19 FORRESTAL CIR - ELECTRIC S , y r
ri "1 ' , CITY OF ATLANTIC BEACH
. .; J 800 SEMINOLE ROAD
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41
,rr,� ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
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ELECTRICAL PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 17-ELEC-2986
Job Type: ELECTRIC ONLY
Description: replace damaged meter can - 120 amps/220 volts/ single
phase
Estimated Value:
Issue Date: 1/12/2017
Expiration Date: 7/11/2017
PROPERTY ADDRESS:
Address: 19 FORRESTAL CIR
RE Number: 171746-0000
PROPERTY OWNER:
Name: MANGANI, MATTHEW P
Address: 19 FORRESTAL CIR
FEES:
Electrical Repairs $35.00
State Elec DBPR Surcharge $2.00
State Elec DCA Surcharge $2.00
Trade Permit Base Fee $55.00
Total Payments: $94.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
ELECTRICAL PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd, Atlantic Beach, FL 32233
Ph(904) 247-5826 Fax (904) 247-5845 i 1- — ALL- c00
JOB ADDRESS: / f CO((cf Al-I Cli .4f4 f r( 372 ?3 PERMIT#
JEA INFORMATION REQUIRED ON ALL PERMITSi(/ AMPS ZZO VOLTS / PHASE
VALUE OF WORK$
NEW SERVICE ❑ Overhead ❑ Underground ❑J Underground up Pole
Residential(Main)Service
0-100 amps 101-150amps 1151-200amps _ amps #of Meters
_Commercial(Main) Service
_0-100 amps ,101-150amps J 151-200amps 1 amps _CT Service amps
Conductor Type Size
Multi-Family (Main) Service
J0-100 amps 101-150amps _151-200amps 1 amps #of Unit Meters
JTemporary Pole . I amps
SERVICE UPGRADE J amps I CT Service amps
NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES,ETC.)
_1100 amps _150amps J200amps amps JCT 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: # circuits @ kw
Number of Lighting Outlets, Including Fixtures:
OTHER ELECTRICAL PROJECTS
Swimming Pool _ Sign 'Smoke Detectors Qty . ITransformers KVA Motors hp
FIRE ALARM SYSTEM (Requires 3 sets of plans)
Qty volts/amps VALUE OF WORK$
REPAIWMISCELLANEOUS
Replace Burnt/Damaged Meter Can J Safety Inspection Panel Change _10H to UG
J Other:
Permit 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
read 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
specified 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
construction. //�� / q
Property Owners Name /1'7a7Yhe</ au dll� '/ Phone Number 9G`1 Cd 3 lv C/Ad-
Electrical Company S F �/ Office Phone Fax
Co. Address: City State Zip
License Holder (Print): State Certification/Registration#
Notarized Signature of License Holder U
„!': ROSE M.NOBLES Sworn and subscribed before m his /09-- day of C\AY 20Ks., e.
':`. = MY COMMISSION#FF 061243
\•.i EXPIRES:November nd eon Signature of NotaryPublic 2-71q. `'� _
--�;o��4 Bonded TMu Notary PuWi Underwriters � g
CITY OF ATLANTIC BEACH
/� 43.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 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 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.
Ec ( reSf ( 61 N ?2Z3 ) 36t(
ADDRESS PHONE NUMBER
PRINT NAME J t
/(/ .7&(
SIGNATURE DATE
Before me this I Z day of - /1- ,20,0 in the county of
Duval,State of Florida,has personally appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of U;142414 County of 1:)t.)\./
❑Personally Known / NN < �I -t/(��1/-
Produced Identification- _ W V S. X5"K -Bio 5 • -0
. "''., ROSE M.NOBLES
f = � :t MYCOMMISSION AFF061243
Notary Signat /AO 41� t�// ?;. -�� a= EXPIRES:November 15,2017
'1 Jtf Cit' Bonded Thru Notary Public Underwriters
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13LDG/Owner-Builder Avif REVISED: 4/16/2009