15 Forrestal Cir alteration permit CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL ALVOTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOBINFORMATION:
Job ID: 17-RAAR-3426
Job Type: RESIDENTIAL ALTERATION
Description: replace front windows & siding
Estimated Value: $2,000.00
Issue Date: 3/14/2017
Expiration Date: 9110/2017
PROPERTY ADDRESS:
Address: 15 FORRESTAL CIR
RE Number: 171747-0000
PROPERTYOWNER:
Name: PARKER, RICHARD & IDA,
Address: 15 FORRESTAL CIR
PERMIT INFORMATION:
FEES:
PLAN CHECK FEES $30.00
BUILDING PERMIT FEE $60.00
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $94.00
PERMIT IS APPROVED ONLY IN ACCORDANCE I&TTH ALL CITY OF ATLANTIC REACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
City of Atlantic Beach APPLICATION NUMBER
Building Department Cro be assigned by the Building Department.)
800 Seminole Road
Atlantic Beach, Florida 32233-5"5
Phone(1)04)247-5826 - Fax(904)247-5845
E-mail: building-delyt@wab.us Date muted: _Q_�10(0 I I
City web-site: hRp:1/www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: tS7 flba_s-�CAI, U Department review required Yes No
Applicant: t)w NJ_f Planning&Zoning
Tree Administrator
Project: Cfn�oL-L
Public Works
Public Utilities
Public Safety
Fire Services
Reviewfee Dept Signature
—Review or Receipt
Other Agency Review or Permit Required of Permit Veriffied By Date
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Amy Corps or Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other.
APPLICATION STATUS
Reviewing Department First Review: M<Pproved. E]Denied.
(Circle one.) Comments:
(EIN:G)
PLANNING &ZONING Reviewed by: Date: 3//,.J/-7
TREEADMIN. Second Review: E]Approved as revised. ODeniec(/
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: E]Approved as revised, E]Denied.
Comments:
Reviewed by: Date:
Revised 05114/09
Building Permit Application OFFICE COPY
City of Atlantic Beach
800 Seminole Road,Atlantic Beach,FIL 32233
Phone:(904)247-5826 Fax:(904)247-5845
Jol:,Adclress:j'.� tdf'1'104:40j Clii-Cill!" la 00� Permit Number: llq-eAA0L-S'Aa(�
Legal DescriPtinn /,j., 1,7 R)Ak 1 -RE#-
Valuation of Work(Replacement Cost) . 00 Hearted/Cooled SF_Non.Heated/Cooled_
Repair Move Demo Pool Window/Door
• Class of Work(Circle one): New Addition Alteration(9� --
• Use of existing/proposed structure(s)(Circle one): Commercial rRZdientlZi>
• If an existing structure,is a fire sprinkler system Installed?(Circle one) s & N/A
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describl in detail the type of work to be pelformed: VoolarLA'S * SW� bVIA 7'-111/W*
4. _71
8"q CIN �411"&w
Florida Product Approval# N1041, / for multiple products use product approval form
Pronerb;Owner In ambition
&I"e
City'- �12 State:tEzlp LA?73--Phone '16141-Y&7 &XI
Owner or)(Yent(if Agenf,"Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company: Qualifying Agent:
Address City_State-rip-
Office Phone Job Site/Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone If
Workers Compensation
Exempt/insurer/Lease Employees/Exirlil Da%A if 6 20
Application is hereby made to obtain a permit to do the work and installations as IndicaLed.I certify that no 1Vrk or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standardsofall the laws regulationg
construction in this junisdiction.I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS,and AIR CONDITIONERS,etc.
OWNER'S AFFIDAVIT:I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
WARNI NG TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF CO M M E N CEM ENT 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
REC94DIN YCuN0 F OMMENCEMENT.
(Signature of Owner or Agent including Contractor) (Signature of contractor)
Sig�!er:LarLd swoti, --day of _day of
to(qLaj[r2ecfi before me�hisj� Signed and sworn to(or affirmed)before me this
I ' cy�f�. I Isx, by
Z Notuy Public-state o:PROTIR
ON
ConernIssix,a:GG064 (Sig tureo�NoW (Signature of Notary)
My Comm Expires Jan 22.2021fSj
]Personally Known OR Personally Known OR
I Produced Identificat _�,832 ID I Produced Identification
Type of Identification:r- P62(- )'l Type of Identification:
CITY OF ATLANTIC BEACH
OWNER/ BUILDER AFFIDAVIT
1.C 0 FLORIDA STATUTES; CHAPTER 489 FLORIDA STATUTES, PART I TONSTRUCTIM4
NTRACTING'REQUIRES OWNER/BUILDLR TO ACKNOWLEDGE THE LAW
DISCLOSURE STATEMENT FOR SECTION 489.103(7),FLORIDA STATUTES:
STATE LAW REQUJRES CONSTRUCTION TO BE I'll 11 LICENSID
CONIRAMORS. YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPUON TO lHAI
LAW. THE EXEMPTION ALLOWS YOU.AS THE OWNER OF YOUR PROPERTY.TO ACT AS
YOUR OWN CONTRACTOR F EN THOUGH YOU DO NOT HAVE A LICENSE. YOUMuST
alLP-ERVISCI�JECONS'rR[IC!I"YOINYOURSEL12� YOLJMAYBtfli,l)OPINIPROVEAOME-OR
IWO FAMILY RESIDENCE Olt A FARM OUTBUILDWO. YOU MAY ALSO BUILD OR
IMPROVE A COMMEIZAL BUILDING Al A COST OF$25,000A0 OR LESS. THE BUILDIN(j,
MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE.
IF YOU SELL OR LEASE A BUJ 1.111 FIG YOU I IAVE BUIL'I YOURSELF Wil I IIN ONE YEAR
AFTER THL CONS I RUC I]ON IS COMPLETE,I HE LAW WILL PRESUME I HAT YOU BUIL-1 >
F1 FOR SALE OR LLASL, WHICH IS IN VIOLATION OF THIS EXEMPTION, XOU MAY No,
HIREAN IFNIACENSED PER�QN A� YQUR CONTRACTOR YOUR CONSTRUCHON, Nltj,%j CL
HE DONE ACCORDING To THE BUILDING CODES AND ZONING REGULATIONS. I I I� 0
YOUR RESPONSIBILITY TO MAKE SURE THAI PEOPLE EMPLOYED By VOU jj,�,
LICENSES REQUIRED BY STATE LAW AND B UN I' LICENSING
URDINANCES. Lu
11. INJURY LIABILITY; SINCE OMERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMFFNT SUGGESTS WORKER'S COMPENSATION INSURANCE BE LL
PURCHASED. 0
Ill. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO
OBSERVE IRS WITHHOLDING TAX AND/011 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. uj
455-228(1)� AN-OCCUPATIONAL LICENSE'IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY u
SEE THE COUNTY TERTIFICATE OF COMPETENCY' OR THE FLORIDA TONTRA&TORS Z
CERTIFICATE' TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE ex
13UILDING DEPARTMENT(247-5626)IF IN DOUBT. C.)
z
V.ACKNOWLEDGEMENT;I HEREBY ACKNOWLEDGE THAT I HAVE READ tHE ABOVE DISCLOSURE j 65 0
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN 0 M t:
OWNER-BUILDER PERMIT. 0 -c
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