769 JASMINE ST RESO21-0045 revision 6-3-21 Revision Request/Correction to Comments **ALL INFORMATION
HIGHLIGHTED IN
41.tr' City of Atlantic Beach Building Department GRAY IS REQUIRED.
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'11111V-1 800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.usPERMIT#: 0Z. "! -{5
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❑ Revision to Issued Permit OR Corrections to Comments Date:
Project Address: 7 G as ('Yl(n e.
Contractor/Contact Name: CD(A-) l\ (-- hie -4 0
Contact Phone: 5•' (JZ 0 Email:
Description of Proposed Revision/Corrections:
•
CDW (\er co ( � Ace-- � 4� V� �
affirm the revision/correction to comments is inclusive of the proposed changes.
(printed name)
• Will proposed revision/corrections add additional square footage to original submittal?
❑No ❑ Yes (additional s.f.to be added:
• Will proposed revision/corrections add additional increase in building value to original submittal?
CI No ❑*yes (additional increase in building value: $ ) (Contractor must sign if increase in valuation)
*Signature of Contractor/Agent:
(Office Use Only)
❑ Approved ❑ Denied ❑ Not Applicable to Department Permit Fee Due$
Revision/Plan Review Comments
Department Review Required:
Building
Planning&Zoning Reviewed By
Tree Administrator
Public Works
Public Utilities
Public Safety Date
Fire Services Updated10/17/18
Owner Builder Affidavit **ALL INFORMATION
117IN HIGHLIGHTED IN
A V City of Atlantic Beach Building Department GRAY IS REQUIRED.
NNW800 Seminole Rd, Atlantic Beach, FL 32233 jj��
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:t1( 5021-0C4
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 REQUIREMENTSEFOR THE ISSUANCE OF AN OWNER-BUILDER�� PERMIT.
Job Address: 7b� JC-Si�Iire. Si ,A tarif7c IBead"� i )UI^ p 2 2?
Owner Name: RtchCIrk VYIofto PhoneNumber:ciO4 -J2.5.-0v-6?\
Mailing Address: 2 ( c1�-Srnch� ��` City: J (anfi(. J2 ' d1 State: EL- Zip: 3��33
1
Notarized Signature of Owner
/ n d6
Tf o oing instrunpent was acknowledged before me this ( day o 0A , 2��, in the State of Florida, County
Vcu1
9/1
Signature of Notary Public a:
Personally Known OR [ ] Produced Identification
Type of Identification:
TONT GINDLESPERGER Updated 10/24/18
MY COMMISSION#GG 353176
:*:
EXPIRES:October 6,2023
''.7,;';u;-;?0° Bonded Thtu Notary Public Underwriters
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