433 E Sailfish Dr RES20-0040 Rebuild Stairs, Reverse Door .v4„ RESIDENTIAL PERMIT PERMIT NUMBER
rz CITY OF ATLANTIC BEACH RES20-0040
�40 800 SEMINOLE ROAD ISSUED: 3/2/2020
`�t" ATLANTIC BEACH. FL 32233 EXPIRES:8/29/2020
•
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:
433 E SAILFISH DR RESIDENTIAL ALTERATION REBUILD STAIRS AND $250.00
RESIDENTIAL REVERSE DOOR
TYPE OF REAL ESTATE ZONING: BUILDING USE SUBDIVISION:
CONSTRUCTION: NUMBER: GROUP:
171377 0000 ROYAL PALMS UNIT 02A
COMPANY: ADDRESS: CITY: STATE: ZIP:
BEACHES EMERGENCY 1447 MAYPORT RD ATLANTIC BEACH FL 32233
ASSISTANCE MINISTRY
OWNER: ADDRESS: CITY: STATE: ZIP:
PERSICO CYNTHIA K 400 GARDEN LN 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.
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
BUILDING PERMIT 455-0000-322-1000 0 $55.00
BUILDING PLAN CHECK 455-0000-322-1001 0 $27.50
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $86.50
Issued Date:3/2/2020 1 of 2
/5' V1r% RESIDENTIAL PERMIT PERMIT NUMBER
;'%' RES20-0040
CITY OF ATLANTIC BEACH
'
n 800 SEMINOLE ROAD
ISSUED: 3/2/2020
°';'�r ATLANTIC BEACH. FL 32233 EXPIRES: 8/29/2020
i
Issued Date: 3/2/2020 2 of 2
5_JA,yrl, City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assi ned by the Building Department.)
, 800 Seminole Road t" i`� O _,004 C
Atlantic Beach, Florida 32233-5445 1—�-�C– �J
Phone(904)247-5826 • Fax(904)247-5845 / jaJS319>' E-mail: building-dept@coab.us Date routed: Z l Q-
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address:
33 S � De artment review required Yes No
Cti `�'( S h
uilding�
Applicant: � [ i ' anning &Zoning
I -
R
Tree Administrator
Project: e b t ' +'s c D60 2_ Public Works
Public Utilities
Public Safety
Fire Services
Review fee $ Dept 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: i I7Approved. � �Denied. ❑Not applicable
(Circle one.) Comments:
BUILDI -
PLANNING &ZONING
Reviewed by: /'Y Date:c:)la S/ao
TREE ADMIN. Second Review: ❑ Pp A roved as revised. I IDeniied. I INot 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
(r:,-.1'''''k,. Building Permit Application OFFICE COPY Updated10/9/18
r ) City of Atlantic Beach Building Department **ALL INFORMATION
.•: 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
'uni9 IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us /
Job Address: I?) St---t 1 ► ` , t r E 5;;Q,3"-5Permit Number: 'IR --SZ.-0�vC)4C
Legal Description 3( — 1 �`� ? 5 " 4Cl ' oksa.l i e.Im5 al I f -D/A e K a? RE# 111 16 19 — MOO
Valuation of Work(Replacement Cost)$ .-5L).00 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition OifAlteration DRepair ❑Move [Memo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial XResidential
• If an existing structure,is a fire sprinkler system installed?: DYes 'No
• Will tree(s)be removed in association with proposed project?❑Yes(must submit separate Tree Removal Permit) , No
Describe in de ail the type of work to be performed: open -��bm 13Zi}S ICS in-
Florida
ithiiiiId s1�.i rs and I�.lJerse... doc fo
Product Approval# for multiple products use product approval form
* Property Owner Information ��
rtr
Name �R�.� "d. Pani/C 0 Address 624/#4 Laeur
City Uti.it. exidi State FL-. Zip 330S3 Phone 96.4 $(PD Sa isti
E-Mail dyers i' G-tl1. tom,
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
• Contractor Information
hi .Name of Company C _',. `irezr 1 i3vtL-1 MI0-,tQualjfying Agent l '6 i--, I - &I D r&.
Address ISO loth dot- 3 city 3tilsn,:,clk 8u4.1,1 State F L- Zip 32'50
Office PhoneniO4-1.-•a14I 11'13'7 1-1(D Job Site Coptact Number qp‘i —' 5t," 5 41a-
State Certification/Registration# E-Mail e.bbi e D_\.:1 6.-x beam.or 5
Architect Name&Phone# IAA
Engineer's Name&Phone# K(A
CO
Workers Compensation Insurer t� ..,e5ci 0f'e d Ld.0 Int ra
15vrc OR Exempt❑ Expiration Date Is tam 3'O2•O
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 forIft'ECTRYCAL WQRK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS,and AIR CONDITIONERS,etc. NOIft inidditibri to the requirements of this- . q
permit,there may be additional restrictions applicable to this property that may be found in the public records of this courjr,and
there may be additional permits required from other governmental entities such as water management districts,state ageoies,or
federal agencies. z
FEB 1 4 2020 a rn-J z ct
OWNER'S AFFIDAVIT:I certify that all the foregoing information is accurate and that all work will be done in compliance wig aj z O
applicable laws regulating construction and zoning. O. W O 0 C6
•;i.';rr :. r`• -.•�. --t. + ti
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE QF COMMENCEMENT M�• ' 0 v `c
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INgEI a
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE 0 .4 o Z CC a
RECORDING YOUR NOTICE OF COMMENCEMENT. I� 1 a _ rn
`,�i a , � ~ I= I?
a s - 1 0�ld-v;-u 0 1 r ten, ui
C U (Signature of Owner or Agent) (Signature of Contractor) LU P
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W 12 w = C
S'gned and sworn to(or affirmed)before me this 3 day of Signed and sworn to(or affirmed)before me this Ny w p 1
St.. U «) w
I:..a u e q NNQt ryi .�. C
Notary Public State of Florid• ',,ar. Notary- . SW* f Fantlaa
y .�' Barbara Joyce Beaman
•y =° Barbara Joyce Beaman t MY Coauniesion GO 195778
ars My Commisaon GG 195776 [ 1 Personally Knoud Expires Oa/19P2022
[ ovally Known OR
*�a rtii Expires 03!1312022
[v]'Produced Identification (1,eProduced Identi€Ca
Type of Identification: ' //atu/ar ' 'f,SP� Type of Identification: 1.)c/'✓2,-- 2-+e s-c
Chs iiiers OFFICE COPY
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OFFICE COPY
"4 PHILADELPHIA One Bala Plaza, Suite 100
INSURANCE COMPANIES Bala Cynwyd, Pennsylvania 19004
610.617.7900 Fax 610.617.7940
A Memhor of ill,'r4,6 is slariim(it o<h PHLY.com
Philadelphia Indemnity Insurance Company
COMMON POLICY DECLARATIONS
Policy Number: PHPK1987869
Named Insured and Mailing Address: Producer: 5772
Beaches Emergency Assistance Brown & Brown of Florida, Inc - Jacksonv
Ministry, Inc. 10151 DEERWOOD PARK BLVD.
850 6th Ave S Ste 400 BUILDING 100, STE. 100
Jacksonville Beach, FL 32250-4256 JACKSONVILLE, FL 32256
(904)565-1952
Policy Period From: 07/08/2019 To: 07/08/2020 at 12:01 A.M.Standard Time at your mailing
address shown above.
Business Description: Non Profit Organization
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS
POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS
INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
PREMIUM
Commercial Property Coverage Part
Commercial General Liability Coverage Part 3,970.00
Commercial Crime Coverage Part 690.00
Commercial Inland Marine Coverage Part 390.00
Commercial Auto Coverage Part 7,287.00
Businessowners
Workers Compensation
Cyber Security Liability End 68.00
Total $ 12,405.00
Total Includes Federal Terrorism Risk Insurance Act Coverage 25.00
FORM(S)AND ENDORSEMENT(S)MADE A PART OF THIS POLICY AT THE TIME OF ISSUE
Refer To Forms Schedule
'Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations
CPD-PIIC (06/14)
Secretary President and CEO
OFFICE COPY
Associated Industries Insurance Company, Inc.
A Stock Insurance Company
PO Box 310704
Boca Raton,FL 33431-0704
WORKERS COMPENSATION WC 00 00 01 A
AND EMPLOYERS LIABILITY
INSURANCE POLICY INFORMATION PAGE
I. Insured: Policy Number: AWC1130762
Beaches Emergency Assistance Ministry,Inc.
850 6th Ave South
Jacksonville Beach,FL 32250 Federal Tax TD: 592564222
Other workplaces not shown above: Board File Number:
See Extension of Information Page Renewal Of: AWCI 110536
Producer: Entity: Corporation
AmTrust North America,Inc. Interim Adjustment: Annual
c/o Brown&Brown of Florida,Inc.-Jacksonville Ncci Code: 25372
Jacksonville Division SIC Code: 0
10151 Deerwood Park Blvd,Bldg l00,#100
Jacksonville,FL 32256
2. The policy period is from 6/22/2019 to 6/22/2020 12:01 a.m.at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed
here:Florida
B. Employers Liability Insurance:Part Two of the policy applies to work in each stated listed in item 3.A.The limits of our
liability under Part Two are:
Bodily Injury by Accident $ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here:All states except ND,OH,WA,WY
and State(s)Designated in Item 3A.
D. This policy includes these endorsements and schedules:
See attached endorsement schedule.
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All
information required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM 11,329
STATE ASSESSMENT 0
TOTAL ESTIMATED COST 11,329
Minimum Premium 929
Issue Date: 4/25/2019 Countersigned By:
Authorized Representative