490 ROYAL PALMS DR - ROOF (--r-1yi y-
,iiiit1CITY OF ATLANTIC BEACH
s 800 SEMINOLE ROAD
v ATLANTIC BEACH, FL 32233
x!0;3 r.P. INSPECTION PHONE LINE 247-5814
REROOF SHINGLE -
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
PERMIT INFORMATION:
PERMIT NO: RERF17-0228
Description: SHINGLE ROOF
Estimated Value: 1250
Issue Date: 12/29/2017
Expiration Date: 6/27/2018
PROPERTY ADDRESS:
Address: 490 ROYAL PALMS DR
RE Number: 171512 0000
PROPERTY OWNER:
Name: GADSON JOHN W
Address: 490 ROYAL PALMS DR
ATLANTIC BEACH, FL 32233-3926
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.
r#,-.#-.. Building Permit Application Updated 12/8/17
1City of Atlantic Beach
800 Seminole Road,Atlantic Beach,FL 32233
Phone:(904)247-5826 Fax:(904)247-5845 p
Job Address: 4 90 ,/,741-- //44<' of, 0,,k. 4t A- ,f/ Permit Number: R c RF I.7 -0 Z
Legal Description RE#
Valuation of Work(Replacement Cost)$725—CA9 Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Addition Alteration Repair Move Demo Pool 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
• 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: k i„st. i e. r- 004
Florida Product Approval# Vii- J 0/Olt-/ — 1=1.9,/SLf9• / for multiple products use product approval form
Property Owner Information n JJ
Name: hji 14 (J dSon Address: 4' Q%0ya ' 7hn #2r.
City 4� fr,/% PGrh State 17 Zip 1'1,}+33 Phone Q0-
E-Mail
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
Exe , /Insurer/Lease Employees/Expiration Date
Application is hereby made to obtain a permit to do e work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit an• hat all work will be performed to meet the standards of all the laws regulationg
construction in this jurisdiction. I understand • at a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEAT 'S,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirements of this
permit,there may be additional restriction applicable to this property that may be found in the public records of this county,and
there may be additional permits required from other governmental entities such as water management districts,state agencies,or
federal agencies.
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
RECORDdNG YOUR NOTICE OF COMMENCEMENT.
Q.,ev
(Signature of Owner or Agent) (Signature of Contractor)
(inclu•• g 'ntractor)
Si ed and sworn to(or affi m-d befo - e t is I/day of Signed and sworn to(or affirmed)bef. - me this day of
oec. , r , by _ .dk Weil , , by
m•-'1,1-.'1:'°r;c TONI GINDLESPE,''S�r 41,Ili _ 4111?.: , ':.. MY COMMISSION#rrt azo
hili • - ignature of Notary) 110 (Signature of Notary)
-:•.� .:oa EXPIRES:October 6,2019
'_ '.
''' Bended Thru Notary Public Underonters
[ ]Personally Known OR
[ ]Produced Identification [ ]Produced Identification
Type of Identification: r.---_,. 2 s-47`) -4-6p_l zOype of Identification:
S riyv1r•
�; CITY OF ATLANTIC BEACH
r,
ii; 11 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.
Alg4) 48Y4LA Or. 9vll -707-o96-1E-
2/DRESS PHONE NUMBER
Jain 14/ duc/sok\
P' .TNJ
itir
/7 jfainfl- /2- 2\(-)-//
le ATURE DATE
Before me thisday of 0 e e 20Pin the county of
Duval,State of Florida,TIRas personally appeared herin by himself/herself and affix s that
all statements and declarations are true and accurate. (`�\
Notary Public at Large, -e of 1( ,County of o Ute_
❑Personally Known
IIP 7 ^ _ 7 _
❑Produced Identification �(r ... V
• oar-u
,,o...,,..-.; TONI GINDLESPEAuER
:,: �_ MY COMMISSION#FF 924951
=; Qa EXPIRES:October 6,2019 ,
Notary Signature: ��, .� ;& °r Banded Thru Notary Public Underwriters J I
F:BLDG/Owner-Builder Affadavit;REVISED: 4/16/2009410