589 CLIPPERSHIP LN - SIDING j r\,\\
,-.j' .; CITY OF ATLANTIC BEACH
si 800 SEMINOLE ROAD
j ' s yf,) ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
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RESIDENTIAL ALT/OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 17—RAAR-3889
Job Type: RESIDENTIAL ALTERATION
Description: PLACING HARDY SIDING OVER EXISTING 3/4 T-111
Estimated Value: $600.00
Issue Date: 5/4/2017
Expiration Date: 10/31/2017
PROPERTY ADDRESS:
Address: 589 CLIPPERSHIP LN
RE Number: 170703-0216
PROPERTY OWNER:
Name: MOORE, PHYLLIS
Address: 589 CLIPPERSHIP LN
PERMIT INFORMATION:
FEES:
PLAN CHECK FEES $27.50
BUILDING PERMIT FEE $55.00
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $86.50
PERM I I 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 by the Buildin Department.)
e - 800 Seminole Road
,s2 Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845\,.> ? E-mail: buildin Vgli
de t coab.us Date routed: /87
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
vol
Property Address: j of C CkpperSk„PLn Ddi ment review required Yes/No
22 BuiluiIding
Applicant: np”
-` .� Icier Zoning
Tree Administrator
Project: 1`C_-0 _. StA,t Public Works
Public Utilities
Public Safety
Fire Services
Review fee $ _ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: FikT3Proved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: / t)„..— Date:s'y'/7
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ['Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
Jam,01-A1-,rJr, BUILDING PERMIT APPLICATION
' it%
,, CITY OF ATLANTIC BEACH DATE ' f !
y� 800 Seminole Road,Atlantic Beach FL 32233 FILE �
aril Y.)), Office:(904)247-5826 • Fax: (904)247-5845 C/��j
Job Address: .5 ' ? C/11- y 5!tel,'. _ . Permit Number: (7— /2/)1 R -Ta-19
Legal Description-35 -t ti )1 - 2 S a 9F- 3ek5e ray f 5l RE# 110 7 (..Y. - 0.2/ 49
Valuation of Work(Replacement Cost) $ 6 00 Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Addition Alteration OP Move e- o Pool Window/Door
• Use of existing/proposed structure(s) (Circle one): Commercial R- •-n i.
• If an existing structure, is a fire sprinkler system installed? (Circle one): Yes (19 N/A
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work to be performed: /2/a c i.N, h a r die. 5,d,.",I) o vim. - ex i-7 l itl q
Yil " 1-// a
Florida Product Approval# /::-/- , 3 -. 3 for multiple products use product approval form
Property Owner Information
Name: //ic Mon re_ Address: 5 , G/,p'' r s`j.) /14/ Al, /.?c 2
City r�-tl< aG1, State, ZZip 3�. 1 Phone ( 904/ 703 /0/ 7
E-Mail torn oe7)-(E. //LcnAo-6,-,ci,%. 00►m
Owner or Agent (If Agent,Power of Attorney or Agency Letter Required) .
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.
Contractor Information:
Name of Company: )Q me 0 u ii e,- Qualifying Agent:
Address: City State Zip
Office Phone Job Site/Contact Number
State Certification/Registration# E-Mail
Architect Name &Phone# •
Engineer's Name &Phone#
Worker's Compensation
Exempt / insurer / Lease Employees / Expiration Date
Application is hereby made to obtain a permit to do the work and installations as indicated. I cert fy that no work or installation has commenced
prior to the issuance ofua 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) mouths, or if construction or work is suspended or abandoned for a
period of six(6 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.
Signature of Property Owner:-/�/0 - %'i14 Signature of Contractor:
Before me
this 3 Day of in- ' Before me this Day of
t% ROBlN C Ooi .",
Notary Public: =`• '' M1' M Notary Public:
EXPIRES. .
1019
,.or►�ao,n
•
1 I hereby certify'that 1 have read and examined t is tip . ' d know the same to be true and correct. All provisions of laws and
1 ordinances governing this type of work 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.
Rev. 5/2/16
FILE CCi •
fCITY OF ATLANTIC BEACH
• r
ffh WNER / BUILDER AFFIDAVIT
�, - t t.• v
•
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 TI-IOUGH 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
Al.LER 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.
i 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.
A DR3? 1 /1s4j l *±i-PPHO UMBER/7 A W/
7
ESSPR?eA E/I;S— 71 1 e .
FI%�a LiIIt.0 6/06 J
SIG,ATU- ) DATE
Before me this 3 day of� /20 'in the county of
Duval,State of Florida,has personally alpeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of ,County of /U 1/0.I �'
t * ' � R08MiCMOORE
l4/PersonallyKnown -y Al MY COMMISSION 0 FF247/Lf
O Produced Identification- .• '= EXPIRES Juno 30,2019 j
•
.;J,f...41••' •� F• •. .. Serwcr.ofMi1
Notary Signatu .e ' � /
F:/BLDG/Owner—Builder Affidavit;REVISED:4/16/2009
ti
l _' ';::f:''� CITY OF ATLANTIC BEACH J O B S ITE COPY
'-'4, .:_=_____:}) I3.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 REQUIRED 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. Ili
`
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER N
CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE 0:.:,'.1 .J Z
455-228(1). AN"OCCUPATIONAL LICENSE"IS NOT ADEQUATE. THE OWNER SHOULD PHYSICA () 2 9. I
W
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACT O G
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE
BUILDING DEPARTMENT(247-5826) IF IN DOUBT. 0V C V G
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE 2 3 ..
F.
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF Z ¢O X
OWNER-BUILDER PERMIT. C.) I Zy
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ADDRESS (h` erSIi iL) * I`—�=v� PHONE NUMBER `L•
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PRINT hhFNNNIIIA iE , ' rod I2 w
le (-5 C//q
SIG'ATU• DATE UI
Before me this 3 day of '/t. - 20 i"r in the county of
Duval,State of Florida,has personally efipeared herin by himself'herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of rf ,County of 11/4, v Q 1
't
:: ROBIN C MOORS
I Personally Known i''`: ! MY COMMISSION N FF2467 i f
❑Produced Identification-
.'.....:t...
. EXPIRES Juni 30,2019_Ili
' AOrAI
Notary Signatu SAP ' J/ 'ij2—(2--- •
F:BLDG/Owner•Builder Affadavil;REVISED:4/16/2009