870 SEMINOLE RD ERES21-0018 Electrical Permit Application **ALL INFORMATION
HIGHLIGHTED IN
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City of Atlantic Beach Building Department GRAY IS REQUIRED.
��' 800 Seminole Rd, Atlantic Beach, FL 32233 E:RESZ i -0018
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
JOB ADDRESS: g70 SEm►aocE RAD A-TCAL)rrc BeJ CH, FL' 3'33PROJECT VALUE $ ,5O00 . Oa
JEA INFORMATION REQUIRED ON ALL PERMITS: AMPS VOLTS PHASE
NEW SERVICE: Overhead ❑Underground ❑Underground up Pole
❑Residential (Main)Service:
❑0-100 amps D101-150amps o151-200amps ❑ amps #of Meters
❑Commercial (Main)Service:
❑O-100 amps D101-150amps o151-200amps ❑ amps ❑CT Service amps
Conductor Type Size
❑Multi-Family(Main)Service:
❑0-100 amps o101-150amps o151-200amps ❑ amps #of Unit Meters
TEMPORARY POLE: amps
SERVICE UPGRADE: ❑ amps DCT Service amps
❑ NEW FEEDER(ADDITIONS, ACCESSORY STRUCTURES, ETC.):
❑100 amps ❑150amps ❑200arnps amps DCT Service amps
16 ADDITIONS, REMODELS, REPAIRS, BUILD-OUTS,ACCESSORY STRUCTURES, ETC:
Outlets/Switches: 0-30amps 31-100amps 101-200am ps
Appliances: 0-30amps 31-100amps 101-200amps
A/C Circuits: 0-60amps 61-100amps
Heat Circuits: # circuits @ kw
Number of Lighting Outlets, Including Fixtures: /o.
OTHER ELECTRICAL PROJECTS:
[Swimming Pool ❑Sign ❑Smoke Detectors (Qty) ❑Transformers KVA ❑Motors HP
FIRE ALARM SYSTEM (Requires 3 sets of plans):
Qty volts/amps
P1 REPAIRS/MISCELLANEOUS:
❑Replace Burnt/Damaged Meter Can ❑Safety Inspection ❑Panel Change DOH to UG
$tbther: re+v!P-6, ADD Gt&tir— ii0141-C-5 updated 10/17/18
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.
Owner Name: CHR-ISTZPHEK 3UMOi.05Kl Phone Number: Hyo SO3 157'f5
Electrical Company: Office Phone: 17W0 ,503 577S— Fax:
Co.Address: fix Itresi IUG re-D, 4F+-"— I City: Are-At irk- e a*Chl State: FL Zip: 3aa33
License Holder: //JJ //// State Certification/Registration#:
Notarized Signature of License Holder (J"'��L(l�
The foregoing instrument was acknowledged before me this Z jday A ii, ,0 (, in the State of Florida,County of
<�?Y?6. TONI GINOLESPERGER Signature of Notary Public
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'• MYCOMMISSION#GG 353178
,'�i.:`.:*: EXPIRES:October [ ] Personally Known OR[ ] Produced Identification
•�fFF F�O.e`, Type of Identification: c ,�-^
, Bonded Thru Notary Public Underwriters yp
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
-, City of Atlantic Beach Building Department GRAY IS REQUIRED.
tar 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: %70 5CiniAot.6 ROAD Art..4&rtc 80101, F[. 32a33
Owner Name: CKgisrarHCt BoKowsk/ Phone Number: AND 503 5775
Mailing Address: $''r0 ,56r►1/NO1-E Rol*b City: pirt.INTIGj44N State: f[. Zip: 3aa33
Notarized Signature of Owner �;�� ", � _'" _• \\
The going instr ent was acknowledged before me this 7 day of-.A(\ , 204, in the State of Florida, County
of (' (/'�—
Signature of Notary Public `A
[ ] Personally Known OR [ ] Produced Identification
Type of Identification: C p( O r 0."U i
?o<rsY? , TONT GINDLESPERGER• Updated 10/24/18
*: - MY COMMISSION#GG 353178
UM
: ' EXPIRES:October 6,2023
Bonded Thru Notary Public Underwriters