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1870 SEMINOLE RD RFNC21-0041 bW 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- ept@coab.us Job Address: J / 0 1i i' 11 le /V% Permit Number: RF MC_.2...t" C0/1 Legal Description 1 f/ /0/ 1 /OKI. C,'\ / ,i t,. . / 6' V)11°1, -f-` RE# 12(�"llCJC is )0 Valuation of Work(Replacement Cost) 62-- He ted/Cooled SF Non-Heated/Cooled • Class of Work: ❑New ❑Addition ❑Alteration ❑Repair Move ❑Demo ❑Pool ❑Window/Door • Use of existing/proposed structure(s): ❑Commercia�Residential • If an existing structure,is a fire sprinkler system installed?: DYes EINo • 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: ( I Mo Ute- n'o /� �� fir, Z. 11/71/,' la/ (/✓ Ae.�2 G;� ., -. �/ ' ,- Florida Product Approval# for multiple products use product approval form Property Owner Information Q /� Name JJ -1) G' 4/1/ S Address /C� 2V ,-24),, ,,n0,--_-... 0 _ City a 1 _ 1 P State / Zip ? )-Z j Phone 1_4-44-- Qg :3E-Mail jperijA,Thf n a,/!o // (. pia. - . 4.O 41 Owner or Agent(If Agent, Po�weer pf Attorney or Agency Letter Required) 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 0 Expiration Date Application is hereby made to obtain a permit to do the work and ins lations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work wi e 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 RECORDING YOUR NOTICE OF COMMENCEMENT. (Signature of Owner or Agent) (Signature of Con .ctor) Signed and sworn to(or affi' .)before me this day of Signed and sworn to(or affirm-: before me this day of 114 , r',. ,rz..rie's � (Signature of Notary) dill , ''''r+'vvu" TONI GIND ESPERGER n n OR [ ]Personally Known OR 4 . 'Y°=_ MYCOMMISSI��Ios ip� [ ]Produced Identification L. _*. - 'r *= Ide 1 fication .rte -ems: EXPIRES:C�ctbl��( � I�.n: Type of Identification: o: e. _- ... Notar�1R�00 * LA), Owner Builder Affidavit **ALL INFORMATION HIGHLIGHTED IN City of Atlantic Beach Building Department GRAY IS REQUIRED. 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 ISA 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: lr2) �n�j Yl'I AKA-1 erif Owner Name: 94,7 1 h4I S)27A7 Phone Number: 404)61-el—AN) Mailing Address: l99rV5e/) ak//., oe,‘,/1 City: . /1aJib I';11�� State: �� Zip:..,?"--.23) Notarized Signature of Own- __ (�v_ ,, Tol ,for ping it struum nt was acknowledged before me this C )day o ' Or.0:4•207 S20Z bin the State of Florida, County YY �.J V Signature of Notary Public [ ] Personally Known OR [ ] Produced Identification Type of Identification: �' v Updated 10/24/18 .SAY Pym,, DLRG MY COMMGINSISION#ESPEGG 353ER EXPIRETONIS:Cct�ber 6,2023178 Bonded fire Notary Public Undetvrtiters Fence Addendum Updated 1/7/2021 ) City of Atlantic Beach Building Department 800 Seminole Road, Atlantic Beach, FL 32233 _2 Phone: (904) 247-5826 Email: Building-Dept@coab.us Property Type: ----1J Residential ❑ Commercial Lot Type/ Features: 1 One Street frontage (interior lot) ❑ More than one street frontage (corner lot,through lot, etc.) ❑ Swimming Pool Fence Material: l Wood ❑ Chain Link ❑ Vinyl ❑ Block/Stone (Plan details required for footings and/or retaining walls) ❑ Other Fence Height: Cl Four Foot(4ft) Six Foot(6ft) El Other Fence Location: Please submit an accurate boundary survey required showing all existing improvements(including building footprint, driveway, swimming pool, etc.) and location of fence/wall and any gates. Plan details required for block wall footings and/or retaining walls and any portion or fencing above 6ft in height. Will the fence be built in an easement? ❑ Yes (must submit separate Revocable Encroachment Agreement) No Will tree(s) be removed in association with proposed project? ❑ Yes(must submit separate Tree Removal Permit) No 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 YOUR NOTICE OF COMMENCEMENT. BOUNDARY SURVEY CC r 11 o Z O O© = _ CJ a., --I • c7 a W (.te ��go 0d o 0Q O Q cl .. t-0 Z l � mEnr � �� • • — N89°57'19"E 100.00' o_ZZ ®.C/" 50.0' f 1.1'OFF 1.2'OFF o �� 28.3' • �) I ED o Q 26.1' (E] N I °' o■ 4pI 15.4' � u1 OIO �f,j'4'�+ 28.2' NT W • C.), 0 -)110. 4 0 �O J 1 c4 .�.�. UJ ZO F--7=.,:.� 4 ° CC I E" • p a co .•4,-.. , 4 28.3' o w -Ca o• 0O ��2 m as i 0 CD rii WAWA �� • • • . VIM 39.T W LL En an _i 1 l. N /W I IC.W" f� cz5m h 640 le/1 'n cv ❑ -Q 4 1 50.0' �oCC� 1.10N N89°5T19"E 100.00' an E—v cu Z zCL Zz co o —b .�p 1 SURVEY NOTES CONCRETE DRIVE CROSSING INTO RAN ON EASTERLY SIDE OF LOT. THERE ARE FENCES NEAR THE BOUNDARY OF THE PROPERTY. B.S.L.-BUILDING SETBACK LINE ., . ' 0 s F. . , c I , e �• ��p �� TARGET No.6415 ? SUR`JEYORS CERTIFICATE Y = I HEREBY CERTIFY THAT THIS BOUNDARY SURVEY ISA TRUE AND CORRECT.REPRESENTATION OF A SURVEYING,� N w SURVEY PREPARED UNDER MY DIRECTION LJ 1/ <T� NOT VALID WWITHOUT AN AUTHENTICATED ELECTRONIC LB#7693 '' SIGNATURE AND AUTHENTICATED ELECTRONIC SEAL, • STATE OF ORA RAISED EMBOSSED SEAL AND SIGNATURE. °yo° o q I °" SERVING FLORIDA sue°,' Digitally signed by Kenneth ).Kenneth 6250 N.MILITARY TRAIL,SUITE 102 .�'%� WEST PALM BEACH,FL 433407 Date:2020.09.29 PHONE (561)640-0800 Osborne 22:27:45-0400' STATEWIDE PHONE (800)226-4807 (SIGNED) �. �;F STATEWIDE FACSIMILE(800)741-0576 KENNETH J OSBORNE (� E.L; IniL� „ WEBSITE: h rgets yirg. PROFESSIONAL SURVEYOR AND MAPPER#ti415 � � � � "1 i�� tIP:��td UNe rl8t