2021 Selva Madera Ct addition permit - transferred to owner builder CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL ADDITION
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOBINFORMATION:
Job ID: 17-RADD-3065
Job Type: RESIDENTIAL ADDITION
Description: TRANSFERRED FROM 16-RADD-2206
Estimated Value: $40,000.00
Issue Date: 1/23/2017
Expiration Date: 7/2212017
PROPERTY ADDRESS:
Address: 2021 SELVA MADERA CT
RE Number: 169506-1650
PROPERTY OWNER:
Name: BURBRIDGE, H CLINTON
Address: 2021 SELVA MADERA CT
PERMIT INFORMATION:
FEES:
BUILDING PERMIT FEE $220.00
STATE DBPR SURCHARGE $3.75
STATE DCA SURCHARGE $3.75
Total Payments: $227.50
PERAUT IS APPROVED ONLY EN ACCORDANCE WITH ALL = OF ATLANTIC BEACH ORDINANCES ASM THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
- ----- 800 Sennincle-RoaT-Atlarifitic Beach, FL 32233
Office (904)247-5826 Fax (904)247-S845
Job Address:AqA S,_jw,& "uv� 04- -Afl".'e. jj�_,(A R_ Permit Number:
Legal Description Y2_20 9 Parcel#
our Pt. Sq.Pt
Valuation of Work$ Proposed Work heated/cooled non-heated/cooled
lgjL4 qj
Class of Work(circle one): New (� Alteration Repair Move Demolition pool/spa window/duir
Use of existing/pro osed structure(s) circle one): Commercial (5;;5doub
If an existing struclare,is a fire spriWer system installed?(Circle one).7---YrT-No N/A
Florida Product Approval#
For multiple products use_Pr_0TUc`taPpr0V_ftTT0_rM
Describe in detail the type of work to be performed:.. &AWA Alf
jitf5evzov woek !!6 icol"IP44e Adl:z_fi�c�
Property Owner Information:
N e: e(. O�d" FLA,1��' �Address::
S�tmja�Zip
z
-Mai oyFax#(Optional)
E ,ArF.E4(%0!.ntmnn1L�
Lontractor information:
CONTRACTOR F.MAFF.ADDRESS-
Company Name: Qualifying Agent:
Address: City State Zip
Office Phone Job Site/Contact Number Fax#
State Certification/Registration#
Architect Name&Phone#
Engineer's Name&Phone
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and Address
Application is hereby made to obtain apermit to do the work and installations as indicated Icartf,that no work or installation has cosentmedprior to the
issuance ofaperout and that all work will bepe
_�armedto meet the standards ofall laws regulating construction in thisjurivalction. Thispermit becomes null
in
and cold i7work is not commenced within six(0 months,or it"consouction or work is g�pended or abandanedlor a
Wp e ri ad of s ixj6)in on ths a t any it.after
w.,kiscommenced I understand that separate permits must be securidjb,Electric work, Mmbing,Slim, sllsPooks, urnftca,,BoffersHeden,
Tarks andAt,Gmildoneri,st.
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 YOVIi NOTICE OF
COMMENCEMENT.
lhare�certify thialhove read and asaimmed this lic.tic.and know the same to be true and comet. Allprovisions oflaws and ordinances governing this
work will be complied with whether spc,iMd herein or mt. The granting of a permit doss not presume to give authority to violate or camel the
provisions ofairy otherfed.cral I 1 �
YYmtca, me regulating construction or theperformance ofconstruction.
Signature of Owner Signature of Contractor
PrintName
Print Name
.. . .......
Before me Before me
this 13-Day of this —Day of
Nor%W AU �w
x`=Ot�l
so Public I Notary Public
Revised 01.26.10
Aft
CITY OF ATLANTIC BEACH
OWNER/ BUILDER AFFIDAVIT
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES. PART I "CONSTRUCTION
CONTRACTING'REQUIRES OWNER I 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
SUPERVISE THE CONSTRUCTION YOURS YOU MAY BUILD OR IMPROVE A ONE-OR
TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD OR
IMPROVE A COMMERCIAL BUILDING Al A COST OF$25,00.00 OR LESS. THE BUILDING
MUSTRE FOR YOUR USE AND OCCUPANCY. ITMAY NOT BE BUILTFOR SALEORLEASE.
IF YOU SELL OR LEASI A BUILDING YOU IIAVF. BUILT YOURSELF WITHIN ONE YEAR
AFTER THE CONSTRUC[ION IS COMPLETE,THE LAW WILL PRESUME THAT YOU BUILT
IT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY N
HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUSI
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. I I IS
YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAV
LICENSES REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING
ORDINANCES
11. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKERS COMPENSATION INSURANCE BE
PURCHASED.
BE IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO
OBSERVE IRS WITHHOLDING TAX ANDIOR FORM 1099 REQUIREMENTS ON THE WORKERS THEY
EMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER A
CIRCUMSTANCES. OWNERS BEING SUBJECT TO$5,ODO PENALTY UNDER FLORIDA STATUTE NO.
455-228(1�. AN-OCCUPATIOt&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 WTH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNEWBUILDER PERMIT.
SIGNXTURE
WmmmwaLl
of
FL- 61AV41
&NN's =FERJJ�=IN�
WC Min #
EMSES
N�,Si,.W.:
u v
TERMINATION OF BUILDING PERMIT BY PROPERTY OWNER
I am the owner of
U�
2. -�2Z and have
contracted with knlzf�e 0(dkev for
improvements on the above property, under Building Permit
I have terminated my contract with the above contractor, before completion of the project, and
wish to transfer the Building Permit to ho,#76 e2e�llte'-
I understand that financial and contractual issues may still apply and are civil matters between
the owner(s) and contractor(s) and we agree to hold the City of Atlantic Beach harmless in
those matters.
Details(optionai)
A copy of this form will be sent to the original contractor.
�21
, i,6,
Property Owners Narne —,;q
Addren �2D21 3�jyr, &02�� C� Fe,cLL , FL-- -?Z2-T:3
Signature of Property Owna'�— (3-9 --hy Date
Beforerncthu; 'W�CA dayof qCLAI.Lon 2OjA—
ignatute of Notary Public �4
J�NIFERJOHNSTON
I J
ON#GO
.2
2�
1-Ar;
'� .. 27