90 W 3rd ST ACC21-0003 Building Permit Application Updated 10/9/18
_ City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
Phone: (904) 247-5826 Email: ��
Job Address: 90 (A-35/ Permit Number: ' LLZ-. 00 3
Legal Description !___,t7 / Lo c �� RE# 7D "'DO
do I,
Valuation of Work(Replacement Cost) $ � O Heated/Cooled SF Non-Heated/Cooled /if`
• Class of Work: (BjJew ElAddition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ECommercial $Residential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s) be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Permit) ,dNo
Describe in detail the type of work to be performed: /d )< 1(0 ul C0 b (77-) /•r% S!1 4.j?'h cJ( c+ J' "e6N-It/`\
0,1 AF eOn1C kirk- SCAB
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name 4 rn63 ,,r7A.J To Address /9() ,YR 5 /
City 4TLAJT) eC, eq c: // State FL Zip ,_,-.1c)3 R Phone go y 3C ""cf7 2c
E-Mail A)i✓/)1A, %6.)6.0e'-,erlA (,C r'1
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company /-1c:1 ell of 0'. i t Qualifying Agent
Address City _ State Zip
Office Phone Job Site Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone If
Engineer's Name&Phone It
Workers Compensation Insurer OR Exempt ❑ Expiration Date
Application is hereby made to obtain a permit to do the work and irgtallations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work wilfbe performed to meet the standards of all the laws regulating
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
REC RDING O ,;7_.•TICE OF COMMENCEMENT.
(Signature of Owner or Agent) (Signature of Contractor)
igned and sworn to(or affi before me this dayof Signed and sworn to (or affirmed)•!before me this day of
t G. e / rC\ , by
I _
— gnature o Notary) / (Signature of Notary)
iJ ;s (P�&-, TOldl GINDLESFERGER
[ J Personally Known OR '�;_ MY COMMISSr0 ' ' Cn n OR
r n
( ]Produced Identification '• EXPIRES:f crthFb}Li. .(de ,ification
Type of Identification: F� Ft° Bonded Thru No: a on:
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
eZIN
'ffi% City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
01 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 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. 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: 0 ki 3 A'b 3
Owner Name: -111-4/11 CS M A.'TO..) Phone Number: f o 7d
Mailing Address: SArei C 'ty: State: Zip:
to:
Notarized Signature of Owner
The f re �o))'ng instrument was ac o ledged before me this Co day of _J , 20 d f, in the State of Florida, County
of lbLy4L-
Signature of Notary Public
[ ] Personally Known OR [ ] Produced Identification
Type of Identification: I
--TONT GINDLESPERGER Updated 10/24/18
rott�cCr� c,
Bonded TMY COMMISSION#GG 353178
EXPIRES:hruNotary
Octoberpubli6,2023cUnde�write'�
a
LOT BLOCK Bo AS SHOWN ON MAP OF
AS RECORI)ED IN PLAT BOOK /(5) PAGE . OF THE PUBLIC RECORDS OF ''A - CO. FLA.
FOR: JAMES N. and FRANSISCA F. MANTON
F.B. NO. ;.� — _-.•;- JOB NO. I.�;Z7 L.F. NO. j; `7 tJ'
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