489 AQUATIC DR - FNCE20-0120 Jf--f Building Permit Application Updated 10/9/18
-' / j City of Atlantic Beach Building Department **ALL INFORMATION
J / HIGHLIGHTED IN GRAY
�.-.it"' 800 Seminole Road, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: 4V1 IrActx.,A IL,u--Y- -‘)JtA, ._.;‘- F I 334‘33 Permit Number: 1� Net Z.l_! -0 1 2C
Legal Description '31t.- -11 -AS - Ac1 E AVtx2k it- Ci,., iNN 1-r3{ d.S- RE# 1 7 i F7 ( C`j ) 365 8
Valuation of Work(Replacement Cost)$ ,ASY4, _Q(7 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: 1New Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial L Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) kNo
Describe in detail the type of work to be performed: Pia r, , __D co o�-..L_r\l_L- 'p c-'}.
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name id‘
f0R SL1[\ma Address 311AAnNY'L_ 6-r1
City .. ....1.\.4-+.. Cit sj} State 1 Zip d.lLI, 9, Phone LI- - bbl-tbc).`1ek,
E-Mail Kk\A-� ,X 103v 4 rnsC\ . C./Cr-rc-.
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Qualifying Agent
''' N
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt❑ Expiration Date
Application is hereby made to obtain a permit to do the w rk and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all w k will be performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a separate rmit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR ONDITIONERS,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.
ignature of Owner or Agent) Signature of Contractor)
ned nd sworn to(or affi ed) .efore me thisZ`S- day of Signed and sworn to(or ffirmed)before me this day of
,7ZC: by El ! ere
b
,•`. ..P�''-., TONIGINDLESPE' ER •tur:�.'`�.a II (Signature of Notary)
,= MY COMMISSION#GG 3 k Al.
:-.`•!.4.7,.,t,, := EXPIRES:October 6,2023
'' fflf3eetadtiillrbibiwataisiCiDicUrderwrlters [ ]Personally Known OR
[ ]Produced Identification
Type of Identification: S S. 0`S t I. 'S4-b 90-c) Type of Identification:
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
}t ° City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
r''t,r Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
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 E 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 ISA 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: b°1 ,,,��c. 9�r PSA /NA-�t. (?,� F I 3a-3.�3
Owner Name: )c,kvIsSLNct\�d'{, Phone Number: 4-Do\-
Mailing Address: ' SC.M\ovra.. \.-.cam City: 4\m tx -k State: F Zip: 31.4), 3
Notarized Signature of Owner m i
The kFZNing instru ent was acknowledged be ore me this-7 Slay o 411. ,2l jh the State of Florida, County
of ?VD—
Signature of Notary Public
[ ] Personally Known OR [ ] Produced Identification
Type of Identification: ( .
Updated 10/24/18
TONI GINDLESPERGER
'c= MY COMMISSION#GG 353178
;,,T•P,_ EXPIRES:October 6,2023 ,
"'•*.f.,W Bonded Thru Notary Public Underwriters
L,LHIIYILU I-UM:ROGER & KELLY SCHMIDT
AQUATIC DR.
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ZONE "XS" DENOTES 0.2%ANNUAL
CHANCE FLOOD HAZARD i�
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THE PROPERTY SHOWN HEREON APPEARS TO LIE WITHIN FLOOD HAZARD ZONE XS,AE AS SCALED FROM FLOOD
INSURANCE RATE MAP 408 FOR DUVAL COUNTY, FLORIDA, DATED 11-2-18 . AND
IS SHOWN AS A COURTESY ONLY AND DOES NOT CONSTITUTE A C£RTIFCATION OF SAME.
TRI-STATE LAND SURVEYORS, INC.
5875 MINING TERRACE #209, JACKSONVILLE, FLORIDA 32257 (904) 880-2535
LEGEND BEARINGS BASED ON R/W LINE AS SHOWN.
CM CONC. MON
IP IRON PIPE
RB REBAR THIS SURVEY DOES NOT REFLECT OR DETERMINE OWNERSHIP.
R/W RICHT-OF-WAY NOT VALID WITHOUT THE SIGNATURE AND THE ORIGINAL RAISED SEAL ,
SAY SIDEWALK OF A FLORIDA LICENSED SURVEYOR AND MAPPER.
D/W DRIVEWAY
\l‘
COV. COVERED AREA THIS SURVEY BASED UPON DESCRIPTION AS FURNISHED, AND WITHOUT
cENTERUNE BENEFIT OF A TITLE BINDER/ABSTRACT OF TITLE AND/OR DEED RESEARCH.
A/c AIR CON0I77ONING PAD
(R) RADIAL DISTANCE
CONC. CONCRETE SCALE: 1" = 20' GLENN M. BROADSTREET, P.S.M. NO. 5814
ESM'T EASEMENT
B.R.L. BUILDING RESTTBCRON
E POINT OF CURVE FIELD WORK DATE.5-23-19
PCREGISTERED SURVEYOR AND MAPPER,
PT POINT OF TANGENCY SIGNATURE DATE: 5-24-19 STATE OF FLORIDA (LB #4921)
F.B. 1218 PG. 3 cop 2O19-334 ORDER NO. 2019-334