176 Pine St PLRS20-0116 Plumbing RemodelOWNER:ADDRESS:CITY:STATE:ZIP:
COMMANDER RONALD E 240 INLAND RIDGE WY ATLANTA GA 30342
COMPANY:ADDRESS:CITY:STATE:ZIP:
TYPE OF
CONSTRUCTION:
REAL ESTATE
NUMBER:ZONING:BUILDING USE
GROUP:SUBDIVISION:
170628 0010 SALTAIR SEC 03
JOB ADDRESS:PERMIT TYPE:DESCRIPTION: VALUE OF WORK:
176 PINE ST PLUMBING RESIDENTIAL PLUMBING REMODEL - 3
FIXTURES $500.00
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
PLUMBING BASE FEE 455-0000-322-1000 0 $55.00
PLUMBING FIXTURES 455-0000-322-1000 3 $21.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $80.00
LIST OF CONDITIONS
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
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.
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.
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.
1 of 1Issued Date: 8/14/2020
PERMIT NUMBER
PLRS20-0116
ISSUED: 8/14/2020
EXPIRES: 2/10/2021
PLUMBING RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
DESCRIPTION ACCOUNT QTY PAID
PermitTRAK $80.00
PLRS20-0116 Address: 176 PINE ST APN: 170628 0010 $80.00
PLUMBING $76.00
PLUMBING BASE FEE 455-0000-322-1000 0 $55.00
PLUMBING FIXTURES 455-0000-322-1000 3 $21.00
STATE SURCHARGES $4.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL FEES PAID BY RECEIPT: R12781 $80.00
Printed: Friday, August 14, 2020 8:20 AM
Date Paid: Friday, August 14, 2020
Paid By: COMMANDER RONALD E
Pay Method: CREDIT CARD 353177830
1 of 1
Cashier: CG
Cash Register Receipt
City of Atlantic Beach
Receipt Number
R12781
Plumbing Permit Application
City of Atlantic Beach Building Department
800 Seminole Rd, Atlantic Beach, FL32233
Phone: (904) 247 -5826 Email: Building-LepL@ccab"us
*{.ALL INFORMATION
HIGHLIGHTED IN
GBAYIS RESUIRED,
PERMIT #:
PROJECT VALUE S!9O.AOJOB ADDRESS:176 Pine Street
Ehew oR REpTAcEMENT INSTALLATIoN and/or fhe-ptpr
TYPE OF FIXTURE
Bathtub
Clothes Washer
Dishwasher
Drinking Fountain
Floor Drain
Floor Sink
Hose Bibs
Kitchen Sink
Laundry Tray
Lavatory
Other Fixtures
QTY QW
ffursceu-nNEous
ESewer Replacement
flBack Flow Preventer
E Lawn Sprinkler System (number of sprinkler heads)
f]Grease lnterceptor (Trap) gallons (Requires 3 sets of plans)
!Wett **slRWDWetlCompletionForm.CompletedformtobesubmittedtotheBuildingDepartmentforfinalinspection.**
flother
TYPE OF FIXTURE
Septic Tank & Pit
Shower
Shower Pan
Slop Sink
Three Compartment Sink
Toilet
Urinal
Vacuum Breakers
Water Con nected Appliances
Water Heater
Water Treating System
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: Ronald'Cornmander Phone Number: i404).488-2068
Plumbing Company:Owner Performed Work Office Phone:
Co. Address:City:State: _Zip:
License Holder:
<lrr-)Al€?r* j
N ota rize d Sig n otu re olJ-,l
H:jil:?","rffillH:i*cknowredgeatero,e
me this {il{^, "r ftwry *203;}1the state of Frorida,
Cynthia Young
irlotary Pubtic Si ure of Notary Public
Personally Known OR
State Certification/Registration #
:, \\; State of Florida
?o",*Xu My Commission Expires 10i05120[0 ldentification
Updated 10/17/18
Commission No,36480 of ldentification:
PLRS20-0116
Owner Builder Affidavit JUli
City of Atlantic Beach Building Depaftment
800 Serninole Rd, Atlantic Beach, FL 32233
Phone : {904) 247 -58?:6 Email: Bu i I d i n$-Dept @ soa b. Us PERMTT#: [ZESWl'oot O
CONTRACTING" REQUIRESFLORTOA SIATIITES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTBUCTION
OWNER / BUILDERTO ACKNOWLEDGE THE LAW:
INJURY LtABtuTy; S|NCE OWNERS MAy BE LTABLE Foft |NJUR|ES TO WORKEftSTHEY HIRE, THE BUILDING DEPARTMTNT
SUCGESTS WORKER'S CCIMPENSATION INSURAI{CE BE PURCHASED. .
tRs wtTHHoLDrf*s; owNERs HtRtNG WORKERS BECOME EMPLOYERS AND SHSUU) ALSO OBSERVE IRS WITHHOLDING
iex arvOlOC ronrr,i 1099 REqUIREMENTS oN THE woRKERs THEY EMPL0Y ON THEIR IMPR0VEMENT TRADES.
FENALTy; UNLICENSED CONTRACTOBS CANNOT BE EMPLOYED UNDER ANY CIRCUMSTANCES. OV\tNEflS BIING SUBJESI
ro $s,ooir PENALTY UNDER FLORTDA STATUTE NO.455-228t1). AN "OCCUPATIONAL IICENSE" lS NOT ADEQUATE. THE
owluin sHoULD PHYSICALLY sEE THE coUNTY "CERTIFICATE oF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE'TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT (5O4-
24?-5S26OR BUILpISS-qglr@e8AB.lJ-5 ) lF lN DOUBT
AC;ffiOW1EIIfiEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I
COMPLYWITH ALLTHE REQUIfrEMENTS FOHTHE ISSUANCE OF AN OWNER.BUILDER PEAMIT.3*
**AI[ItiSoaMATIOhl
tItGHUErmOl$ .
cmYl$.*E{tslRES.
ll.
il|.
lv.
3lob Address:
Owner Name:
'tt*N
*l-,*"f Phone Number:4a{ {*S I z*&l
MairineAddress: tS{ &i*.: .i*,* Wtr state:;.,*t,r, ,zip:,,3,4#,,.7';
tztotarl*d Slgnature at Awner
i nstrument was acknowledged before me this 2f arvof ]Jg*-* ,1CI$,in the State of Florida, County
signatureofNotarypublic ab,llrlqt %*^ -**lt"v
I J Personally Known O* K Produced ldentification
Type of ldentificatio n, k^,fgiu \- - -
STATE LAW REQIJIRES CONSTRUCTICIN TO BE DONE BY LICENSED CONTRA TORS. YOU HAVE APPLIED
FOR A PERMIT UNDER AN EXEMPTION TO THAT LAW. THE EXEMPTICIN ALLOWS YOU, A5 THE OWNER
OF YOUR PROPEfrfi, TO ACT AS YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A
LICENSE.
YOIIMUS,T SUPEBUISE THI CONSTRUqfig[ll YOURSELt._ - _-
RESIOETCT ORA FAHM OUTBUILDING. YOU MAY
ALSO BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF $25,OOO.OO OR LESS.
riil nulr.grme nn$sr sr ron vouB us,r SNp =q$$gP,tl't-.S, [ {vtAY Nor BE BUILr FoR SALE oR LEASE.
YOURSET WffHIN ONEYEAR AFTERTHE
CONSTBUCTION IS COMPLTTE, THE LAW WILL PRESUME THAT YOU BUILT IT FOR SALE OR LEAsE, WHICH
15 IN VIOLATION OF THIS EXEMPTION.
fpu rurav rtrgr nlFr Ar-r unucrusrp penson nsvpys.gg$s4srgE YgyR coNsrRucrloN MUsr
ffitofne BUILDING CoDEs AND zoNlNG REGULATIoNS.
tr ts YouR FE$PoNSlHurr ro n4AKE 5UHE THAT PEOptE EMPIOJHPSI]rSU HAlrgUCE{rlSEs
ffi CHERYI JEAN 8AR8ER
Notary Public - State olFlorida
Commission # G6 12f,679
My Comm. Expires Jul 26,2021
Bmded thrcugh Nali@ri l,lottry As!fl .
udated $/24/18
PLRS20-0116 & ERES20-0185