364 2nd st elec 2013 ilz CITY OF ATLANTIC BEACH
j 800 SEMINOLE ROAD
-� ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
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Application Number . . . . . 13-00003334 Date 8/29/13
Property Address . . . . . . 364 2ND ST
Application type description ELECTRIC ONLY
Property Zoning . . . . . . . RES SF DISTRICT
Application valuation . . . . 0
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Application desc
22 amps
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Owner Contractor
PHILLIPS PHYLLIS S OWNER
364 2ND ST
ATLANTIC BEACH FL 322335230
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Permit . . . . . . ELECTRICAL PERMIT
Additional desc . .
Permit Fee . . . . 57 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 2/25/14
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Other Fees . . . . . . . . . STATE ELEC DCA SURCHARGE 2 . 00
STATE ELEC DBPR SURCHARGE 2 . 00
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Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 57 . 00 57 . 00 . 00 . 00
Plan Check Total . 00 . 00 . 00 . 00
Other Fee Total 4 . 00 4 . 00 . 00 . 00
Grand Total 61 . 00 61 . 00 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
CITY OF ATLANTIC BEACH
f - OWNER / BUILDER AFFIDAVIT
1. 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.
111. 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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826) IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
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ADDRESS PHONE NUMBER
SSI' f� ll � S
P T AME
S z9 13
G TURE DATE
Before me this day of 20 in the county of
Duval,State of Florida,has personally appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of County of
Personally Known
Produced Identification- u y L G
RAHAM
1 +; 11 LIC
•r. `+`' 0MMISSION#DD 957760
Q• FBbruary 14,2014
Notary Signatu •.pF F, yarded Thru Notary Public Underwriters
F:BLDG/Owne Builder Affidavit;REVISED: 4/16/2009
ELECTRICAL PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd,Atlantic Beach, FL 32233
// Ph(904) 247-5826 Fax (904) 247-5845
JOB ADDRESS: 4 01 S- PERMIT#
JEA INFORMATION REQUIRED ON ALL PERMITS AMPS VOLTS PHASE
VALUE OF WORK$
NEW SERVICE ❑ Overhead ❑ Underground ❑T Underground up Pole
❑Residential(Main) Service
❑0-100 amps ❑101-150amps ❑151-200amps ❑ amps #of Meters
❑Commercial(Main) Service
00-100 amps ❑101-150amps ❑151-200amps []-amps OCT Service amps
Conductor Type Size
❑Multi-Family(Main)Service
❑0-100 amps ❑101-150amps ❑151-200amps ❑ amps # of Unit Meters
El Temporary Pole ❑ amps
SERVICE UPGRADE ❑ amps ❑ CT Service amps
NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES,ETC.)
❑100 amps ❑150amps ❑200amps ❑ amps OCT Service amps
ADDITIONS,REMODELS,REPAIRS,BUILD-OUTS,ACCESSORY STRUCTURES,ETC.
Outlets/Switches: amps 31-100amps 101-200amps
Appliances: "amps
31-100amps 101-200amps
A/C Circuits: 0-60amps 61-100amps
Heat Circuits: # circuits @ kw
Number of Lighting Outlets, Including Fixtures:
OTHER ELECTRICAL PROJECTS
❑Swimming Pool ❑ Sign ❑Smoke Detectors_Qty []Transformers KVA ❑Motors hp
FIRE ALARM SYSTEM (Requires 3 sets of plans)
Qty volts/amps VALUE OF WORK$
REPAIRS/MISCELLANEOUS
❑Replace Burnt/Damaged Meter Can ❑Safety Inspection ❑Panel Change 0O to UG
❑Other: Cd 4 &G L
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. /
Property Owners Name s '" - r" • s Phone Number
Electrical Company Q (off Office Phone Fax
Co.Address: City State Zip
License Holder(Print): State Certification/Registration#
Notarized Signature o
SHIRLEY L 2
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