1175 seminole rd signed application ----'-'1'-',%,, Building Permit Application Updated 10/9/18
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,� City of Atlantic Beach Building Department **ALL INFORMATION
HIGHLIGHTED IN GRAY
IS REQUIRED.
\ FL 32233
800 Seminole Road, Atlantic Beach,
DFS J.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: I l 1 5 S IA_ ek Permit Number:
Legal Description KZ IS T 1�•• v\.au S 0 RE#
Valuation of Work(Replacement Cost)$ ji C 3 Op Heated/Cooled SF Non-Heated/Cooled 19 S51 C4• Class of Work: 'Jew DAddition DAlteration DRepair DMove DDemo ❑Pool DWindow/Door
L
• Use of existing/proposed structure(s): DCommercial Ni Residential
• If an existing structure,is a fire sprinkler system installed?: DYes RjNo
• Will tree(s)be removed in association with proposed proiect? DYes(must submit separate Tree Removal Permit) 1k No
Describe in detail the type of work to be performed: J s..k...„\ ` Ti,,,,i ,c& > -\� k e u� t-5 / [f c.4ri a
for- L i j h i n j L a - T+ 1 S s rt.- - �ri c� e& i%-1.-- A. �,S0,,,,, ►J. /
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name 7.j.e rj— fificio vie% Address l ) 'TS St,M rr.b /c- 72
City 4+ vvy.t-rt ��.,,� State r(.._ Zip�2Z3'�_Phone 477— /1 ,0
E-Mail r pit( 11Ao+L k . e_a.n t
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company S c.., 1-C A 5 S?iY1r►b I Qualifying Agent
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone# N /A — k \\,..0e.
p v %.
Engineers Name&Phone# iJ/Ar — e w\,,.„1 ,FyL
Workers Compensation Insurer u OR Exempt❑ 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 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
RECORD OUR N!OF COMMENCEMENT.
(Signature of Owner or Agent) (Signa ure of Contractor)
ed and worn to(or affi m:. before me is Z----- ay of Signed and sworn to(or affirmed)before me this day of
` R- , , ZOZ I, • ! _ I:L'L ,by
- (Signature of Notary)A (Signature of Notary)
;su ;�,I TONI GINDLESPERGER
[ ]Personally Known OR „ ;.4?..::r r: MY COMMISSION#GG 353178 [ ]Personally Known OR
`_,, :";•,_ Q EXPIRES:October 6,2023
'••`OF'F c°,' Bonded Thru Notary Public Underwriters
Electrical Permit Application "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#:
JOB ADDRESS: ,er, + : PROJECT VALUE$
IEA INFORMATION REQUIRED ON ALL PERMITS: AMPS VOLTS PHASE
❑NEW SERVICE: 0 Overhead ❑Underground ❑Underground up Pole
Dtesidential(Main)Service:
00-100 amps 1:3101-150amps 0151-200amps 0 amps #of Meters
DCommercial(Main)Service:
❑0-100 amps 0101-150amps 0151-200amps ❑ amps OCT Service amps
Conductor Type Size
❑Multi-Family(Main)Service:
lam3-100 amps 0101-150amps 0151-200amps 0 amps #of Unit Meters
❑TEMPORARY POLE: amps
SERVICE UPGRADE:❑ amps OCT Service amps
❑ NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES, ETC.):
0100 amps 01S0amps 0200amps ❑ amps DCT Service amps
❑ ADDITIONS, REMODELS, REPAIRS, BUILD-OUTS,ACCESSORY STRUCTURES, ETC:
Outlets/Switches: t. ; 0-30amps 31-100amps 101-200amps
Appliances: 0-30amps 31-100amps 101-200amps
A/C Circuits: 0-60amps 61-100amps
Heat Circuits: # circuits @ kw
Number of Lighting Outlets, Including Fixtures:
— OTHER ELECTRICAL PROJECTS:
❑Swimming Pool['Sign ❑Smoke Detectors (Qty) ❑Transformers KVA [Motors HP
n FIRE ALARM SYSTEM(Requires 3 sets of plans):
Qty volts/amps
n REPAIRS/MISCELLANEOUS:
OReplace Burnt/Damaged Meter Can ❑Safety Inspection :Panel Change DOH to UG
❑ether:
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 per oes not give authority to violate the provisions of any other state or local law regulation construction or the performance of
construction. (/
Owner Name: Phone Number: � Cf 7 77 /7
Electrical Company: Office Phone: Fax:
Co.Address: City: State: Zip:
License Holder: CD()i\P _'` State Certifi Registration#:
Notarized Signature of license Holder _
The foregoing instrument was acknowledged before me this y of I (2024 in the State of Florida,County of
Signature of Notary Public
otiaYagc, Ti ill GINDLESPERGER [ ]Personally Known OR[ ]Produced Identification
:*' MY COMMISSION#GG 353173 Type of Identification:
=�;r���.. EXPIRES:October 6,2023
Banded Thru Notary Public Underwriters
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
'MY 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: /! $a rc,1 '7 k 4f14 —L u33
Owner Name: T41)),‘,1-1— ! " �' " -dam` Phone Number: !U f_ 7 i 7- /7/6'
Mailing Address: S7,4-114..i kb() ✓P City: State: Zip:
Notarized Signature of Owner /. t/(t;e1/ 7
The fqr-evingX:;frnent was acknowledged before me this/3day of p ( ,202 `in the State of Florida, County
of t)
1144
Signature of Notary Public
trRY?� TONI GINDLESPERGER
‘4..'1,-1 MY COMMISSION#GG 353178 [ ] Personally Known OR [ ] Produced Identification
w6
EXPIRES:October 6,2023
FOF Bonded Thru Notary Public Underwriters
' ' Type of Identification: ,
Updated 10/24/18