870 Seminole Rd ERES21-0018 Permit PacketOWNER:ADDRESS:CITY:STATE:ZIP:
BUKOWSKI CHRISTOPHER
MICHAEL 870 SEMINOLE RD ATLANTIC BEACH FL 32233-5446
COMPANY:ADDRESS:CITY:STATE:ZIP:
TYPE OF
CONSTRUCTION:
REAL ESTATE
NUMBER:ZONING:BUILDING USE
GROUP:SUBDIVISION:
171968 0000 SELVA MARINA UNIT 03
JOB ADDRESS:PERMIT TYPE:DESCRIPTION: VALUE OF WORK:
870 SEMINOLE RD ELECTRICAL RESIDENTIAL ELECTRIC - REWIRE AND
LIGHTS $5000.00
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
ELEC REPAIRS AND MISC 455-0000-322-1000 0 $35.00
ELECTRICAL BASE FEE 455-0000-322-1000 0 $55.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $94.00
LIST OF CONDITIONS
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
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.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN
YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT
MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU
INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
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.
1 of 2Issued Date: 2/3/2021
PERMIT NUMBER
ERES21-0018
ISSUED: 2/3/2021
EXPIRES: 8/2/2021
ELECTRICAL RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
2 of 2Issued Date: 2/3/2021
PERMIT NUMBER
ERES21-0018
ISSUED: 2/3/2021
EXPIRES: 8/2/2021
ELECTRICAL RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
DESCRIPTION ACCOUNT QTY PAID
PermitTRAK $94.00
ERES21-0018 Address: 870 SEMINOLE RD APN: 171968 0000 $94.00
ELECTRICAL $90.00
ELECTRICAL BASE FEE 455-0000-322-1000 0 $55.00
ELEC REPAIRS AND MISC 455-0000-322-1000 0 $35.00
STATE SURCHARGES $4.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL FEES PAID BY RECEIPT: R14789 $94.00
Printed: Wednesday, February 3, 2021 3:25 PM
Date Paid: Wednesday, February 03, 2021
Paid By: BUKOWSKI CHRISTOPHER MICHAEL
Pay Method: CREDIT CARD 419935424
1 of 1
Cashier: CG
Cash Register Receipt
City of Atlantic Beach
Receipt Number
R14789
~+; CENTRALSQUARE
Electrical Permit Application
City of Atlantic Beach Building Department
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab .us
**ALL INFORMATION
HIGHLIGHTED IN
GRAY IS REQUIRED.
ERESZ l -00 l8
PERMIT#: ______ _
JOB ADDRESS: f70 ~JJVOt.6 ~AD, A-TL.A-IJTIC.. SEA-CH, Ft. 3oQ'i3PROJECT VALUE$ $000. OD
JEA INFORMATION REQUIRED ON ALL PERMITS: __ AMPS
0 NEW SERVICE: □ Overhead □Underground □Underground up Pale
□Residential (Main) Service:
□0 -100 amps □101 -lS0amps
□Commercial (Main) Service:
□151 -200amp s
□0 -100 amps □101 -lS0amps □151 -200amps
Conductor Type _______ Size ______ _
□Multi-Family (Main) Service:
□0 -100 amps □101 -lS0amp s
0 TEMPORARY POLE: ___ amps
□151 -200amp s
□ ___ amps
□ ___ amps
□ ___ amps
□ SERVICE UPGRADE: □ ___ amps □CT Service ___ amps
□ NEW FEEDER (ADDITIONS, ACCESSORY STRUCTURES, ETC.}:
VOLTS
□100 amps o lS0amps □2 00amps □ ___ amps □CT Service ___ amps
PHASE
# of Meters ---
□CT Service ___ amps
# of Unit Meters ---
~ ADDITIONS, REMODELS, REPAIRS, BUILD-OUTS, ACCESSORY STRUCTURES, ETC:
Outlets/Switches : J,l::;.__0-30amps ___ 31 -lO0amp s ___ 101-200amps
Appliance s: ~0 -30amps ___ 31 -lO0amps ___ 101-200amps
A/C Circuits : ___ 0-60amps ___ 61 -lO0amps
Heat Circuits : ___ # circuits @ ___ kw
Number of Lighting Outlets , Including Fixtures : /~
□ OTHER ELECTRICAL PROJECTS:
□Swimming Pool □Sign □Smok e Detectors ___ (Qty) □Tran s forme rs ____ KVA □Motors ___ HP
0 FIRE ALARM SYSTEM (Requires 3 sets of plans):
Qty ____ volts/amps ____ _
0 REPAIRS/MISCELLANEOUS:
□R e pla ce Burnt/Damaged M eter Can □Safety Inspection □Panel Change □OH to UG
~ther: 7!w1fl-,G, ADD t.,lf>.Hr /7,,(.rt,;/l..E-5. Updated 10/17/18
Permit becomes void if work does not commence within a six month period or work is suspende d or abandone d for six months. I h ereby certify th at I have
read th is app li cati o n and know th e same t o be t rue and correct . Al l provisio ns of laws and ord in ances governi ng t his work wi ll be complie d with whether
speci fied o r not. The perm it does not gi ve aut hority to v io la t e th e provisio ns of an y other st ate or loca l law re gul at io n construction or t he perfo rman ce of
con st r uction .
Own er Name : (!Ht.lt>10'PH6/f. OUl'<OwSl'I Phone Numb er: 1/¥0 $03 61.,S
El ectric al Co m pan y : ________________ Office Phon e: '{JltJ S:<>3 517$-Fax : ------
Co . Address: B/D ,/iM1A:}()(,,G U>, A,._. l!CJC I~( .. 1 City: M~ru.. 8EIK.H St ate : ..E.J,,,_ Zip : ~Q.3,3
Notarized Signature of License Holder -f::::,,"""".....,,_~-"""""'-"""-----+--+-----,-------------------'
Th e fore goi ng in strument w as ackn owl edge d before me t h is .z,5.day X-,,....&...1.!k....-2\o::~ f Florida , Co u nty of ___ _
_.-i!f:'.~~~-, TON I GIND LESPE RGER f/.~'\.~ MY COMMISSI ON #GG 3~3178
~:::~~i? EXPIR ES:-Octob er 6, 2023
·-.. ~~.f~•·•' Bonded Thru Notary Public Underwriters
[ ] Person ally Kn own OR [ ] Produ ced Id entification
Ty pe of Id entificati o n : ___ D~~L-___________________ _
Owner Builder Affidavit
City of Atlantic Beach Building Department
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us
**ALL INFORMATION
HIGHLIGHTED IN
GRAY IS REQUIRED.
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 BUILD IN G 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 INJURIE S TO WORKERS THEY HIRE , THE BUILDING DEPARTMENT
SUGG ESTS WORKER 'S COMPENSATION INSURANCE BE PURCHASED ..
Ill. 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 "CERT IFI CATE OF COMPETENCY " OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTA IN IF A PERSON IS A LI CENSED 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 TH E REQUIREMENTS FOR THE ISSUANCE OF AN OWNER -BUILDER PERMIT.
Job Address: ~10 SOYIIJJ0L6 ~OAD, ATlA~rt(! 8Gll-lH, FL. 3~.;133
Own e r Name: Cl¥,l'5 ro?rl£fl 2,oxo 1JJ'51:-/
Mailing Addres s: g''1O 'SGIYII/JOt.,G ~.4b
Phone Numb e r: i/1-/l> $03 ..S17,S
City : J!Tµtvnc. 8tfAC:.H State : __._f'_L, ___ Zip : 3ola33
Notarized Signature of Owner_c_~ .... ~~----~~-J4=~·-----------------------
The ~oin g in;:rnent wa s ac knowledged before m e this -ZS day of~ 0....
of L.2C?cf~
, 2~, in th e State of Florida , County
[ ] Personally Known OR [ ] Produced Identification
Type of Identification : Cc ( O t 9-ed cs:> -D L
_..··,'if-.~~~--TONI GINDLESPERGER
,f,•'A"-. ': MY COMMISS ION#GG353178 \i~:iJ EXPIR ES : -October 6, 2023
·<~ii~f.~'f··· Bonded Thru Notary Public Underwriters
Update d 10/24/18