337 4TH ST - PERMIT RES18-0148 CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL -ALTERATION RESIDENTIAL
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
PERMIT INFORMATION:
PERMIT NO: RES18-0148
Description: Bathroom remodel
Estimated Value: 2000
Issue Date: 5/8/2018
Expiration Date: 11/4/2018
PROPERTY ADDRESS:
Address: 337 4TH ST
RE Number: 1698350000
PROPERTY OWNER:
Name: GOELZ LARKIN L
Address: 337 4TH ST
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.
NOTICE: In addition to the requirements of this permit,there may be additional restrictions
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.
* 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.
City of Atlantic Beach
APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road
'49. ..... Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 - Fax(904)247-5845
E-mail: building-dept@coab.us Date routed: -2-
City web-site: http://vmw.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 4�k .artment review required Yes ,. No
Applicant: Qoe-� Planning Zoning
Tree Administrator
Project: Public Works
Public Utilities
Public Safety
Fire Services
lkev'few fe e- - -bep
. 0 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: [KA�pproved. E]Denied. []Not applicable
(Circle one.) Comments:
PLANNING &ZONING Reviewed by:_ tl"' Date: 57'
TREE ADMIN. Second Review: DApproved as revised. []Denied E]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
-----------------------
OFFICECOPYBuilding Permit Application n"i L
N
Cit of Atlantic Beach
y
800 Seminole Road,Atlantic Beach,FL 32233
APR 2 4 2018 �1
Phone:(904)247-5826 Fax:(904)247-5845
Job Address: Permit Numben. Lb
IiE#
Legal Description
Valuation of Work(Replacement Cost)'5_2-JC1�70 Heated/Cooled SF Non-Heated/Cooled
e 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�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:
A
_Alu [_Mum _tiltb
Florida Product Approval# for multiple products use product approval form
Property Owner Information —1
Address:
Nam�.
City �tate F-L- zip P h o n e LCAVE 4— 2�6 1-
E-Mail La
Owner or Agent(If AgerWPower of Atto0ey or Agency Letter Required)
Contractor Information
Name of Company:. Qualifying Agent:
Address C it
Ye r
Office Phone Job Site/Contacti N RW
State Certification/Registration# E-Mail. 'CITY OF A I LANT1 L;BEACH
SF-E PERMITS FOR ADDITIONAL
Architect Name&Phone#
Engineer's Name&Phone# RIE-QUIREMENTS AND CONDITIONS
Workers Compensation
DATE: > 'I- )OL&
'P
Exempt insurer/Lease EmploR&V/TW&1JnIA jef:
Application is hereby made to obtain a permit to do the work and installations as indicated. I ce.�ifyt�hao work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the stanclards'of all the laws regulationg
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS,FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the req.ulrements of this
—dition.afrest'ricticins applicable.to this property I t a:�'� s n y and
p6rmiti.there may,be ad h t may be found in the public retotds of thi c6u
the ibe�aclditlb`nitail,pefmi' ifies such as wafer management districts,state agencies,or.
,re ts required from other governmental ent .... . .
fecleral,aAencies.,
bwNER'S.AFF]DAVIT: 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
OMMENCEMENT.
RECI OU"9TICE UF.LUlVl[VlhNL1--1V1I
(Signature of Contractor)
t-SigndLUIt!U1%J%fV11U1 U1 MS-LI
(including contractor) e this day of
signed and sworn to(or affirmed) before me this q4 day o,f Signed and sworn to(or affirmed)before m
A. 101-1 ,by
L-6-4�, ") Cn 1).6 f L -
--------------
JENNIFERJO b-lvrq
04
§R' My COMMISSION GG
EXPIRES:Odober 2 ature of Notary) (Signature of Notary)
Bonded Thru Notm Public Ur*
Personally Known OR Personally Known OR
Produced Identification Produced Identification
Type of Identification:-IFL- ymo-,Ls Type of Identification:
V CITY OF ATLANTIC BEACH
OWNER/ BUILDER AFFIDAVIT
1. 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. TEE 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,WIRCH 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.
11. 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(l). 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.
Lk.�" etv e
ADDRESS PHONE NUMBER
V1
I! NAME
DATEI
Before me this day of 20kin the county of
Duval,State of Florida,has personally-appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of County of
El Personally Known
5�roduced Id.ritification- L JFNNI�EiZHNST
L R JOHNSTON
My COMMISSION#GG 042984
EXPIRES:October 27,2Q20
?'�nGdThrj Notary Public ftermhN
Notary Signature*_�Nx E
F:/BLDGIO�er-BuilderAffadavit�'kEVISED:4/16/2009