262 S NAUTICAL BLVD FNCE21-0007 .;' ',;,- Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Departmento
**ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: 1uilding-Depth coab.u., IS REQUIRED.
c� 0(707Job Address: ` "Z /14(..) �/e2/ Permit Number: �� � ' -
Legal Description /-t/1'l I1 -1-5- Z9'C 5 ' / (0- 15' 13LK 1/ RE#)4 l q1 • °ccU
Valuation of Work(Replacement Cost)$ 52 2-5— Heated/Cooled SF Non-Heated/Cooled
• Class of Work: [$(New ❑Addition ❑Alteration ❑Repair EMove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial IKResidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes EINo
• Will tree(s)be removed in association with proposed project? ❑Yes(must sub it se arate Tree Removal Perm ONo
Describe in detail the type of work o be performed pL��E, g,,1i�)li7/2 : (7W7.--f, - .7 �r� )��'
U'(7f— 19- e / '( 74" /1I Tc Y%Lc/L— Th(i f i,L,et ______
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name 3o�`C D/►7/414.i Address /114/017;07/7e_--
City
�Ut/l i'}� /
City A ti-s 1� �'/{ State 4 �Zip Phone i(L? " J[ — 'R5c (
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information \
Name of Compa y ')� - C - /U C' Qualifyin Agent /4-/gc.:- L/Sc 4_LC_
Address/t u] „1,,44,,,, 1? //,4 City iii, State - Zip ZZ
Office Phone & • (lP /,2 3 Job Site Contact Number do % r ---t- ,. LXX
State Certification/Registration# E-Mail J 21 )6 #/77 6 o 'CIL. `:
Architect Name&Phone#
Engineer's Name& Phone# 4 ' J
Workers Compensation Insurer 62)/Vii Of i,,..\ C.t,I -e,,),IOR Exempt n 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 regt.irements ofFthis -" I
applicableproperty ty,and
permit,there maybe additional restrictions to thisthat maybe found in the public records of this conn
there may be additional permits required from other governmental entities such as water management districts,state agencies,or
federal agencies. JAN - 7 2021
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 COMMENC ,TIENT MAY
RESULT IN YOUR P £ YING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO • :TAIN FINAOING, CONSULT WITH YOUR LENDER OR N ATTJ. NEY BEFORE
• ECOR k ING YO , NOTICE OF CG OMENCEMENT. 7/7.‘
U(Sig re of Owner or Agent) (Signature of Contra tor) U-
�� '-i-* ✓1
S ned and sworn to(or affi ;.)b:fore thi day of Signed and sworn to(or affirme )before me this !' day of
Zo2-( , by !Oa *! In � S IUPC. ,'22c', by A L�rod-�I1
L •
1i��1_ ) .WII
... Signa re of Notaryl
� • . ure . ,
YTONI GINDLESPERGE' �■
`.i ti�prn c MICHELLE NICOLE MCNAIR
,: MY COMMISSION#r 2023 . '_. MY COMMISSION#HH 019008
I
:;>. � X IRES:0 �jber 6, f ,.40,2.:?.
� I�
"' i 'd (}Q)�d+, ;b:ic Undery ers [ ]Personally Known OR ',;„11.i.. EXPIRES:July 8,2024 4
' — KJ Produced ldentificatio ''Fo C�`•' Bonded T ruNotaryPublicUnderwriter
Type of Identification: uhl L.. Type of Identification: '`"
Owner Builder Affidavit **ALL INFORMATION
`, HIGHLIGHTED IN
!' � y fa City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 r n �-7 _
`j 'T Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: 1 K)c_l�I -000 7
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 1
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 $5,000 PENALTY UNDER FLORIDA STATUTE NO.455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE
OWNER SHOULD PHYSICALLY SEE THE COUNTY"CERTIFICATE OF COMPETENCY"OR THE FLORIDA"CONTRACTORS
CERTIFICATE"TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904-
247-5826 OR BUILDING-DEPT@COAB.US) IF IN DOUBT.
V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I
COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT.
Job Address: 26Z NW 1 tCik-L 6 L/> C.
Owner Name: K by v401,1€{ S Phone Number: 11/0 9/ ¶ -1
Mailing Address: #f11( : op y: �� State: Zip: '�ZZ322
Notarized Signature of Owner A . — -
I
The fc,�iegoi `
ng strument was acknowledged M ore me this 7 day of ,6!1,4,1 , 20 Z f in the State of Florida, County
T
lk:,v ,
Signature of Notary Public Q—
[ ] Personally Known OR [ ] Produced
\ Identification
Type of Identification: J. C___sss _
TONI GINDLESPERGER Updated 10/24/18
:,t :.a MY COMMISSION#GG 353178
' T"�•o EXPIRES:October 6,2023
:Fok F° Bonded Thru Notary Public Underwriters
www
NOTICE OF COMMENCEMENT
State of b Tax Folio No. 13f 'J I D • woo
County of 1/A-L-
To Whom It May Concern:
The undersigned hereby informs you that improvements will be made to certain real property, and in accordance with Section 713
of the Florida Statutes,the following information is sjed in this NOTICE OF COMMENCEMENT. �� �
Legal Description of property being improved: La ( L�1 t �j(X,IL L 5GIt}Sp(_it / 356,(7
I c J7 - 2S - 2R
C _
Address of property being improved: "4,2_ N�4ICA I�L..\I1 J• A43 1-7-1_ -j Z2�J
General description of improvements:_U1_4441
Owner: C� Sommtss Address: AG: 115
Owner's interest in bite of the improvement:
Fee Simple Titleholder(if other than owner):
Name:
Contractor: GL. . �.( 1 „
Address: 10 t L5 UFi) 0.36/2.1-1 14. 4. IO6, 6 `L ?j 2--z-Lc,
Telephone No.: Tai [oy'6 121/ Fax No:
Surety(if any)
Address: Amount of Bond$
Telephone No: Fax No:
Name and address of any person making a loan for the construction of the improvements
Name: N (
Address: ((
Phone No: Fax No:
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may
be served: Name:
Address:
Telephone No: Fax No:
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section
713.06(2)(b), Florida Statues. (Fill in at Owner's option)
Name:
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is one (1)year from the dat: o;r• Gr•i : . --_•-- :•----__._.;
;r°t• . •.�c; GINDLESPERGER_
specified): . ,,, _
Wert *= '' ' •' ' 353178
��.•`::; EXPIRES:October 6,2023
THIS SPACE FOR RECORDER'S USE ONLY OWN I �0"`P onded7hruN•
"' tart'P blit Underwriters
ONl
Doc#2021005357,OR BK 19528 Page 765, Signe /_ Date: Z
NumberPages: 1
Recorded 01/07/2021 03:35 PM, Before me th• A day• Q 0 2 in the Co ty of Duval,State
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL Of Florida,has personally appeare i1 o ar. OM @ S
COUNTY Notary Public at Large,State o • •a,noun�l.' al.
RECORDING $10.00 My commission expires: Comair
-
Personally Known: b C,- _or
Produced Identification:
MAP SHOWING BOUNDARY SURVEY OF
LOT 19, BLOCK 4, SEASPRAY, AS RECORDED IN PLAT BOOK 35, PAGES 64
AND 64-A, OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA.
�OD T'S MMER ..,=,...,.l! á44 iv
.N 'sr P a• 4 `�v
HELMSMAN LANE
;!0'RIGHT OF WAY)
•
S 6728'0C" E 100.00' (PLAT)
minx
S 67'28'00' E 100.10' (MEASURED)
_ 1C1ill e1 •
çLX4.7
ffi• I
' P�
N
Q `f 1 3y
A w
�i is R 1-
LO I. ,' a SI'E 162 I J Qz'
: ."1. 4 1 , D I >0'
LOT 20 ; ; p05 11'..4 �b
BLOCK 4 I ir .,A;;%/ 1�S 1 ,'� o
0. `,i�.l,` •67'28'00" E
D
N N I Q '�" R;I�� •`•;