0 STANLEY ROAD - FILL FOR DITCH Building Permit Application Updated 12/8/17
V City of Atlantic Beach
;,- 800 Seminole Road,Atlantic Beach,FL 32233
Phone:(904)/ 247-5826/Fax:(904) 47-5845
1
Job Address: 0 S /4-Ni L C lA
,k . .,4r V!I . Permit Number:
Legal Description 'F 17•'.25 -2 c t v ii bb NN1/QS S/n pi 1.U / 2 RE# ! -72 /33 -006 0
Valuation of Work(Replacement Cost) $ Heated/Cooled SF Non-Heated/Cooled
• 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 a 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:
Fitt— 11\1 Dl %cH AS _5H-awr.) jt) SU/2VE'-f Foe /7.2i33 "On
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name: V 1 C (2. _P
, 0t _Peg 3 u Address: 3 c7 19 .7o '1A YE ,
City G 4 Eici 761 State /—L zip_"3 4 2 2 2 Phone 70 6 ~- 6_3 I -.550 4--•i
E-Mail V 1..aer b to c/ Ci h a p • C t r1„--L
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company: Qualifying Agent:
Address City Sta : Zip
Office Phone Job Site/Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone
Workers Compensatio
Exempt/Insurer/Lease Employees/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 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 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 N(.440,_ OF COMMENCEMENT.
ot,,, .-._ 5/zJ/2b
(Sig.:ture of Owner or Agent) (Signature of Contractor)
(including contractor)
Signed and sworn to(or affirm•d)be ore me this day of Signed and sworn to(or affirmed)before .'- • . .. .
) - •
(Sid . otary. `5PL ,l. ate 01 Flo ricia
/ (Signature of Notary)
4,'''' _ °® N.[ ]Personally Known OR = ..:ii,. • C� ssio� GG 172481
roduced Identification ' X10 comm.expires Jan.21.2022 [ ]Personally Known OR
[ [ ]Produced Identification
Type of Identification: i„r,�iiel/� Type of Identification:
Sr lril-.,
%r
CITY OF ATLANTIC BEACH
OWNER / BUILDER AFFIDAVIT
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. 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.
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ADD ESS PHONE NUMBER
1C--/-vr bor6ui
PRINT NAME jigifeM
„.41.11'41~4 1 5——/2 c 7.I/2 0
SIGNATURE F' DATE
i ,
Before me thi ,/ day of/ u. 2(in the county of
Duval,State• lorida,has pe . at a•peared herin by himself/herself and affirms that
all statements and declarations are true=nd accurate /A
Notary Public at Large,State of g"ILO! of /1/1/-7(4 W to p
❑P ovally Known
ted Identification- PAMELA J.SHUMATE
N`,. �'"4,402:#P
-l` Notary Public.State of Florida
,+�.
Commission#GG 172481
a 1 i int+:-�,
Notary Signature: r�,,I w. -41111111.... ._ My comm.expires Jan.21,2022
F:/BLDG/Owner-Builder Affadavit;Rli VISED: 4/16/2009
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MAP SHOWING SURVEY OF
THE NORTHEAST 1/4 OF THE SOUTH ;./2 OF THE WEST 1/2, TOG:':i:ER WITH THE SV!'it:w`S:
1/4 OF Till' SOUTH 1/2 Of THE WEST 1/2 or LOT 13, DoNNER'S RERLAT AS RECORDED
IN FLA: Dm( 19, ',AGE 15 OF THE OURRENT PJBLIC i
RsClf OF DUVAL CUUNM
FLORIDA. (/ /
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LOCATIONN-
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GRASSED 0
CITY ROWd g
'No s.R.L s I72/33-Q000 am t?
I UEPEB'L CIIRTIZY THAT THE I'I1OPLRIY St:O4N HERSON IS IN FLOOD ZONB 'C' A.,
SHOWN Ort THE MOOD tIAEARD BOUNCAPY MAP von THE CITY or A>'L'HT.0 UACH, t:.OPIDA_
I HEREBY CBRTIFY TO TOMMY LYLES THAT I HAVE SURVEYED THE LANDS AS SHOWN
IN THE ABOVE C1►PTICN AND ':IIAT THIS MTP IS A TRUE ANO :OPREC: RE2RESENTATION
St THAT SURVEY AND THAT THE SJRVEY REPRESENTED HEREON MEETS THE MI"t t!uM
STAZJCARD REQUIREMENTS ADOPTED BY THE 'FLOEIDt STATE BOARD OF PROFESSIONAL
LAND SURVEYORS CHAPTER 21-148 AND THE FL:RIDA LAND TITLE ASSOCIATION.
\b‘s......L\s")R...)st.4i ....
DONN W. BOATWRIGKT, LS.
FLORIDA REQ.LAND SURVEYOR No. 3295
SCAR:' _3 - ABO7WRiG� Ll
17.1.� R,S::RVCYOfiB. ttJlrsN/��a. � tii4 ,I�iP
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DRAWN BY:'6�- 1301 PENMAN ROAD SUITE D SHEET_.!- OF____.
F.R. #: t' ` JACKSONVILLE BEACH. FLORIDA 241-8560