354 Seminole Rd RES19-0167 VOID ee � �
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Building Department
City of atlantic Beach, FL
Buildin g Permit App lication z ( 9 Updated 10/9/18
City of Atlantic Beach Building Department "ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
-urt}''
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED..
Job Address: 3,5 c -,^7/AJU/C Ad. Permit Number: � � f LJ � G
Legal Description RE#
Valuation of Work(Replacment Cost)$ r�60 Heated/Cooled SF Non-Heated/Co led
• Class of Work: VI/New ❑Addition ❑Alteration ❑Repair ❑Move o ❑Pool ❑Window/Dr
• Use of existing/proposed structure(s): ❑Commercial V11eidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes QNo /No• Will trees be removed in association with ro osed ro'ec . ❑Yes must submit s rate Tree Removal Permit
Describe in detail the type of work to be performed:
ii \\ t
Florida Product Approval# I( '_O '1 V L -iple produIs use product approval form
Property Owner Information
Name A dre ;,_,01%f0rmU,1t,,,,,,,/.ssd'
City -A Stat Zip—W,2_73 _P h o1h.
E-Maile. —I
Owner or Agent If Agent, Power of Attorney or Agency Letter Required) .
Contractor Information
Name of Company `"�'�G� Qualifyin nt
Address G S L.�t �U / City. G State AL Zip 07
Office Phone - 6 49 44 Job Site Contact Nu ber -
State Certification/Registration# E-Mail .�
Architect Name&Phone# eAJ,V ,v► '
Engineer's Name&Phone#
Workers Compensation Insurer J 1J OR Exempt 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 the laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,`pnd AIR CONDITIONERS,etc. NOTICE: In addition to the requirements of this
permit,there may be additional restrictions applicable td this property that may be found in the public records of this county,and
there may be additional permitquired from other govemental entities such as water management districts,state agencies,or
federal agencies.
OWNER'S AFFIDAVIT: I certify that all the foreg formation I 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.
1,U i
Signature of Owner or Kgent) / (Signature of Contractor)
igne and sworn to(or affir ed)before this y of Signed and ZR
before me this day of
�9 by ,vJ_ e .r
tgrfatur nature of Notary)
TONI GINDLESPERGER
= [
]Personally
]Personally Known OR : ■, MY COMMISSION iiFF924951
[ ]Produced Identification y'•, EXPIRES:October 6,2019 [ ]produced' Bonded Thru Notary Public Underwriters
Type of Identification: A,,, Type of Iden
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
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. CONTACT THE BUILDING DEPARTMENT(904-
247-5826 OR BUILDING-DEPT@COAB.US ) 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 ANOWNER-BUILDERPERMIT..
Job Address: S s Y S eM%'J 0/C I?d, Zg4,r4, �1%G �Jc�• .-'G ,3w3
l 7
Owner Name: J� : b<f�r, S �d, S32 e Cf __J
J�/ Phone Number:G(��{� O s�� z( y7
Mailing Address:�� 07 SG/VI/M✓JIC 1?J City: f T��yT✓G Z/ J).State: �L Zip: � 3
Notarized Signature of Owner
The fa oing instrument was acknowledged before me this2EIday o 120 the State of Florida, County
of
Signature of Notary Public
]-Personally Known OR [ ] Produced Identification
Type of Identification:
�+.�
TONI GINDLESPERGER Updated 10/24118
MY COMMISSION#FF 924951
EXPIRES:October 6,2019
°Q
Bonded Thv Notary Public Underwriters
AGREEMENT TO ACCEPT TRANSFER
Gv�' OF UNCOMPLETED BUILDING PERMIT
This agreement and a new Permit Application are required
to transfer an uncompleted building permit.
I S e Y-. , Phone VW LI- ,
Address1 a 0 7 �Se..��,�Ule /?a� /1 3a�
Email 'f C --''' 7t ,
State Certification/Registration # , understand that Building
Permit 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) (� /
T v�G �Y CA
State of Florida
County of Duval
The foregoing instrument was ac nowledged before me this day of 7-0
by who person Ily appeared before me
and acknowledged that he/she/they signed the instrument voluntarily for h purp a ekpre ed in i
930
ESPERGER Signature of Notary PubPersonally Known OR ON#FF924951ctober 6,2019Produced IdentificationPObcUndewntere
Type of Identification: