418 SKATE RD - FENCE �j 8.%1.7YJn
$, CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
FENCE WALL OR BARRIER - FENCE
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
PERMIT INFORMATION:
PERMIT NO: 17-FNCE-3743
Description:
Estimated Value: 2000
Issue Date: 5/24/2017
Expiration Date: 11/20/2017
PROPERTY ADDRESS:
Address: 418 SKATE RD
RE Number: 171558 0000
PROPERTY OWNER:
Name: JAKE AND JENNA THOMASON
Address: 418 SKATE RD
ATLANTIC BEACH, FL 32233
GENERAL CONTRACTOR INFORMATION:
Name:
Address:
Phone:
Name:
Address:
Phone:
PERMIT INFORMATION:
Please see attached conditions of approval
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOU PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB
SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY
BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
* A notice of Commencement is only required for work exceeding an estimated value of
$2,500.For HVAC work, a Notice of Commencement is only required when HVAC work
exceeds and estimated value of$7,500.
Building Permit Application Updated 5/5/17
City of Atlantic Beach
800 Seminole Road,Atlantic Beach,FL 32233
Phone:(904)247-5826 Fax:(904)247-5845
Job Address:
—fIK SkIrE kPAO Permit Number: ad I=Ajce-34-43
REN
Legal Description
Valuation of Work(Replacement Cost) " d Heated/Cooled SF Non.Heated/Cooled
Class of Work(Circle one): a Addition Alteration Repair Mov em Pool Window/Door
• Use of existing/proposed str ure(s)(Circle one): Commercial esldenti
• If an existing structure,is a fire sprinkler system installed?(Circle one . e• s N/A
Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe 1.detail thetypeof work to be performed: Q &"D �'Go .G
Y��F FE2 P&Zwn I Z 2-O 0"ASIL-
Florida Product Approval N for multiple products use product approval form
Pro ert Owner Information �I y SI. r,,,� O _q
Name: LµA. Ad
O
City Ikk( H { l;7 State Zip Phone
E-Mail Rb. . koh. a ,4Ma (•N I L'
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company: Qualifying t:
Address City State_Zip
Office Phone Job Site/ act Number
State certification/RegistrationIf E-Ma
Architect Name&PhoneN
Engineer's Name&Phone N
Workers Compensation
EvemDt/insurer/tease Employees/Expladon Data
Application is hereby made to obtain a per ' to do the work and installations as indicated.l certify that no work or installation has
commenced prior to the issuance of a p it and that all work will be performed to meet the standards of all the laws regulationg
construction in this jurisdiction.l un rstand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOIL ,HEATERS,TANKS,and AIR CONDITIONERS,etc.
OWNER'S AFFIDAVIT:I certi hat all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
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.
(Signature of owner
AgenU (Signature of Contra r)
(ind in contractor)
Si ned and sworn
ntto((or a Irm )before m thi ay of Signed and sworn to(or affirmed)be re me this_day of
b by
aryl (Signature of Notary)
tip'ITONT GINDIESPERGER
{pkq pry ccsNISSION*FF92Q51
a'.�`r.�ei EXPIRES:Ccicosts 2019
I ....
Q eo•mf mNN":ary PUEk WdenMm ( )personally Known
Per.
Produced Identification ,t _ ( 1 Producetl ldentifi flan
Type of ldentiNcation: ( SZS — 'IzrJ'�gj Typeafldemifcan:
Z¢7 —d
. YIVbYijr:.
CITY OF ATLANTIC BEACH
OWNER/ BUILDER MITIDAM
I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 'CONSTRUCTION
CONTRACTING' REQUIRES OWNER I BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.101 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 MIPROVE 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 FOR ORYOU,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 PERSONAS 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 COLRaTY OR MUNICIPAL LICENSING
ORDINANCES.
IL INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED.
111. 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 PHONENUMBER
PRINT NAME I/ I
SIGNAT
Safa Nis yoR/ .20` la dle count,of
Duval, tale of Florida,hi pe souni...aad hedn M M1lasaVl M1 Mf lana eflirms Nal
an alatamema and declarationsa accurate.
Noi Public at]i State of Count,of
❑FeRonmvl(nwm Z5 -58 _z TO NI GNDIEBPEI GER
❑Pmeicea laenli!Im- 'R` .,, M,
GOMMISSICNtFF924951
EXPIRES'.Ocl0dGr6,2D19
�2 mmaama N+'vn peeucuoaer.ann
Nafary SiOnature:
F9B1➢Gg—Builau AMdualAEV ..i/IQR009
AGREEMENT TO ACCEPT TRANSFER OF UNCOMPLETED BUILDING PERMIT
This agreement and a new Permit Application are required to transfer an uncompleted
building permit.
j`n71oyv Phone 9 ° y 03 -OP
Address� �� Sy` � (L 'AD
NIkhO• C��aA Sw/ Mkl � rd`
Email 5p<k�2•�iD /' �`'(�
State Certification/Registration # understand that Building
Permit 1'7-P:-_t-)CE -37 was started by another contractor and is currently
uncompleted.
I agree to, after reviewing the approved plans and the unfinished as-built construction, to
submitting a Revision Form and revised construction drawings to the Building Department to
correct any deviation between the approved plans and as-built construction, where found.
I understand that, based on the current inspection record, I am responsible for the Code
compliance of the finished project.
Details (Optional)
Signature of Contractor/Owner Builder =Br
ate u r/� fyy7Before me this20aSignature of NoSPERGERSSICN YFF929 1'.Ocbber 6,2019ow,P �UNerwihr
MAP SHOWING BOUNDARY SURVEY OF
LOT 15 r 19 _AS SHOWN ON MAP OF
wr REPLAT OF PART OF ROYAL PALms UNDP TWO A
AS RECCRDEO W PLAT BOp( x _PAf Id IW q� Opc 2 rC RECCIPOS O�UJVA( CIX/N1Y, 1Q%DA
CER77F7ED FOR:ALLISON W FLl45YM' NR MAWAY&REYNOTD P ❑!M DARE A`✓S CO.
54'R/W uR DRAWAC£& UALT
u� akin
Nome'02 F' 80.66
rrAw r w
xo w � ' .. . revxxx rNu
(elm L.J 220' CL_
R O
q' I r-S.'ORY sRH.Cb Lu
co
220• ..j
WF
ry 0
...� • .909'1808$ .B5'
SKATE ROAD
(60',R149
scorn EO: W.O. mm-B7, 2-9-15
ECQ'MEO: WO /89-2559; 5-29-59
AN'PRO>E SHOW)HEREON APPEARS M L WMW RoW HAZARD ZONE_BL AS SC FRGIE ROOD
NSLARANCE RATE NAPS_ FDR WVAL COUNTY. ROWA, DATED 6-J-13 . ANO
f5 SNOMN AS A CWRIESY QYLY ANp DCE5 NOT CONSAAJIE A fFRAF^..AADN C'F SANE.
TRI-STATE' LAND SURVEYORS, INC.
5875 MlMNG TERRACE 8209, JACKSONWLE; FLORIDA 32257 (904) 880-2535
�y &ARWGS BASED W RVW [Mg AS SHOWJ.
w A[BeR MTS SJRYFY ODES NOT REFLECT W CETERNINF OWVDt,w
ALM NtnFV-NNY NOT V. l WNW, ME 9GVATURE AND WE 0.4IGA✓AL RAISED g,LL
N
y OF A ROWDA UaM"SVRWE AND NAPPER.
rov vwen yaE ^T5 S Wy BASED UPW DESCIT'PADN AS RWM'A ,, AMC Wwwr
E ¢eAw.Mz (gNEETT OF A AAE NAWFR ABSTRACT OF RRE AND DEED RISE'
4L AN c4MrwsM.nio
m mm Y
1fY_ LL BROW 39J
tPr, FA4F2VT
mss mraw uneerrme
�Y Mg9R DATE SSD-4f
a Pawl cr Hent �(kS>EA£D SW2�'Y�4 N
preo•<-g TAMdFI ARMS DA R:' a-1-91 STAtE CT RgRIDA (LB fl92t)
a cm: DRDEB NQ
S f=111-1'
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
&WI c.) INSPECTION PHONE LINE 247-5814
FENCE WALL OR BARRIER - FENCE
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
PERMIT INFORMATION:
PERMIT NO: 17-FNCE-3743
Description:
Estimated Value: 2000
Issue Date: 5/24/2017
Expiration Date: 11/20/2017
PROPERTY ADDRESS:
Address: 418 SKATE RD
RE Number: 171558 0000
PROPERTY OWNER:
Name: ALLISON V FORSYTH
Address:
GENERAL CONTRACTOR INFORMATION:
Name:
Address:
Phone:
Name:
Address:
Phone:
PERMIT INFORMATION:
Please see attached conditions of approval.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOU PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB
SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY
BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
* A notice of Commencement is only required for work exceeding an estimated value of
$2,500. For HVAC work, a Notice of Commencement is only required when HVAC work
exceeds and estimated value of$7,500.
I
City of Atlantic Beach APPLICATION NUMBER
Js • • Building Department (To be assigned by the Building Department.)
,I 800 Seminole Road I - rN
j.. _ M Atlantic Beach, Florida 32233-5445
..'„ 111,— Phone(904)247-5826 • Fax(904)247-5845 Date routed: CJ�
�? E-mail: building-dept@coab.us
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: Li S t-cut_ Dena�rtm1ent review required Yes` No
uildi V
Applicant: Dt,k LZoni��
�' Tree Administrator
Project: '� nl cca__ �}� �k u006)..0.1\ ,P_ works
e-i?uhlic 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: Approved. ❑Denied.
(Circle one.) Comments:
BUILDING / ,
PLANNING &ZONING Reviewed by: ill Date: 171'i 217
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
s==vir City of Atlantic Beach APPLICATION NUMBER
S jr ''- Building Department (To be assigned by the Building Department.)
-- `` 800 Seminole Road
Atlantic Beach, Florida 32233-5445 1 F N cc- - 3--1 L(
Phone(904)247-5826 • Fax(904)247-5845
LJ—��>r E-mail: building-dept@coab.us Date routed: OLt l<< I
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 0 S kclkL (4a . Department review required Yes No
uildin '
Applicant: DUJ y1124 nq & Zoning,
Tree Administrator
Project: `LI \C.QL-e- (}'2k 1,)00n P_ bli ` orks�
c 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: Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING & ZONING
Reviewed by: d,,..•.,/ l-----it-----" Date: SPA 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. I (Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
;;s .1- ` ,�, City of Atlantic Beach
APPLICATION NUMBER
.; Building Department
�• (To be assigned by the Building Department.)
J =- ;% 800 Seminole Road E!Ni. y
�� �� Atlantic Beach, Florida 32233-5445 I 1 FN C.(_." -1-1q 3
Phone(904)247-5826 • Fax(904) 585
'�-artis) E-mail: building-dept@coab.us A R 1 3 2017 Date routed: OL{ E l i I
City web-site: http://www.coab.us
BY:
APPLICATION REVIEW AND TRACKING FORM
Property Address: Li t 1 S-C(.V L 2._a . D rtment review required Yes No
uildi
Applicant: 1A)y'1; ---fng &Zoning
�' Tree Administrator
Project: '( L nl`C---Q- k*D * 1.300,0A J Qbli_Works
c'-P-ubbc 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: IVApproved. ['Denied. 6y147
(Circle one.) Comments: iee /#44/44 44fma
BUILDING /p�/
`
PLANNING & ZONING yyff �
Reviewed b i�'2�6 f!j4�/ 2224-4__
�e,i,,,7 Date:
TREE ADMIN. Second Review: A roved as revised.
❑ pp ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: I 'Approved as revised. I (Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
City of Atlantic Beach APPLICATION NUMBER
(1-.51.AV:
t. � Building Department
c� (To be assigned by the Building Department.)
;, (j - 8tla SeminolecRoad E C E 1� I --- N (4-..-.- 3-1q3
j - Atlantic Beach, Florida 32233-5445
�1r y _•.
Phone(904)247-5826 • Fax(904) 247- 5 3 I
x r'� V E-mail: building-dept@coab.us APR 13 2017 Date routed: OLf 1<1 I I"4-
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: L[ D S -c k- Q_Ul . D,rtment review required Yes No
:uilditlg:---
Applicant: DU-3 0-Q--( ' -inn. &Zonin•
Tree Administrator
Project: Lp\(.ct_L 6D * W000UA Wilki2ii Works
• . Utilities
Public Safety
Fire Services
Review fee $ pz 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: V . ['Denied.
(Circle one.) Comments: 1
BUILDING N
PLANNING &ZONING yt/ A" Date:__±_*_LZ_Reviewed by:
TREE ADMIN. Second Review: A roved as revised.
❑ pp ❑Denied.
WORKS Comments:
yUe
BL UTILITIES
PU LIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
I
FILE COPY
„ .,„„iv-y.4, BUILDING PERMIT APPLICATION
J \`1\ CITY OF ATLANTIC BEACH DATE
' J
r 800 Seminole Road,Atlantic Beach FL 32233
l'71,01119 Office:(904)247-5826 • Fax:(904)247-5845
Job Address: 1"//S S/f L° Rd Permit Number: I t- r-N(L-39- 3
Legal Description i-D /S- E)o c<< / 9 RE#_ / X155
Valuation of Work(Replacement Cost)$ 4 i'.96' Heated/Cooled SF If 74 Non-Heated/Cooled
• Class of Work(Circle one): • Addition Alteration epair Move 11emo Pool Window/Door
• Use of existing/proposed structure(s)(Circle one): Commercial 'estdential
• If an existing structure, is a fire sprinkler system installed?(Circle one): Yes No dal
• 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: ^/ 6
plaeuz all -ref\c.e_ - add ��t:v ��.rc e - �0,�%t
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name: n) li 3 ciV\ I-v15(PikAddress: ! -4 3 8 SN(Val` fr j o' .
City ( State F( Zip 3g,1‘3:5 Phone 9 D LtI- 4 I/Q - 3 7.9 -7-
E-Mail
( -7-
E-Mail a,-(o t`s 19 Co 0 Cd. C_Jo.( , c curl
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: Qualifying Agent: _ c-
Address: at -�3e City
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 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 a
period of six(6J months at any time after work is commenced. l understand that separate permits must be secured for Electrical Work,Plu ing,
Signs, Wells,Pools,Furnaces,Boilers,Heaters, Tanks and Air Con '' ne •
Signature of Property Owner: U etJUA)o A 2,..21--- ignature of Contractor:
Before me
this tt Day of kpf t . 16 U 1 Before me this Day of
Notary Public: Notary Public:
I hereby c .t. e J tt�
have MdFeRclot ivroptc l th 1 application and know the same to be true and correct. All provisions of laws and
ordinance r.,..t ; limy egtu tls$imvIliGtli64,4c emplied with whether specified herein or not. The granting of a permit does not
presume h , ,„1, trite mess,°( Zq;r�pd'!th"'provisions of any other federal, state, or local law regulating construction or the
petformat*cs 30' :, lrnpj(d d7h Notary Public Undermiters
. '„+ . , II --r . ID Rev. 5/2/16
MAP
SHOD GARY SURVEYOP —
LOT._____If____BLOCK— 19 AS SHOWN ON MAP
— REPL4d OF PART OF ROYAL PALMS UNIT TWO AOS
AS RECORDED W PIAT BOOK 31 PAGES 16-160
OF THE PUBLIC RECORDS OF DUVAL COUNTY,
CERTIFIED FOR:ALLISON W. FORSYA'• HATHAWAY& REYNOLDS PA• CHICAGO 77TLE INS ca CERTIFIED
irmir�
54'R/#FOR DRAJNAGE& UTILITIES
1 1
C 0-I'k`c4- •-e-'c-- i
N0r18'02"I 80.65' J
NO!G171.1N2 1/2 - ------u- _-_-- _ - i v. ._ elft
..-`'7 •. CORNER t'AUS
k1 70"Om" INEE
dd ,,,.?s ill, -,, 1
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•
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- sOr16'g2 i 60.65' , -— -
t
f t
. . -- _7 i
SKATE ROAD
(60'D/W)
RI1FIED: W.O. #2015-67,• 2-9-15
E:.�
ECR 1F1£I2: W.O. #99-2569,- 5-29-99
THE'PROPERTY SHOWHERRN APPEARS TO LIE WNW ROOD HAZARD ZONE
A
INSURANCE RATE"MAP 408 FOR DUVAL COUNTY, FLORIDA, DATED 6-3-13 AS SCALED FROM ROOD
IS SHOWN AS A COURTESY CWLY AND DOES NOT CONSTITUTE A CERTIFCATION OF SAA/E. AND
TRI--STATE LAND SURVgYORS, INC.
5875 MINING TERRACE #209, JACKSONVILLE, FLORIDA 32257 (904) 880_2535
:£GJ.D BEARINGS BASED ON RAI/
�'' CONC.` LINE AS SHOW.. 1
!ROY
R8 APJA THIS SURLY LOGES NO;REFLECT OR DEIERMINE OWVERSHIP•
RA +T--OF xaY
s7x uq;l NOT VALID WITHOUT THE SIGNATURE AND THE ORIGINAL RAISED SEAL
DAV DRtEtyAr OF A FLORIDA LICENSED SURLEYOR AND MAPPEA..
OM COWRED AREA THIS SURVEY BASED UPON DESCRIPTION AS FURNISHED, AND .WITHOUT I
zYT 4u BENCr1T OF A iln,.,E BINDER/ABSTRACT OF TITLE AND/OR DEED RESEARCH4
A/C Air COAD!^act6 PAD
(R) RADIAL DISTANCE
cava cogcrt:E CALE: 1`= 20' GLENN M. BROA
mrr EA.aAt'aT .SM. O. a8!
8 RL 81.11:04Y3 RESIRIC710N
UNE
PC •E7-D WORK DATE 5-3D-9r
Pc POW a a REGISTERED SG7ZLYOR AND MAPPER,
PTPO1N Or TANGENCY 1GNATURE DATE- B_1-81 STATE OF FLORIDA (LB#4927)
PG cin S1-r149
ORDER NO. ' - ••
FAR/FQfL( Idgfla0 QUIZ of Qaa 9ESl-QB8:xe3 A3MJ1S OM 31d1S-181
i
1.40%-i.,
J 1r'
_r CITY OF ATLANTIC BEACH
'J%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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE"IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826)IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
- STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
i-II6 SLiotp td q'oy- d-4l- cfq ,
ADDRESSI e , PHONE NUMBER 716,
J iJ�
PR NT NAE -
V..- ( __-L4011/1 //(--J,- /-"zit z_Ai "Id- /7"
SIGNURRT E
DATE
Before me this 1 day of I ' ` 20t'q in the county of
Duval,State of Florida,has personally appeared herin by himself I herself and affirms that
all statements and declarations are true and accurate.
liNotary Public at Large.State of F L— ,County of b LA.4(t
❑Personally Known
,eroduced Identification- t-�l-'-I S `I L��, r±_r�,..,„ ER,oINS?ON
"Y 1`"4's MY COMM
ISSION$ �2
964
i t ` '.? EXPIRE--October n.
2020
Notary Signature: �V" h 1 ,7: Bon '(htu Merl vrffbls
Ft/BLDG/Omer-Builder AIM 't;REVISED.4/16/2009