)
described in and whal executed the foregoing instrument, who acknowledged to me that he or she
executed the same fireely and voluntarily and for the uses and purposes therein mentioned.
MAY A.ARVIN
Notary Public,State of Honda
Notary Public r surrCounty and State My Comm.Expires WIWA20
CITY OF A=C BEACK FLORIDA.a Commission No.FF994922
municipal corporation:
Approved:
-RW&jANR6wp&W-Public,Works Director
sca"rit wltjim� cd�
For Permits where city sidewalk is impacted,
City Manager approval required:
Jim Hanson,City Manager
Page 2 of 2
-4so
IL
1490_1�
CITY OF
4)WNER
CITY OF ATLANTIC BEACH
OWNER/ BUILDER AFFIDAVIT
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART I 'CONSTRUCTION
FCON�TRACTING'REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW.
DISCLOSURE STATEMENT FOR SECTION 489.103M FLOREDA STATUTES:
TI1''
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED
AN E)
CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDER MMPTION TO THAT
LAW.FTIMEXEWTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY,TO ACT AS
S YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST
UPERVISE 16 QMTRUCTION YOURSELF YOUMAYBUILDORImPROVEAONE—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 FORYO&ME AND OCCUPANCY. IT MAY NOi BE BUILTFOR SALB 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 UNLrCENSE )PER2OAS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST
BE DONE ACCORDING To THE BUILDING CODES AND ZONING REGULATIONS. IT IS
YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE,���
LICEIISES REQUIRED BY STATE I AW 4ND BY COIUNT1
I .—
IL INJURY LIABILITY; SINCE DOWNERS MAY BE LIABLE FOR INJ
THE BUILDING DEPARTM —It�E
�EM -L LFAULI, VUR INJURIES TO WORKERS THEY HIRE
PURCHASED, ENT SUGGESTS WORKERS COMPENSATION INSURANCE B�
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
CIRCU ASTANCES. OWNERS BEING SUBJECT TO$5,000 PENALTY
455-228(l). AN-OCCUPATIONAL LICENSE'IS NOT ADEQUATE, THE UNGDER_FLORIDA STATUTE NO.
SEE THE COLo, , It,1111"UAD, OF OWNER SHOULD PHYSICALLY
CERTIFICATE' TO ASCERTAIN IF A PERS COMPETENCY' OR THE FLORIDA "CONTRACTORS
-5826)IF IN DOUBT.
BUILDING DEPARTMENT(247 ON IS A LICENSED CONTRACTOR. TELEPHONE THE
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.
PRINTNAMVE
SIGNATURE
v
Beforn,me it", it ,
Dunla"c,R.Ond .4 2� 1,1:courl,0
a,Zl,_a'yo aVu.
'if-tatennamn.oddeUmomme;Nom u bboaii, nexandaffionstuat
Notm,Public at Lor,e,Santa of F( County of_L_)fuvj
Iz- y
Note,Silin.tme
FM�wrauldffAfNda�,Ra�mm,�.nm
Cl-Z OF ATLANTIC BEACH
CONSTRUCTION PERMIT WITHIN CITY RIGHTS OF WAY AND EASEMENTS
500 Seminole Road 90�247�8[10
a'o Atlantic Beach,Florida 32233-5445 Fat 904-247-5945
PLEASE SUBMIT(3)COMPLETE SETS OF PLANS MTH APPLICATION.
Data 0
JobAddreess F�l ErUtDBY THE CITY_
Permitee: , G� U41th-S Telephone
Permittee Address: I a_q q Ac>w I, ,�! -NZ
Requesting Penmission to Construct lt�ul�' V.X MA 01AC"A�
Location: (Reference to Cross-Stmet) P ii,,-
1. Applicant declares that prior to filing this application he has ascertained the location of all existing utilities,
both aerial and underground and the accurate locations am shown on the sketches.
A Letter of Notification was mailed to the following Utilities/Municipaiities:
Jacksonville Electric Authority Yes( ) No Date,
Bell South Telephone Company Yes( ) Noo Date:
Ferrell Gas Yes No Date:
Gonricast Yes No Date:
2. Whenever necessary for the Construction, repair, improvement maintenance, safe and efficient operation,
alteration or relocation of all, or any portion of paid street or easement as cletennined by the Director of Public
Works, any or all of said poles, wires, pipes, Cables or other facilities and appurtenances authorized
hereunder, shall be immediately removed from said street or easement or reset or relocated hereon as
required by the Director of Public Works, and at the expense of the Permittee unless reimbursement is
authorized.
3. All work shall meet City of Atlantic eac or F orkla Department of Transportation Standards and be
performed under the supervision (Contractor's Project
Superintendent) located at Ja4tA Jiwg-JIeQVi OT�Irr4Q&L,_Telephone*._IDI-,L�q-�5-73
4. All materials and equipment shall be subject to inspection by the Director of Public Works or his designee.
5. AN city property shall be restored to fis original condition as far as practical, In keeping with city specifications
and the manner satisfactory to the city.
S. A sketch of plans covering details of this installation, as well as, a copy of a recent survey shall be made a
part of this permit Calculations showing any Increase in Impervious am on owner's lot or In the city
Rlaint of Way am to be Included with this application.
7. This permittee shall carnmence actual construction in good fafth with days. If the beginning date Is
mom than 60 days from data of permit approval, then permittee must review the perinit with the Director of
Public Works to make pure no changes have occurred in the area that would affect the permitted construction.
8. It is understood and agreed that the rights and privileges herein set out am granted only to the extent of the
CWS rigt , nienest in the land to be entered upon and used by the holder, and the Holder will, at all
times, assume all risk of and indemnify, defend, and save harmless the City of Atlantic Beach from and
against any and all loss, damage, and cost of expenses arising in any manner of the exercise or attempted
exercises by the holder of the aforesaid rights and privileges-
9. The Director of Public Works shall be notified twenty-four (24) hours prior to starting work and again
immediately upon Completion.
OWNER -1
signed IQ� / (4x MAY A.ARVIN
Barbra mn,this day ofl]LLN'�L—Iin�t�h—e. of Duyal, Notary Public,State of Florida
d has racnally appeared
,StateofFlo' my uomm.Expires 08111112020
m: arsonally Knoxm: Commission No.FIF994922
M . I Produced!Identification:
R-O.W. Permit Attachment of for
R.O.W.Permit# i sued '200 Atlantic Beach,FL 32233
_is —
Owner's Name: mv,-e-
Property Address: R'71 S�-ey" 6 ki 041.
Subdivision:
Lot#/Block#:
R.E.#:
REVOCABLE ENCROACHMENT PERMT
THIS REVOCABLE ENCROACHWNT PERMT, issued on this _ day of
, 200, by Atlantic Beach, Florida, a municipal corporation organized and existing
under the laws of the State of Florida, hereinafter referred to as "C= and
of Atlantic Beach,Flori4 hereinafter referred to as"USER!'.
VVITNFSSETH:
That the CITY does hereby grant the USER permission on a revocable basis as described herein the
right to enter upon the property of the City of Atlantic Beach for the purpose as described in the City of
Atlantic Beach Right-of-Way/Easement permit numbers noted above(copies attached).
This work is generally described as:
Any facility maintained, repaireA emoted, and/or installed in the exercise of the privilege granted
remains subject to relocation or removal on thirty (30) days notice by CM to the USER, said notice to
USER shall be given by certified mail, return receipt requested, to the following address:
The depositing of said notice of cancellation in the United States mail shall constitute the notice of
cancellation and the burden is upon USER to keep the CITY informed of USER!s proper address.
The USER shall promptly make my and all necessary repairs to my facility emoted or maintained in
the exercise of the privilege herein granted and shall at all times maintain said facility in good and safe
condition.
In the event it is necessary for the CITY or the City's approved representative or other franchised
utility to enter upon the above-described property of the CITY, the USER shall replace at the USER's
sole expense, my and all material.necessarily displaced during the action of maintaining, repairing,
operating,replacing,or adding to of the utilities and facilities of the CITY or franchise utility provider.
The facilities allowexi by the permit shall meet the current requirements of the City Code, Building
Codes,Land Development Code,and all other land use and code requirements of the CITY,including
City Code Section 19-7 (h) which states "Driveways that cross sidewalks: City sidewalks may not be
replaced with other materials, but most be replaced with smooth concrete left natural in color so that it
matches the existing and adjoining sidewalks."
Page I of 2
- - - - - - - - - - - - - - - - - - - - - - -
The USER, prior to making my changes from the approved plans and/or method, must obtain
written approval from the City of Atlantic Beach, Public Works Department, for said change. The
USER shall, at the discretion of the CITY,be requested to submit as-built drawings showing the change
within thirty(30)days after the day of completion.
This permit shall inure to the benefit of, and be binding upon, the USER and their respective
successors and assigns.
USER shall meet the terms and conditions;of this permit and to all of the applicable State and CITY
laws and/or specifications, to include utilities locate requirements and me limitations/requirements of
public rights-of-way and other public land. USER Rather agrees that the CITY and its officers and
employees shall be saved harmless by the USER from any of the work hercin under the terms of this
permit and that all of said liabilities are hereby matured by the USER.
DATED and SIGNED this dayof . 20A�
4-By: A)�--—"— d--�
Property Owner -
(to be signed in presence of the Notary)
STATE OF FLORH)A
COUNTY VDUVAL
On this of 20#1��persona
Public J�= ftrysaid Co and State, fou tj� �y appeared before me, a Notary
�ridaR� t' the property owner of
Atlantic Beach, F1 o me to be the persou(s)
described in and wW execifted the foregoing instrummt; who acknowledged to me that he or she
executed the same fteely and voluntarily and for the uses and purposes therein mentioned.
MAYA.ARVIN
Notary Public,State of Hoffila
Notary Public r said'County,and State My Comm.Expires 08/10/2020
'TaC BEACH,FLORII)A,a Commission No.FF994922
municipal corporation:
Approved: rnex,
A A�'
"-PuKi Works Du' ector
ra I - �Jxze'
46"itt�rt 11colao D. L.. 'If?
For Permits where city sidewalk is impacted, 9r�p CA"\
City Manager approval required:
Jim Hanson,City Manager
Page 2 of 2
- -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
I ce te:3
c;L I I
ka cm
�ha Sok 6c6:N,. %&.;z Z�� A
CITY OF ATLANTIC BEACH
OWNER/BUILDER AFFIDAVIT
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES. PART I 'CONSTRUCTION
CONTRACTING"REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW.
DISCLOSURE STATEMENT cv��ZUIAUA 439.103(7),FLOREDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE By LICENSED
CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPTIONTO THAT
LAW. THE EXEMPTION ALLOWS YOU.AS THE OWNER OF YOUR PROPERTY,TO ACT As
YOUR OWN CONTRACTOR EVEN THOUGH YOU Do Noy HAVE A LICENSE. YOU MUST
DORIMPROVEAONE-OR
OU MAY ALSO BUILD OR
0 OR LESS.
UILTFOR SALE ORLEASE
FRSELF WITHIN ONE YE;��
RESUNIE THAT YOU BUILT
METION YOU MAY NOT
UR CONSTRUCTION MUST
ING REGULATIONS. IT is
L Y YOU HAVE
hEIMMAL I ICENSING
If. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY H I IRE�
PURCHASED.
THE BUILDING DEPARTMENT�SUG6'��110�MMPENSATION INSURANCE BE
Ill. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO
OBSERVE IRS WITHHOLDING TAX ANDADR FORM 1099 REQUIREMENTS ON THE WORKERS THEY
EMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENALTY; MhLICENSED CON ACTORS CANNOT BE EMPLOYED UNDER
A
CIRCUMSTANCES OWNERS B—EING SUbpJECT TO—$5,0M00PE5AL—T%—NDER FLORIDA STATUTE NO
455-228(l). AN-0 CUPAT NALLICENSE-IS OTADE U THE OWNER SHOULD PHYSICALlY
SEE THE COUNTY -CE FICATE
CERTIFICATE" TO ASCER F OMPETENCY, R THE FLORIDA "CONTRACTORS
BUILDING DEPARTMENT( IN IF A PERS IS A LICEN ED CONTRACTOR. TELEPHONE THE
7 826)IF IN DO BT.
V ACKNOWLEDGEMENT;I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
Si��TEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
C;,r)
i6r,r�- C � Qd
PHONENUMBER
2 ty d
p.d:"P&r! I la,0�bY4.ff1"h=un
all-fatan'..t. M
Notary Pubir at Las,,a.Stata,0
0 P=Y=
0
TOM GINDLUPE%M
Nolaqsignawra: MY COMMISVON#FF W�l
UPIRES:�Iober 6,Mg
ORDEREDBY
The Law Offkes of Rod Schloth
t
2187 S Third:St
L So
JacksOnvitte Bch,I FL 32250]
I
904-372-9351
beach@rod-law.com
FL1307,1912
BOUNDARY SURVEY I
OUVALCOU4rY so W(a)
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RW
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U�TED IVIONt X THIS"OK P�WAS IMFID I�TOE CITY 01
��N,C%I K" �Olt
COEVIT NVIINIER ftll,Wl 7zEvx'3 . . . . . . AFFMIATE
MEMBERS