571 Selva Lakes Cir RERF20-0003 Shingle PRIVATE PROVIDER INSPECTIONS PERMIT NUMBER
PERMIT RERF20-0003
\-11 ISSUED: 1/13/2020
7 CITY OF ATLANTIC BEACH EXPIRES: 7/11/2020
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: PERMIT TYPE: DESCRIPTION: VALUE OF WORK:
PRIVATE PROVIDER
571 SELVA LAKES OR INSPECTIONS ADDITION SHINGLE ROOF $27000.00
COMMERCIAL
TYPE OF REAL ESTATE ZONING: BUILDING USE SUBDIVISION:
CONSTRUCTION: NUMBER: GROUP:
172027 5528 SELVA LAKES UNIT 02
COMPANY: ADDRESS: CITY: STATE: ZIP:
A.J. WELLS ROOFING 5432 WELLER PL JACKSONVILLE FL 32211
OWNER: ADDRESS: CITY: STATE: ZIP:
BLACKBURN LESLIE 571 SELVA LAKES CIR ATLANTIC BEACH FL 32233
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.
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
BUILDING PERMIT 455-0000-322-1000 0 $104.50
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $108.50
Issued Date. 1/13/2020 1 of 2
PRIVATE PROVIDER INSPECTIONSPERMIT NUMBER
AF/fp,,,,,
'\ PERMITRERF20-0003
s,
" ISSUED: 1/13/2020
`4,.2V CITY OF ATLANTIC BEACH EXPIRES: 7/11/2020
Issued Date: 1/13/2020 2 of 2
=Yf'-'"/.,= Building Permit Application Updated l0/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
\art pr IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 5-11 ( ceit/6Li •eee (antic 8th Fl 32233 Permit Number: RE RI= Zo- 3o c 3
Legal Description 1-4%`I ( 1-7-3s- aim Sel u La-P--es moi-1- L0-1-- (o(,. RE# /1])..4a 7-52 4'
Valuation of Work(Replacement Cost)$a7, 'OO •DO Heated/Cooled SF ISSS Non-Heated/Cooled HI 7
• Class of Work: DNew DAddition ❑Alteration ❑Repair DMove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): DCommercial ❑Residential
• If an existing structure,is a fire sprinkler system installed?: DYes ❑No
• Will tree(s) be removed in association with pro osed project? ❑Yes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed:'3.erso V An A rep(G4Ce O 1.4.&f-- 5 L i nsp.e cooc
Florida Product Approval t' l•e- F1-40(6,1 4: I /Linalerl(� 1 riAs-ofor multiple products use product approval form
Property Owner Information (( -
Name ( l IQ— tgt iLx.rn S Address 7( SQ, ixi Lakes 6 r
City (}4-(Cc.rv{-ICr .2.4t.a. State R Zip 3 123 3 Phone 10L f -99'-1 H'1 l
E-Mail Le511l0 yea,60 •GOM
Owner or Agent(If Agent, ower of Attorney or Agency Letter Required)
Contractor Information
Name of Company 1'I Loutsje.e.i.r,s e �Si-r 0 nQualifying Agent -}v(-('uyi � SAddress SIoS( Co I Jnri3--tie CitylA% State n Zip 322-1 t
Office Phone gall- Sc?-00( "c Job Site Contact Number 630 Li-44-(0-0(x140
State Certification/Registration#CCC 132.leg 7 I E-Mail I i rr-.dp a jc�e.4(scc/ • CO P•—•
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer 'Rrf45e4 e.Id OR Exempt 0 Expiration Date 0. '31 '.zOpo
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,and AIR CONDITIONERS,etc. 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.
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.
(Signature of Owner or Agent) (Signature of Contractor)
S' °ed and sworn to(or affirmed)before me this"day o�lfrlSigne and sworn to(or affirmed)before me this T. day of
V a-r , 2-0 2v ,by A 4' tit.✓ Gu S ja.-1 , 21)20 , by 4. 11---- . =
o r' Notary Public State of Florida ► Notary Public State of Ronda
+P fir* Kimberly Wilds $ Kimberly Wilds
� �7 My Commission GG 938971 < My Commission GG 938971
[ Personally Known OR y'' oc„dr Expires 04/28/2021 Personally Known OR \a r. Expires 04/28/2021
[ 1 Produced Identification [ ]Produced Identification
Type of Identification: Type of Identification:
Doc # 2020007481, OR BK 19065 Page 1351 , Number Pages: 1,
Recorded 01/10/2020 01 :26 PM, RONNIE FUSSELL CLERK CIRCUIT COURT DUVAL COUNTY
RECORDING $10. 00
NOTICE OF COMMENCEMENT
(PREPARE IN DUPLICATE)
Permit No. Tax Folio No.
State of FloridaCounty of- DUVAL .-.
To whom It may concern:
The undersigned hereby informs you that Improvements will be.made to certain real property,and In
accordance with Section 713 of the Florida Statutes,the following information Is stated In this NOTICE OF
COMMENCEMENT. �1 �1 ✓ c o
Legal description of'property being improved: 1-17 I k 11-o+s-aq G 1 -1%fa--
L Le 4— cp L
Address of property being improved J7/ Ike Z5` n714-0-0-1<-
3 7.233
7c..37733
General description of improvements: ROOF REPLACEMENT
Owner Lccr4j` � A G ry 1
Address 5 !1 i�EZ.r4• L. ciat e1 4 !`
Owners interestin.siteofthe improvement.PRIMARY RESIDENCE
Fee Simple Titleholder(if other than owner)
Name
Address
Contractor A.J.WELLS ROOFING AND CONSTRUCTION
Address 5651 COLCORD AVE JACKSONVILLE,FL 32211
Phone No.904-553-0069 I Fax No. 904-551.4283
Surety(if any)
Address Amount.of bond$
Phone No. Fax No.
Name and address of any person making a loan for the construction of the improvements.
Name
Address •
Phone No. Fax No.
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other
documents may be served:
Name
Address
Phone No. Fax No.
In addition to himself,owner designates the following person to receive a copy of the Lienor's Notice as provided in
Section 713.06(2)(b),Florida Statutes.(Fill In at Owner's option).
Name
Address
•
Phone No. Fax No.
Expiration date of Notice of Commencement(the expiration date is one.(1)year from the date of recording unless a
different date Is specified): $ o
gg cs
THIS SPACE FOR RECORDER'S USE ONLY 0 NER
• /' - /�� ,• E .f /7/f"
Before me this ,day o I: . '1 In the
CountyDuv 1 .t too I Ida,h ersonaily appeared 'g
��QsC , .Y 18
herein by ggra
himself/herself and affirms that all statements and declarations herein Z Y
are true and accurate
a2t6Z:=2)
Note -ublic et •ge,Si:-of FLORI County of ow._1! '
My •mmisslon expires:'-rut
Personally Known � ped or-
Produced Identification �/
&Materials
LEGACY Geotechnical
&Testing
ENGINEERING, INC Calibration&Product Testing
6424 Beach Boulevard Phone 904-721-1100 •
Jacksonville, FL 32216 Dispatch 904-735-1100
E:dpotter®Iegacyengineeringlnc.com Cell 904-322-4797
PRIVATE PROVIDER CONTACT INFORMATION CONTRACTOR CONTACT INFORMATION
Services to be provided: ��w l�� ' ' 1 at S
❑Plan Review Primary Contact:
❑Inspections(Foundation/Slab) 0 Inspections(Above Slab)
Position: OW MX--
❑Inspections(Mechanical) 0 Inspections(Electrical) Q
❑Inspections(Plumbing) Inspections(Complete Permit) Phone#: - I v'-4440-0(0 I 650
NOTE: Private Provider to perform al jaa ections in the category selected.D ��3 _Dvr�Q
Name of Firm:
a � t n eerl i'-'ne._
-'econdary Cont f7�' V Il
Primary Contact: V l b 0 "`Q- --
Phone#:_ "
Position: C /e-fV�Av��A -e
► t{'--104 - l 1 DO ,hone#: -V(-44.-re (). I I(I$
OWNER&PROJECT INFORMATION
Permit Number:� Residential 0 Commercial
Address:`( / S '/✓a LeA '
Property Owner: (,eS It e QrkGA ' C/►omt�ur r\ f t dividuuaallu 0 Corporation 0 Partnership
Primary Contact: It t1 Phone#: -)O� 77 7" f/o 4-7 (
I have elected to use one or more private providers to provide building code plans review and/or inspection services on the
building that is the subject of the enclosed permit application,as authorized by s.553.791,Florida Statutes. I understand that the
local building official may not review the plans submitted or perform the required building inspections to determine compliance
with the applicable codes,except to the extent specified in said law. Instead, plans review and/or required building inspections
will be performed by licensed or certified personnel identified in the application. The law requires minimum insurance
requirements for such personnel, but I understand that I may require more insurance to protect my interests. By executing this
form, I acknowledge that I have made inquiry regarding the competence of the licensed or certified personnel and the level of
their insurance and am satisfied that my interests are adequately protected. I agree to indemnify,defend,and hold harmless the
local government,the local building official,and their building code enforcement personnel from any and all claims arising from
my use of these licensed or certified personnel to perform building code inspection services with respect to the building that is
the subject of the enclosed permit application.
I understand the Building Official retains authority to review plans, make required inspections,and enforce the applicable codes
within his or her charge pursuant to the standards established by s.553.791,Florida Statutes.If I make any changes to the listed
private providers or the services to be provided by those private providers,I shall,within 1 business day after any change,update
this notice to reflect such changes. The building plans review and/or inspection services provided by the private provider is
limited to building code compliance and does not include review for fire code, land use,environmental or other codes.
NOTARY AS TO 0 ,..---r
I attest this inform. '= and accurate to the best of my Knowledge. Before me this -dayof J ah //a''1 ,20 2.0
Personally appeared1C1141-4/114.r
/ s r W^^
Property Owner Signature 0 Owner Authorized Agent Who executed the foregoing instrument,and acknowledged before
me the same was executed for the purposes therein expressed.
444li,� /e 61/1 f Type of ID produced: / /.. O . [11
Print Name r ) Notary(Si_..5i �'� / •' /
Printed Name: - l rvrb w i /d s
/g�zp zp . -It
My Commission Ex.ires:
Date
+t Notary Public State of Florida
Kimberly Wilds
My Commission GG 938971
SA;-10/ Expires 04/28/2021