1221 MAYPORT RD - APPLICATION NOT ACCEPTED ?S�`Ly�✓v�
, eik,; CITY OF ATLANTIC BEACH
a s 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
(904) 247-5800
Your application for a I CE ENDO (k)CN Permit, received Z /7 El/ 7
cannot be accepted for the following reasons:
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The Application is not complete. Please complete all lines and provide all
requested information.
The Application is not properly signed and notarized.
The faxed or emailed copy received is not legible or does not show the entire
document.
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NOTE: Please submit clear, legible documents, including all information requested on the application form. Documents
will be reviewed for complete information and electronically scanned to produce the final permanent record,all documents
must be clean,clear,and of sufficient density and having enough contrast to produce an acceptable and complete scanned
image.
GBUILDING DEPT. ( o < <c\j, \es elm
DATE /a
7
1
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach, FL 32233
Office (904)247-5826 Fax (904) 247-5845
Job Address: 1221 Mayport Road Permit Number:
Legal Description See Attached Survey Parcel # 171090-0110
Floor Area of 84 Sq.Ft. Sq.Ft
Valuation of Work$ 150,000 Proposed Work heated/cooled 84 non-heated/cooled_
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s)(circle one): Commercial Residential
If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No N/A
Florida Product Approval#
For multiple products use product approval form
Describe in detail the type of work to be performed: The proposed work includes the installation of an Ice Vending
Machine with associated water and electrical connections.
Property Owner Information:
Name: Shoppes of AlA North LLC Address: 1221 Mayport Road
City Atlantic Beach State FL Zip 32233 Phone
E-Mail or Fax#(Optional)
Contractor Information:
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 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 apertod of six 16)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.
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.
I hereby certify that I have read and examined thisplication and know the 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 violate or cancel the
provisions of any other federal,state,or local law regulating construction or the performance of construction.
Signature of Owner Signature of Contractor
Print Name Print Name
Sworn to and subscribed before me Sworn to and subscribed before me
this Day of , 20 this Day of ,20
Notary Public Notary Public
Revised 01.26.10
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_:.s.,::„... . CITY OF ATLANTIC BEACH
13"W INR / BUILDER AFFIDAVIT
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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.
ADDRESS PHONE NUMBER
PRINT NAME
SIGNATURE DATE
Before me this day of ,20_ 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 ,County of
o Personally Known
❑Produced Identification-
Notary Signature:
F:BLDG/Owaer-Builder Affadavit;REVISED:4/16/2009