95 W 13TH ST - WINDOW TO DOOR , rr
f ',?I•17,
:' ' v' , CITY OF ATLANTIC BEACH
e i f 800 SEMINOLE ROAD
,iv . v ATLANTIC BEACH, FL 32233
"�o- >r INSPECTION PHONE LINE 247-5814
RESIDENTIAL - ALTERATION RESIDENTIAL
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
PERMIT INFORMATION:
PERMIT NO: RES17-0102
Description: REMOVE WINDOW AND REPLACE WITH A DOOR
Estimated Value: 700
Issue Date: 7/18/2017
Expiration Date: 1/14/2018
PROPERTY ADDRESS:
Address: 95 W 13TH ST
RE Number: 170804 0500
PROPERTY OWNER:
Name: HILL ROBIN C
Address: 95 W 13TH ST
ATLANTIC BEACH, FL 32233-3417
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.
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S..m„, City of Atlantic Beach APPLICATION NUMBER
,;1±...m-„,„ City
Building Department (To be assigned by the Building Department.)
800 Seminole Road RE-_ -S
� �17-
C) I OZ
� ''�W ', Atlantic Beach, Florida 32233-5445
\v V Phone(904)247-5826 • Fax(904)247-5845 ii`<0;tl9� E-mail: building-dept@coab.us Date routed: 7 it 8 7
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: C] 5 ‘A) I ( De. - • . ent review required Yes No
:uilding
Applicant: ( CIU e--i2 ' -'•
t •. &Zoning
/� l Tree Administrator
Project: 2 ErnovE V 3 I N 0 O �.�J Public Works .
Public Utilities
RCpLA CC co( oo g. 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: A� A pproved. ❑Denied. ❑Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING
Reviewed by: Date: 1 % $cll
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied. ['Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: Approved as revised. ❑Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
•
J _ '\ CITY OF ATLANTIC BEACH
'� 100' 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.
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY
CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE"IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE' TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826)IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
•
95 TLA) 1341A 6-t- R84- 653-651-7
ADDRESS �" + PHONE NUMBER
PD b I n (-I 1 [1
PRINT NAME
s ) c e1 1 /»1/7
SIGNATURE y 1 DATE
j
Before me this 1 / ,day of. 3 2(1 in the county of
Duval,State of Florida,has personally appea d herin by hi self/herself and affirms that
all statements and declarations are true and ccurate. /0,,
V
Notary Public at Large, .te of ( ,County of (
Ilb❑Personally Known 4 C
❑Produced Identification- O _fr. I_ i _ v �r
_4 '•i ,�':•.y4,, TONI GINDLESPERGER •
g11:131_ ►: MY COMMISSION Il FF 924951
r • EXPIRES:October 6,2019
. Notary Signature: 11-:;5,;:... -9,,
;;, Banded Thru Nota___Public U___tern
4111) .
F:/BLDG/Owner-Builder Affndavil;REVISED:4/16!2009
CoJ
Building Permit Application Updated5/5/17
City of Atlantic Beach
800 Seminole Road,Atlantic Beach, FL 32233
"" Phone: (904)247-5826 Fax: (904) 247-5845 6 / Z_
Job Address: 95 W I St Permit Number: `" 17- pj
Legal Description RE# 17 0 8o4 -OSOC
Valuation of Work(Replacement Cost)$ 700.0V Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Addition Alteration Repair Move Demo Pool indow/Door
• Use of existing/proposed structure(s)(Circle one): Commercial esi
• If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No 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 w�,pprk tobe perforp i d: remove ezrsfi wi ndn•✓£ S;n c4.d reple Ct2loar 36 47, The
.F,il in 1^ ffdar 'TI I i—end hY�+}Q ►�/1e0�. (aa 5 F .4- 2 ci srp d is it drtl `�lo�'r 1 1n� �1
22 2 "fed
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by J; sv'7 1£6avie SKdV> 4C� I r;vne-L;,.e klea fkiersarr,Do'Al c'.d PooreWrepej Iri .
Florida Product Approval# ¢-L /9-rn 3 for multiple products use product approval form
Property Owner Information
Name: %c ); Address: 015 W )3' 51-
City A41_ State PL Zip 3.2.253 Phone_ rl�LI— 8"53—6517
E-Mail v-e-12<t1 03 0 c2.at.COm
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required
Contractor Information
Name of Company: Qualifying Agent:
Address City State Zip
Office Phone Job Site/Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation
Exempt/Insurer/Lease Employees/Expiration Date
Application is hereby made to ob .in a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issua. e of a permit and that all work will be performed to meet the standards of all the laws regulationg
construction in this jurisdict'.n.I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACE ,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.
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.
CU.
(Signatur• . +wner or Agent) (Signature of Contractor)
(incl ding contractor
Signed and sworn to(or of rme.)befor: me this d. of Signed and sworn to(or affirmed)before me this day of
Jlafy ,bil .'A , by
-al r,"._�!► .'r•, ' (S': ature of Notary)
TONI GINOLESPERGER
MY COMMISSION#Fr 924951
11
]Personally Known OR EXPIRES:October 6,2019
6cndedThruNotaryPublicUrderwnters PersonallyKnown 0:
( I ]
I ]Produced Identification�. ( ]Produced Identification
Type of Identification: Type of Identification:
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