1340 VIOLET ACC21-0004 -'''.4. Building Permit Application Updated 10/9/18
_ ; City of Atlantic Beach Building Department **ALL INFORMATION
VW-4.
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
It IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 13ctV Vt Ott S`r, 471,12q... -n t. g+'y¢Cn tL Permit Numbe : ACQ.2._I - loo 4-
(< Legal Description St1 ,3 SFN.C`_ k *.) iLo*Z exk),4Z71 E# 171((0 — 00 1 0
LOT ��r�
Valuation of Work(Replacement Cost)$ 3t.v(' t Heated/C3ooled ZSZ SF Non-Heated/Cooled
• Class of Work: ❑New Addition ❑Alteration ❑Repair ❑Move ❑Demo DPool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial DResidential
• If an existing structure,is a fire sprinkler system installed?: DYes DNo
• 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:
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name LI(-- Mh.Nua.>>r► Address I3uo VIOLET'
City -cc- -t-r C v%.7'740-c'n State Pt- Zip 3LLS? Phone C.ctJy) 61•-4,- 1-1,-6
E-Mail lrule„,e14 _ Manvfro••() yah.0 • cur"
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Qualifying ,:-nt
Address City State Zip
Office Phone Job Site Cont.• 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 dot,- work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and at all work will be performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand t .t a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATER ,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirements of this
permit,there may be additional restrictions .pplicable 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 YOURTICE OF COMMENCEMENT.
(Signatur of Owner or Agent) (Signature of Contractor) /
igned and sworn to(or of rmOd) •-fo : me is/ day of Signed and sworn to(or affirmed)before this day of
,cs-�Z( , b,��= CN , by
Zws nFre oll f.ry) dr gnature of Notary)
a,yiia:;:k TONI GIND fliNE t ll
[ ]Personally Known OR sr••• �;" y Kr wn OR
�•� MYCOMMISSI
[ ]Produced Identification : ���i =*= QI`l radigi 138de tification
. n::a EXPIRES:0c tbQ[ tiff ion:
Type of Identification: F.-"'' ' DundnJ Thru Notary Public Underwriters
Owner Builder Affidavit **ALL INFORMATION
?4 HIGHLIGHTED IN
a � City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
N` 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: 1j`-1l vF..— t. Tt-arrtt 13T24.3-0-1 31.'1-1
Owner Name: N.\V— MA►., Phone Number:
Mailing Address: 13`-10 NA° ST City: A-114-‘1- State: fit, Zip: 3IA-
Notarized Signature of Owner
The fo oing instr ment was acknowledged efore me this 1 y of 0 l� 20 2_, n the State of Florida, County
of Nrn✓�
•
Signature of Notary Public
[ ] Personally Known OR [ ] Produced Identification
Type of Identification: �.--
Updated 10/24/18
2; !.HV.P�i
TO-NI GINDLESPERGER
%,,:
MY COMMISSION#GG 353178
'rF GQ� EXPIRES:October 6,2023
of r' Bonded Thru Notary Public Underwriters
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