487 Royal Palms Dr DEMO20-0040 Int Demo L`P'r PERMIT NUMBER
� � DEMO PERMIT
y"t',, sf` DEMO20-0040
_, CITY OF ATLANTIC BEACH ISSUED: 12/30/2020
7'-''V-.
y 800 SEMINOLE ROAD
49109 ATLANTIC BEACH. FL 32233 EXPIRES: 6/28/2021
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.
JOTICE: In addition to the requirements of this permit,there may be additional restrictions applicable to this property
hat may be found in the public records of this county, and there may be additional permits required from other
:overnmental entities such as water management districts, state agencies, or federal agencies.
JOB ADDRESS: PERMIT TYPE: DESCRIPTION: VALUE OF WORK:
487 ROYAL PALMS DR DEMO INTERIOR ONLY INTERIOR DEMO $1000.00
TYPE OF REAL ESTATE „” `` BUILDING USE
ZONING: SUBDIVISION:
CONSTRUCTION: NUMBER: GROUP:
171484 0000 ROYAL PALMS UNIT
02A3.00
COMPANY: ADDRESS: CITY: STATE: ZIP:
OWNER: ADDRESS: CITY: STATE: ZIP:
JACOBS TERRY STUART 487 ROYAL PALMS DR ATLANTIC BEACH FL 32233-3925
YARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT II\
'OUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT
AUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU
NTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
tECORDING YOUR NOTICE OF COMMENCEMENT.
LIST OF CONDITIONS
toll off container company must be on City approved list . Container cannot be placed on City right-of-way.
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
DEMOLITION 455-0000-322-1000 0 $100.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL:$104.00
Issued Date:12/30/2020 1 of 1
rr fr Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
' 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept >coah.us n oo4O
Address: S �ot3&! pa ms Or- Permit Number: . Em32O - oo4O
Legal Description ,3 t It I 2S - 241 E cup .i -c "� tie # I . I Lt U`(-o do
Lo } 11�
Valuation of Work(Replacement Cost)$' 1000 Heated/Cooled SF Non Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move %Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial 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) ❑No
Describe in detail the type of work to be performed:
e 61.0- ATO-Oh 0—AA- dci wvI U)
Florida Product Approval# for multiple products use product approval form
Property Owner Information nn �i JCLCObS Gs-40-4-c-
Name
c'
Name 'o 1L Sit'ax\o P e 'CV y T eVYjAddress L( 8 I- e O L &-1 PcA ms ,D r
City at-taitetk•iC 'SR et.C...h State Zip 32"2-32 Phone 203 2 -q-Lf (Q3�--
E-Mail f:t. lpO.).10 1 ZZ 1 M gritc.'4:Q • C OW)
Owner or Agent(If Agen , Power of Attorney or Agen y Letter Required) M O—v -. ,,(A-Li C(_-vt r (L o 4-e.s-1caG
Contractor Information
Name of Company Qualifying Agent
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 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 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
RECO 'IN YOUR NOTICE OF COMMENCEMENT.
(Signature of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed) before me this 34 day of Signed and sworn to(or affirmed) before me this day of
41 , by
es Notary Public State of Florida ' '' - ' / Fddim_
• Noel E Tission ay of Notary) (Signature of Notary)
+� My Commission NH 055848 (Signature
—io'M1r Expires 10/21/2024
Personally Known OR [ ] Personally Known OR
[ Produced Identificatio ) [ ]Produced Identification
Type of Identification: ,L1 /,i6-124? Type of Identification:
Recorded 12/17/2020 01 :20 PM, RONNIE FUSSELL CLERK CIRCUIT COURT DUVAL COUNTY
IN THE FOURTH CIRCUIT COURT,
IN AND FOR DUVAL COUNTY, FLORIDA,
PROBATE DIVISION
CASE NO.: 2020-CP-002971
DIVISION: PR-B
IN RE: ESTATE OF
TERRY STUART JACOBS,
Deceased.
1-11
x:11
f'r
ti-:
LETTERS OF ADMINISTRATION r r
TO ALL WHOM IT MAY CONCERN 3
n.:
WHEREAS, TERRY STUART JACOBS ("Decedent"), a resident of Duval County,
Florida,died on May 8, 2020,owning assets in the State of Florida, and ;41
• WHEREAS, MARK JULIANO has been appointed Personal Representative of the Estate
of Decedent and has performed all acts prerequisite to issuance of Letters of Administration in the
Estate,
NOW, THEREFORE, I, the undersigned circuit judge, declare MARK JULIANO duly
qualified under the laws of the State of Florida to act as Personal Representative of the ESTATE
OF TERRY STUART JACOBS, deceased, with full power to administer the Estate according to
law; to ask, demand, sue for, recover and receive the property of Decedent; to pay the debts of
Decedent as far as the assets of the Estate will permit and the law directs; and to make distribution
of the Estate according to law.
ORDERED on this \c, day of�SLCQ.,...�.,x� , 2020.
Circuit Judge
Copies to: 1116
Jeffrey R. Bankston, Esq.
Alfred V. Nicoletti, Esq.
2215 South Third Street, Suite 103
Jacksonville Beach, Florida 32250
Primary E-Mail: eservice@bapblaw.com
Secondary E-Mail: anicoletti@bapblaw.com
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
' 111141i City of Atlantic Beach Building Department GRAY IS REQUIRED.
r r
'7_■_r 800 Seminole Rd, Atlantic Beach, FL 32233
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: —1 rs 9 iC U LI a.„C Pckki 1
Owner Name: m�IC. J u CANUU � � d'� T� Y oneumber: '1 0-2, 2'A_ i Q 'J+
Mailing Address: 21:10 Catu 41_0 City: (1410 4-i c ge CLC.I State: PL_ Zip: 3 2233
Notarized Signature of Owner )4M `
Theoing instr ment was acknowledged before me thia30 day of�EC_ , 00n the State of Florida, County
of OC
Signature of Notary Public C� 41111b.
[ ] Personally Known OR [ ] Produced Identificat .
Type of Identification: 3 4So`SS7 to 9 - 04-7—C
s�'Y?q'.= TONI GINDLESPERGER
Updated 10/24/18
•. : MY COMMISSION#GG 353178
:a. huu'
`,•o; EXPIRES:October 6,2023
�rFo'F F Vic' Bonded Thru Notary Public Underwriters