377 PLAZA - ERES19-0316 .mss' �'' ELECTRICAL RESIDENTIAL PERMIT PERMIT NUMBER
4', f— "�9"a.C'j
r ,, CITY OF ATLANTIC BEACH ERES19-0316sA 800 SEMINOLE ROAD ISSUED: 10/24/2019
1-011I!)a ATLANTIC BEACH. FL 32233 EXPIRES:4/21/2020
MUST CALL INSPECTION'°PHONE LINE (904).247-5814 BY 4.PM FOR NEXT DAY INSPECTION'.
:ALL WORK MUST CONFORM TO'THE CURRENT 6TH EDITION (2017) OF THE'FLORIDA BUILDING
CODE,NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES . .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
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.
JOB ADDRESS a : ' PERMIT. TYPE: DESCRIPTION. `, VALUE OF WORK:
377 PLAZA ELECTRICAL RESIDENTIAL ELECTRIC-JAW $300.00
REPLACEMENT
TYPE OF `REAL ESTATE BUILDING USE• -
ZONING.: SUBDIVISION:
CONSTRU CTION , ° NUMBER: 'GROUP:.
170017 0000 ATLANTIC BEACH
.:y . COM PANY.,°a.°a. ADDRESS • ° 'CITY: STATE.: • ZIP:
•
OWNER ADDRESS : CITY: •STATE: ZIP:
LISA BRUNO REVOCABLE
TRUST 377 PLAZA ATLANTIC BEACH FL 32233-5441
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT
IN YOUR 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.
LIST OF CONDITIONS ,
Roll off container company must be on City approved list. Container cannot be placed on City right-of-way.
° .
-
FEES .
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
ELEC REPAIRS AND MISC 455-0000-322-1000 0 $35.00
ELECTRICAL BASE FEE 455-0000-322-1000 0 $55.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL:$94.00
Issued Date: 10/24/2019 1 of 2
, 1 Electrical Permit Application 1 **ALL INFORMATION
" HIGHLIGHTED IN
s •.... ) City of Atlantic Beach Building Department GRAY IS REQUIRED.
'' 800 Seminole Rd, Atlantic Beach, FL 32233 ER ( - 031(c
Y'`;' Phone: (904) 247-5826 Email: Building-Dept@.coab.us PERMIT#:
JOB ADDRESS:13 Th P lillZR If-flan-tic `I3(OCk ` PROJECT VALUE$r 300_.
3_ z33
JEA INFORMATION REQUIRED ON ALL PERMITS:1J5O 'AMPS c ?$VOLTS( / i PHASE
❑ NEW SERVICE: ❑ Overhead ❑Underground Underground up Pole
❑Residential (Main)Service:
❑0-100 amps o101-150amps o151-200amps ❑ amps ##of Meters
❑Commercial (Main)Service:
❑0-100 amps . o101-150amps . o151-200amps o amps oCT Service "amps .
Conductor Type Size
oMulti-Family(Main)Service:
❑0-100:amps' o'101-150amps o151-200amps o amps #of Unit Meters.
n TEMPORARY POLE: amps
❑ SERVICE UPGRADE: o amps oCT Service amps
❑ NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES, ETC.):
❑100 amps ❑150amps o200amps o amps oCT Service amps
❑ ADDITIONS, REMODELS, REPAIRS, BUILD-OUTS,ACCESSORY STRUCTURES, ETC:
Outlets/Switches: 0-30amps 31-100amps 101-200amps
Appliances: 0-30amps 31-100amps 101-200amps
A/C Circuits: 0-60amps 61-100amps
Heat Circuits: #circuits @ kw
Number of Lighting Outlets, Including Fixtures:
❑ OTHER ELECTRICAL PROJECTS:
oSwimming Pool oSign oSmoke Detectors (Qty) oTransformers KVA oMotors HP
n FIRE ALARM SYSTEM (Requires 3 sets of plans):
Qty volts/amps
Vn REPAIRS/MISCELLANEOUS:
oReplace B rnt/Damaged Meter Can ❑Safety Inspection_ oPanel Change DOH to UG
tither:
.7�AWW/• ieiD lacem&r Updated 10/17/18
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have
read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether
specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of
construction.
Owner Name:r l -1 5 R BR-
R U Nom_____ _.-i Phone Number:1.._goq -g.2)----S514:5-
g.2Z_S5ys
Electrical Company:p Y: rvilorry v(,r_e QC."]"Y•1C. 'rN0.-._._jOffice Phone:1.m 9O . qhs' tqo 4,---i Fax:
' I
Co.Address:F PI sEc)-4 aLIo2Q_) _ _____ . ___._-- _ _ _ ._- ---- City:( stleksonVlIR - istate:l Zip:r?22`t l ;
License Holder:1 (�7( 1 State Certification/Registration#:I
4_
Notarized Signature of License Holder6 _` l
The foregoing instrument was acknowledged before me this, day .0 ;0 in th State of Florida,County of i a.--
:nature of Notary Publi e , .-
.......... ,; TONI GINDLESPERGER '
+; :*; MYCOMMISSION#GG 353178 ] Personally Known OR[ ] Produced Identification
e" ...;.`= EXPIRES:October 6,2023 I. pe of Identification: 13(nSo SC)-• - I — G7 1 — O
... ..
a .•• Bonded Thru Notary Public Underwriters
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department 1 GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.usPERMIT#:CgeS(9 -0�1
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.00CUPANCY..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$5,000 PENALTY UNDER FLORIDA STATUTE NO.455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE
OWNER SHOULD PHYSICALLY SEE THE COUNTY"CERTIFICATE OF COMPETENCY" OR.THE FLORIDA"CONTRACTORS
CERTIFICATE"TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904-
247-5826 OR BUILDING-DEPT@COAB.US) IF IN DOUBT.
V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I
COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT.
Job Address:{ 3 4- 'PLA--Z-Pr I
Owner Name L 154-1 `3id,V NO Phone Number:I 9q 32 Z 3.' 5
Mailing Address:F-37±— -_l P12.-CI Crty:FA ._---- ge-flel-- State:. �-� Zip:4 322-33
Notarized Signature of Owner' ,0,--L
Thecf .�egoing instqqument was acknowledged before me this Zday e M , 20 1 Jin the State of Florida, County
of [ vc7.____,
41111 A
Signature of Notary P /1 dr
-------------
Pr-Personally Known OR [ ] Produced Identification
Type of Identification: 13 G S 0 -S 2-0 -s i - (o Z f
INDLE$PERG Updated 10/24/18
iltTONTG �.
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MYCOMMISSION#GG 353178EXP�IR"ES:Od�ber6,2023•f' °I. 1 ���yNotarYPubic Uncle:yam