41 6th St POOL20-0040 Revision 6.9.21DESCRIPTION ACCOUNT QTY PAID
PermitTRAK $100.00
POOL20-0040 Address: 41 6TH ST APN: 170112 0000 $100.00
BLDG SUBSEQUENT PLAN REVIEW FEES $100.00
BLDG 2ND PLAN REVIEW FEE 455-0000-322-1006 0 $50.00
BLDG 2ND PLAN REVIEW FEE 455-0000-322-1006 0 $50.00
TOTAL FEES PAID BY RECEIPT: R16059 $100.00
Printed: Thursday, June 10, 2021 4:15 PM
Date Paid: Thursday, June 10, 2021
Paid By: POOLS BY JOHN CLARKSON, INC.
Pay Method: CREDIT CARD 466640758
1 of 1
Cashier: CG
Cash Register Receipt
City of Atlantic Beach
Receipt Number
R16059
~+; CENTRALSQUARE
Revision Request/Correction to Comments
City of Atlantic Beach Building Department
800 Seminole Rd, Atlantic Beach, FL 32233
.. ALL INFORMATION
HIGHLIGHTED IN
GRAY IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: POOL20-0040
0 Revision to Issued Permit OR D Corrections to Comments Date:06/02/2021
ProjectAddress:_4_1_6_th_S_t_re_et ______________________________ _
Contractor/Contact Name: Pools by John Clarkson/ Cindi
Contact Phone: ')O<t , i?>-.3 -':f oS-0 Email: cindi@pbjc.com
Description of Proposed Revision/ Corrections:
Adjusted site plan to show water retention area per meeting with Scott on site.
l,_P_o_o_ls_b..:..y_J_o_hn_C_l_a_rk_so_nl_C_in_d_i ___ affirm the revision/correction to comments is inclusive of the proposed changes.
(printed name)
• Will proposed revision/corrections add additional square footage to original submittal?
EJNo D Yes (additional s.f. to be added: ____________ )
•~ill proposed revision(c_orrec~ions ad~ addi_ti~nal increase in building value to original submittal?
lJNo 0•ves (add1t1onal increase in building value: l O O O ) (Contractor must sign if i n crease i n va l uation) ,
(Office Use Only)
D Approved D Denied D Not Applicable to Department Permit Fee Due$ _____ _
Revision/Plan Review Comments. _____________________________ _
Department Review Required:
Building
Planning & Zoning
Tree Administrator
Public Works
Public Utilities
Public Safety
Fire Services
Reviewed By
Date
Updated 10/17/18
-LANDING PAD BUILT BY OTHERS
-LANDING PAD SIDES -NOT INCLUDED
-LIMESTONE COPING TREAD BY PBJC INC.
-LIMESTONE FACE BY PBJC INC.
EXISTING
DRIVEWAY
.......-ACCESS
(DRIVEWAY)
EXISTING PORCH TO BE ·
REMOVED BY HOMEOWNER~
-(2) STEPS BY PBJC t=~~z_~~---i--=--LIMESTONE COPING TREAD INC
-MUD SET LIMESTONE 18" x 36" PAVER DECK
-NEW 4" CONCRETE SUB-SLAB INC.
-3' x 4' x l' THICK CONCRETE SUB SLAB EDGE FOR
FUTURE FIREPLACE
-CENTER THICKENED CONCRETE SLAB ON POOL
EXISTING PORCH TO BE
REMOVED BY HOMEOWNER
I
-(2) STEP S BY PBJC STANDARD DECK DRAIN
-LIMESTONE COPING TREAD INC
-LIMESTONE FACE & SIDES INC.
NOT INCLUDED
-LANDING PAD BUILT BY OTHERS
J-BOX
PURELINK
-LANDING PAD SIDES -NOT INCLUDED
-LIMESTONE COPING TREAD BY PBJC INC.
-LIMESTONE FACE BY PBJC INC.
r-1
I i
i
i
I ..;
-LIMESTONE PAVER FACE & SIDES INC.
GRASS BY OTHERS
(3) W/Rs
BENCH
SET PARALEVEL AUTOFILL BEHIND COPING
I 6' 6' 6' 3'-6"
DEEP T DEE
MDX W/ SDX
-18" x 36" x 1" THICK LIMESTONE COPING
-10 1/2" MAX. BEAM
I
-SET SKIMMER BEHIND COPING
;---==~====:F:==:u=Tu:==::R::E:=====,,t==:..-SQUARE LID
, , ,
I .
POLARIS 360 -DRAINLINE
+
COVERED PORCH
NOT INCLUDED
-P/E ON TOP OF DECKING GUEST HOUSE EXISTING STEPS TO REMAIN
-VSSHP165AUT
-cs 250
-PLC 700
-WATERLINE HOOK-UP OF AUTOFILL BY
TRAWICK
-6614 AP-L PURELINK
-PDA-P4
-PX 100W TRANSFORMER Hydrauhcs
-3 PORT J-BOX PUMP #1: MDX·R3 & SOX ON SIDE
-(2) JLU4C 24W 100' LTS Branch Line: 3"
Trunk Line: ---=2._5°_· __ _
Return Line: ----"-2'_' __ _
Skimmers: ____ !~---
Jandy Pump: ---'-'VS;.;.F'""HP_16~5-'-AVT'---
Jandy Filter: ___ CS....c....2_50 __ _
Heater: ___ __,N/_A ___ _
Minimum TOH : ___ ~_4=8' __ _
Maximum Flow: __ 8""2_G_PM_'s __
,$-BENCHMARK
-1/2" TOP OF COPING
-1 1/2'' TOP OF TILE
-2" TOP OF POOL BEAM
SCALE : 1/8"= l'
Company Info
Add ress: 600 St. Johns Bluff Rd. N.
City: Jacksonville
State/Zip: Fl / 32225
Pho ne #: 904.223.4050
Fax#: 904.223.0735
E-mail: Info@pbjc.com
License#: CPC 009595 & 1457425
& 1459376 & CBC 1263546
Customer Info
Client Name : Margol Residence
Job #: "'26=8=8 ________ _
Address : 41 6th street
Zip: 32.233
Neighborhood: Atlant ic Beach
Builder. Resident ial
Project Manager. =-=Jo=nn:.:.,y ____ _
Designer Name : =-=Jo::.=::e.:....I _____ _
Specs
Pool Perimeter: """60::....' _____ _
Pool Area : =-20.::..:0;....;.fl.:....' ______ _
Spa Perimeter: .:.:N/"-'A'--------
Spa Area : "'""Nl"""A'----------
Gallons : 4,951 gallons
LST: 10 GPMs
HST: 20 GPMs
Deck Area : -"42::.:.7...:.fl:....' ______ _
Lanai Area : :..::N:..:..IA,....__ ______ _
Footer: ""'N'-'-/A,....__ _______ _
Dist to PIE: ,:.2.:....1' _______ _
Safety
SAFETY 1: Fence by Owner
SAFETY 2: PGRM -2 Pool Guard Alarm
Notes
Notes: -Drainline from Skimmer #1
-Maintain min. 1" step down from
all doors
Revision
RE: AWO 1 Date: 01/05/2021
RE: Pre-Site Date: 01/22/2021
RE: AWO 2 Date: 04/19/2021
RE: AWO 3 Date: 06/01/2021
RE: Date: ----1 ----
fools by John Oarkson
an aquatech" builder
Gen. Plan
1" LIMESTONE PAVERS
~-__.___....._____.___"""-=""""-_____.__ ___
12"
'\k-36" --+-~
THICKENED ED GE OF
CONCRETE SUB SLA B
4" TH I CK CONCRETE
SUB SLAB
Concrete Sub-Slab
Scale: N. T.S.
Company I nfo
Address: 600 St. Johns Bluff Rd. N.
Oty: Jacksonville
State/Zip : _Fl..,_/_3_22_2...;..5 ______ _
Phone#: 904.223.4050
Fax #: 904.223.0735
E-mail: Info@pbjc.com
Lice nse#: CPC 00 9595 & 1457425
& 1459376 & CBC 1263546
Customer I nfo
Client Name: Margol Residence
Job #:-=26.:.;8""8~---------
Address: 41 6th street
Zip: 32233
Neighborhood : Atlantic Beach
Builder: Residential
Proj ect Manager: ,;;..Jo""'n"""n.._y _____ _
Designer Name: _Jo_e_l ______ _
Specs
Pool Perimeter: """60=-'--------
Pool Area: ~20 ... 0'""ft .... 2 _______ _
Spa Perimete r: ... N~/A _______ _
Spa Area : '"N"'"/A-=----------
Gallons: 4,951 g allons
LST : 10 GPMs
HST: 20GPMs
Deck Area: ..:.4=.;27'-'ft"'-2 _______ _
Lanai Area: _N~/A~--------
Footer: ""N""/A..,___ ________ _
Dist to P/E: -=2..:..1' ________ _
Safety
SAFETY 1: Fence by Owner
SAFETY 2: PGRM-2 Pool Guard Alarm
Notes
Notes: -Drainline from Skimmer #1
-Maintain min. 1" step down from
all doors
Revision
RE: AWO 1 Date: 01/05/2021
RE : Pre-Site Date: 01/22/2021
RE: AWO 2 Date: 04/19/2021
RE: AWO 3 Date: 06/01/2021
RE : _____ , Date:-----
Pools by John Oarkson
an aquatech" builder
Detail Page A-2
CENTER POOL ON
17'-0" MEASURE MENT
---,-----
....____._a• 10"-~_r--20· ;;71
--~·-······-------------- ---e~ _______ :::._· _______ r
t-s··---1-,,!0frl , ,
+30"
P/E TO SET ON DECK-..._.
COVERED PORCH
NOT INCLUDED
' .
' ' ' . ·--
Hydrauhcs
PUMP #1: MDX·R3 & SDX ON SIDE
Branch Line : 3"
Trunk Line: 2.5"
Retvrn Line: 2"
Skimmers: 1
Jandy Pump: VSFHP165AUT
Jandy Filter: CS250
Heater: N/A
Minimum TDH : N48 '
Maximum Row: 82 GPM's
..---------+-ACCESS
(DRIVEWAY)
EXISTING STEPS
-$, BENCHMARK
• 1/2" TOP OF COPING
• 1 1/2" TOP OF TILE
• 2" TOP OF POOL BEAM
SCALE:1/8"=1'
Company Info
Address: 600 St Johns Bluff Rd. N.
City: Jacksonville
State/Zip: Fl / 32225
Phone#: 904.223.4050
Fax #: 904.223.0735
E-mail: Info@pbjc.com
License#: CPC 009595 & 1457425
& 1459376 & CBC 1263546
Customer Info
Client Name : Margo! Res idence
Job#: .:::2.::.:68::.:8,....._ ________ _
Address : 41 6th street
Zip: 32233
Neighborhood : Atlantic Beach
Builder: Residential
Project Manager: .::.Jo=.an.:.:..n:.,.y _____ _
Designer Name : .::.Jo.::.:e:c:..I ______ _
Specs
Pool Perimeter: ""6~0' _______ _
Pool Area: .:::20.::.:0::.;fl:.:..' _______ _
Spa Pe ri meter: .:..:Nle.:.A..:...... ______ _
Spa Area : .:..:N~/A..:...... _______ _
Gallons: 4,951 gallons
LST: 10 GPMs
HST : 20 GPMs
Deck Area: ""'42::..:7-'ft~•--------
Lanai Area: :..::N:..:..IA.:..._ _______ _
Footer: .:..:N~/A..:...... ________ _
Dist to P/E : .:::2..:.1' ________ _
Safety
SAFETY 1: Fence by Owner
SAFETY 2: PGRM-2 Pool Guard Alarm
Notes
Notes: • Drainline from Skimmer #1
• Maintain min . 1" step down from
all doors
Revision
RE : AWO 1 Date: 01/05/2021
RE: Pre-Site Date: 01/22/2021
RE: AWO 2 Date: 04/19/2021
RE: AWO 3 Date: 06/01/2021
RE: -----1 Date:-----
fuols by John Oarkson
an aquatech" builder
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roe
ft)ds by Phn Clarkxm
City of Atlantic Beach
800 Seminole Rd.
Atlantic Beach, FL 32233
Pre aredbpy la)erli/14
Signature:
Phone: 904-2234050
Date: 9-2 0
Applicable codes: 2017 Edition Florida Building Code
2014 NEC Current JB LDC
( V-IY
Page i: Survey
Page 2: Pool Plan
Page 3: Steel
Page 4: APSP
Page S: MDX
Page 6: SDX
Page 7:Hydraulics
Page 8: Type of Pump
Page 9: Type of Filter
Page 10; Type of Heater (if any)
Page I I : Alarms
State Certified License:CPC License # 009595 & 1457425, CPC CBC
Contact: Lawrence Rahim 904-923-1305
Home Owner Information:
Name:
Adress:
POOL20-0040
2017 (> l:d111 n 1-lond 8u1IJ1ng Code
p C 1 UN
Pap 2 Pool Plan
Pqc3. tecl
Paac4:APSP
Paac5: MDX
Paao6:SD
Paao7:H)dnulia
... : Type of Pump
Paae 9: Typo ofl'lher
um.-nt JB L I>C
Pap 10; Type ofllelta (if my)
.. 11:Alllmt
Phont 904 223 -4050
D,1lt 12-~-2 U
CPC Liccme# 009595 & 1457425, ~pC 14~YJI,., C & l2iP3S4f1
,
City of Atlantic Beach
Swimming Pool Permit Checklist
Permit Application
Proof of Property Ownership
Recorded Notice of Commencement
Boundary Survey
Tree Removal Application
Plans and Specifications
Engineered Pool Steel Drawings
Contractors Information
a DEP Permit
Variance Approval Letter
Permit Application:
I. In "description " box, indicate type of work being performed (i.e. "swimming
pool", "above ground pool, etc.")
2. Application must be signed and notarized by the pool contractor and property
owner.
Proof of Property Ownership:
If the current owner is officially listed as owner with the Property Appraiser, only a
photo I.D. is required. if the current owner is not listed, a copy of the Recorded
Warranty Deed must be provided.
Contractor information:
Building contractors must provide a current copy of the following:
Florida State Contractors license
General Liability insurance
Workman's Compensation
Duval County or Atlantic Beach Business Tax Receipt (Occupational
License)
'*The hiring of a contractor is not required if the property owner is building the
swimming pool for his own use and, submits an Owner-Builder affidavit when
applying for the pool permit.
Recorded Notice of Commencement:
If value of proposed work (value = replacement cost) exceeds $2,500, a recorded
N.O.C. (Notice of Commencement) must be submitted with application. The
County Clerk has a satellite office located at 1543 Atlantic Blvd. in Neptune Beach.
City of Atlantic Beach
Swimming Pool Permit Checklist
D Permit Application
D Proof of Property Ownership
D Recorded Notice of Commencement
D Boundary Survey
□ Tree Removal Application
D Pla ns and S pecifications
D Engineered Pool Steel Drawings
0 Contractors Information
0 DEP Permit
n V a rian ce Approv al I etter
Permit Application:
1. In "description " box, indicate type of work being performed (i.e. "swimmi ng
pool", "above ground pool , e t c.")
2. Application must be signed a nd nota rized by the poo• contractor and property
owner.
Proof of Property Ownership:
If the current owner is officially listed as owner with the Property Appraiser, only a
photo 1.0. is required. If the current owner is not list ed, a copy of the Recorded
Warranty Deed must be provided.
Contractor Information:
Building contractors must provide a current cop y of the following:
-Florida State Contractors license
-General liability Insurance
-Workman's Compensation
-Duval County or AUantlc Beach B u siness Tax Receipt (Occupational
Licen se)
--The hiring of a contractor is not required if the property owner is bu il ding the
swimming pool for his own use and, submits a n Owner-Builde r affidavit whe n
applying for the pool permit.
• rePI,cement coat) exceeds $2,500, a recorded
at be submitted with application. The
at 1643 AttanUc Blvd. ln Neptune BElach .
TREE REMOVAL PERMIT APPLICATION
City of Atlantic Beach
Community Development Department
800 Seminole Road Atlantic Beach, FL 32233
(P) 904-247-5800
INSTRUCTIONS
1. Complete and sign this application.
2. Attach required exhibits as listed on application checklist.
3. Contact the Community Development Department if you have questions.
4. Submit the completed application and all required exhibits, along with
application fees to the Permits Desk at Atlantic Beach City Hall.
SITE INFORMATION
ADDRESS q J
SUBDIVISION BLOCK*
APPLICANT INFORMATION
NAME
ADDRESS 91 (D 36 CITY
FOR INTERNAL OFFICE VSE ONI Y
PERMIT #
C) Legacy Tree s 25.00
C) Single- Two-Family Residential $25.00
C) Multi-family Residential $250.00
C) Commercial / Industrial $250.00
C) Institutional/ Other Non-Residential $250.00
170)) 2-000
LOT g
STATE E!— CODE
PHONE - 65101 CELL*X OWNER C) LEGAL AUTHORIZED AGENT
TREE REMOVAL PERMIT APPLICATION PACKAGE CHECKLIST
PLEASE ATTACH THE FOLLOWING EXHIBITS:
•Additional information may be required. depending upon circumstances unique to individual applications
EXHIBIT A (Option 1) - PROOF OF OWNERSHIP: copy of Warranty Deed that verifies record of owner (Clerk of Courts)
EXHIBIT A (Option 2) - LETTER OF AUTHORIZATION: Please complete if the applicant is not the owner
EXHIBIT B - TREE INVENTORY and TREE PROTECTION PLAN
EXHIBIT C - TREE MITIGATION WORKSHEET
NO ReesEXHIBIT D - TREE MITIGATION PLAN by
SITE PREPARATION CHECKLIST
PLEASE PREPARE YOUR SITE AS FOLLOWS:
Mark all trees identified for removal with RED or ORANGE nagging. paint or tape
Mark all trees identified for preservation with BLUE or GREEN flagging, pain or tape
Mark property corners with stakes or paint
Barricade all trees to be preserved on the property at the dripline
1 HEREBY CERTIFY THAT INFORMATION PROVIDED IN THIS APPLICATION IS CORRECT. AGREE TO COMPLY WITH ALL
PROVISIONS OF CHAPTER 23 (PROTECTION OF TREES AND NAIVRAL VEGETATION) t CCOCS AND
ORDINA CES or THE CITY or- BF-ACE'.
SIGNA 'RE OF APPLICANT
02 TREE REMOVAL APPLICATION03.OY2018
POOL20-0040
P: 11 I ■• ILL • ._ ___
TREE REMOVAL PERMIT APPLICATION
City of Atlantic Beach
r Community Development Department
-.,..;;;...;, 800 Seminole Road Atlantic Beach, FL 32233 I FOR INTERNAL OFFICE USE ONl y
~IT#-------(P) 904 -247-5800
INSTRUCTION S
1 Complete and sign this applica t ion
2 Attach required exhibits as listed on appllcallon checklist
0 LegacyTrte
O Single / Two family Rcs,dent,al
O Mulu-Fam,ly Resid nt,al
S 2S.OO
S12S.OO
S2SO .OO
3 Contact t he Community Development Department If you have quernons
4 Submit t he completed appllcatlon and all required exhibit s, along wl1h
application fees t o t he Permits Desk at Atl anti c Beach City Hall
D Commercial/ Industrial S250 .00
O lnst1tut1onal / Other Non-Resident la I S250 00
SITE INFORMATION
ADDRESS '-/) (p~ & REt /70112.-0COO
SUBDIVISION BLOCK# / 5 LOT• I l. -----------------------_ _._ _____ _
APPLICANT INFORMATION
NAME fh~ r<'a~\
ADDRESS -y I ~ ~ 5t,.
LI, f; L&!J:sb <tXJo \. (loA
c1n Ai1Mf1c._ 'Be~ STAH Fl 21r com 3ZZ 35
PHONE. t C.ELL ,i ~OWNER 0 l EGAL AUTHORIZED AGENT
TREE REMOVAL PERMIT APPLICATION PACKAGE CHECKLIST
PLEASE ATTACH THE FO LLOWING EXHIBITS:
•Additional Information may be required, depending upon circumstances unique to lndlvldual applications
0 EXHIBIT A (Option 1) -PROOF OF OWNERSHIP: Copy of Warranty Deed tha t verifies record of owner (Clerk of Courts)
□
D
D
□
EXHIBIT A (Option 2) -LETTER OF AUTHORIZATION: Pl ease complete If the applicant Is not t he owner
EXHIBIT B -TREE INVENTORY and TREE PROTECTION PLAN
NO i\(ees be{~ \'E?roveo'
b'1 ?CV6 by ~Y)f\ Clt.t
EXHIBIT C -TREE MmGATION WORKSHEET
EXHIBIT D -TREE MITIGATION PLAN
SITE PREPARATION CHECKLIST
PLEASE PREPARE YOUR SITE AS FOLLOWS:
0 Mark all trees identified for removal with RED or ORANGE nagging, paint or tape
D Mark all trees Identified for preservation with BLUE or GREEN nagging, pain or tape
D Mark property comers with stakes or paint
D Barricade all ttees to be preserved on the property at the drlpllne
I HEREBY CERTIFY THAT All INFORMATION PROVIDED IN THIS APPLICATION IS CORnlCT. I AG REC 10 COMPl Y WITH ALL
PROVISIONS OF CHAPTERll C,ROTECTIONOFTREE5ANDNA1VRAL VEGETATION) I\ND A! L OTIU-P r.fTL 'l" l ( m· . 'l
ORDINA CES OF THE CITY Of ATLANTIC IEAOi,
EXHIBIT A: LETTER OF AUTHORIZATION
City of Atlantic Beach
Community Development Department
800 Seminole Road Atlantic Beach, FL 32233
(P) 904-247-5800
OWNER INFORMATION
NAME
ADDRESS 4)
STATE
AGENT INFORMATION
NAME
ADDRESS
CITY STATE
FOR INTERNAL OFFICE USE ONLY
PERMIT #
PHONE* 904- 03)-SYol
CELL
PHONE
CELL
71P CODE
is hereby authorized to act on behalf of
the owner(s) of those lands described
in the attached application and as described in the attached deed or other such proof of ownership as may be required
in applying to the City of Atlantic Beach, Florida, for an application related to a Tree and Vegetation Removal Permit
1 HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IS CORRECT: Signature of Property Owner(s) or Authorized Agent
SIG TURE OF OWNER OR LEG REPRESENTATIVE PRI T OR TYPE NAME
SIGNATURE OF APPLICANT PRINT OR TYPE NAME DATE
Signed and sworn before me on this
Identification verified:
00th Sworn:Yes No
DEBORAH h'ERUNG
MY COWSSIONSGG356196
EXPtRES:Nowrbet17.2023
02
County of. _
Notary Signature
My Commission expires
• ■ ■ •
•
EX JUOJ T A: LETTER OF AUTHOR I ZATION
City of Atla nt ic Boach ,,
Community Development Department
800 Semlnolc Road Atlant lc Bea ch, FL 32233
(P) 904-24 7-5800
FOR INTERNAL OFF/CE USE OHL Y
PERMIT# _____ _
OWNER INFORMATION
NAM E E:li 2at:.elh ~(
ADDRESS 4) tp'l1! 8-o
CITY A-l l@+,c.. $ €a6'
AGE NT INFOR MATION
PHONE II 904-C,3) -----
CE LL 11
STATE ...:..F_(:;___ ZIPCODE .$223:,
NAME PHONE# ----------------------------------
AD D RES 5 CELL# ----------------------------------
CITY STATE 71P<ODE
1s her e by dut ho rized to act o n behalf of
the owner(s) of those lands described
in the attached application and as described In the attached deed or other such proof of ownership as may be requ ired
in a pplying to the City of Atl antic Beach, Florida, for an applica tion related to a Tree and Vegetation Removal Permi t
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IS CORRECT: Signat ure of Property Owner(s) or Authorized Agent
SIGNATURE OF APPLICANT PRINT OR TYP E NAME DATE
Signed and swom before me on this
E\ I~ '!10-a2'
, ~ by St ate of Fl.0"1cb.
Coun ty of .~-1aJ
ldtntlflatlon vtrlfltd:_Qj{ _____________________ _
~~-
Notary Signature ~
My Commlulon explrei J l.:,J ]-'>
CITY OF ATLANTIC BEACH
OWNER / BUILDER AFFIDAVIT
1. FLORIDA STATUTES; CHAPTER 489. FLORIDA STATUTES. PART 1 •CONSTRUCTIONCONTRACTING- REQUIRES OWNER / BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.103(7). FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSEDCONTRACTORS, YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPTION TO THATLAW. THE EXEMPTION ALLOWS YOU. AS THE OWNER OF YOUR PROPERTY'. TO Acr ASYOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE.SUPERVISE THE CONSTRUCTION YOURSELF. YOU MAY BUILD OR IMPROVE A ONE - ORTWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD ORIMPROVE A COMMERCIAL BUILDING AT A COST OF $25,000.00 OR LESS. THE BUN-PINGMUSINE±QRXOVB-VSEAND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASEIF YOU SEIL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEARAITER THE CONSTRUCTION IS COMPLETE, LAW WILL PRESUME THAT YOU BUILTIT FOR SALE OR LEASFh WHICH IS IN VIOLATION OF THIS EXEMPTION. YQV MAY NOT
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING
YOUR CONSTRUCMON
REGULATIONS. MUST
IT ISYOUR RESPONSIBII,'DI' TO MAKE SURE THAT J'EOPt.1i
n. iNJURY SINCE OWNERS FOR TO WORKERS THEY HIRE.THE EUILDING DEPARTMENT SUGGESTS WORKERS COMPENSATION INSURANCE BEPURCHASED.
Ill. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSOOBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEYEMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENALTY;c NNCIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE NO.455-228(1). AN 'OCCUPATIONAL IS NOT. ADEQUATE. THE OWNER SHOULD PHYSICALLYSEE THE COUNTY •CERTIFICATE OF COMPETENCY' OR THE FLORIDA •CONTRACTORSCERTIFICATE- TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THEBUILDING DEPARTMENT (247-5826) IF IN DOUBT.
V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURESTATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF ANOWNER-BUILDER PERMIT.
32833ADDRESS PHONE NUMBER
PRINT E
st DATE
Before me thb day of he county otDuval. State of Florida. has personally appeared herin by himself I herself and affirrns thatan statements end dedatabons ere true and accurate.
Notary Public at Large. State of qqaQ
DEBORAH WERLING
Produced -MYCOMMiSSlON#GG3S6196
Boc,dedmuNot...r€
Notary Signature:
REVISED
IT\' OJ• A TLA 1 TI DEA 11
<!B \VNER / BUILDER AFFIDAVIT
I FLORI DA STATUTES ; CH APT ER 489, rLORIOA STATUTES, PART 1 "CONSTRUCTION
CONTRACTING" REQUIRES OWNER/ BUILDER TO ACKNOWLEDGE THE LAW
DISCLOSURE STA TEMl:Nl fOR 1'.CTION ~!1 9 I 03(7), f LORIDA ST A nm.:s
STATr LA\\' RCQUIRl·S ONSTRUCTION 10 Ill l)QNI BY l lCfNSH)
ONffiACTORS YOU IIA\11:. APr'Lll:.D l'OR A l'LRMII UNDlR AN LXl:.Ml'llON 10111A1
LA w Tl If EXEMPTION All.OWS YOU, AS Tl IE OWNfR or YOUR PRO Pl Rn'. TO AC1 A S
YOUR OWN CONTRACTOR 1:.Vl:.N TIIOUGII YOU DO NOT IIAVl:. A LICl'.NSF YOU MUSJ
SUPER\IISE THE CONSTRUCTION YQURSEL[, YOU MA y nun.n OR IMPROVF A ONT O H
TWO FAMILY RES IDENCE OR A FARM OUTI3UI LOING YOU MAY ALSO UUIU) OR
IMPROVF A COMM ERCIAL BUILDING AT A COST OF S25,000 00 OR LESS TI 1J! nun DI
MUST Bl; toRYOUR US!· AND OCCUPA NCY IT MAY NOT Uli UUILl !'OR SAU~ OR Ll:AS I •
I F YOU SFI I OR Ll:.ASC A BUILl)lNG YOU IIAVI• BUILT YOURSELI WITIIIN ONl. YEAR
Al7"ER THE. CONSTRUCTION IS CO MPLl:.Tt, Tllb LAW WILL l'RESUMl:. THAT YOU DUlL T
IT l'OR SALi• OR LEASE, WIIICII I S IN VIOLATION OF 1111S E.'<EMl'TION YOU MAY NOI
HIRE AN UNUCENSPQ PERSON AS YOLJR CONTRACIQ.R. YOUR CONSTRUCTION MUST
llE DONE ACCORDING TO Till· llUILDING CODES ANO ZONING RI GUI.Al ION S IT IS
YOUR RLSPO:-JSIOll lfY TO MAKI SllHI TIIA1 l'I or1 I I i..tl'I OYI n 1n· Y<l\ II \ I
J )( I ' I (' .I: j r II I ~ r ·1 \ r ' ) ' 1 \
<,I Jl"'A;-;ll~
'' ll~JUk'I' LIi AIL1T\', SINCE .Q_WNl;8~ MAY fj; 1._!A61£;. fOR lrwfilf,S 10 WOhKERS THC'\' HIRE,
HiE BUILDING OCPAR1MENT SUGGESiS WORKERS COMPENSAilON INSURANCE BE
PURCHASED
Ill. IRS WITHHOLDING; OWNERS HI RING WORKERS BECOME EMPLOYERS ANO SHOULD ALSO
OBSERVE IR S WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY
EMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENAL TY; UNUCENSE P CONTRACTORS CANNOT BE EMPLOYED UNDER ANY
CJRC UMSTANCES, OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA SiATUTE NO .
455-228(1 ). AN ·occ u p AT)ONAL L )C ENSE" IS NOT ADEQUATE, THE OWNER SHOULD PHYSICALLY
SEE T HE COUNTY "CERTIFICATE OF COMPETENCY-OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICEN SED CONTRACTOR TELEPHONE THE
BUILDING DEPARTMENT (247-5826) IF IN DOUBT.
V . ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE T HAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
'.32233
PHONE NUMBER
J
TREE & VEGETATION AFFIDAVIT
City of Atlantic Beach
Community Development Department
800 Seminole Road Atlantic Beach, FL 32233
(P) 904-247-5800
FOR INTERNAL OFFICE USE 0M r
PERMIT #
SITE INFORMATION
ADDRESS q I (DEB
SUBDIVISION
) 0002-
APPLICANT INFORMATION
MO bl
BOYE)vec/
s-)ha
BLOCK ) S LOT ) Z
NAME
ADDRESS
(-11 Y
36
bch
C] RESIDENTIAL C) COMMERCIAL OTHER
PHONE
32233 909.
STATE 3233
Icec f con OWNER [Z] LEGAL AUTHORIZED AGENT€sb@aos.
I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation", ofthe Municipal Code of Ordinances for the City of Atlantic Beach Florida and/or I have participated in a pre-application meeting with the Administrator of those regulations. Subsequently, I affirm that no regulatedtrees and no regulated vegetation will be damaged, destroyed and/or removed from the above-describedproperty and/or adjacent properties including right-of-way.
1 HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IS CORRECT: Signature of Property Owner(s) or Authorized Agent
IG ATUREOF APPLI
SIGNATURE OF APPLICANT (2)
Signed and sworn before me on this
Identification verified:
Oath Sworn: Yes No
PRINT OR TYPE NAME DATE
PRINT OR TYPE NAME DATE
day of 70u by State of
County of
DEBORAH WERLING
MYCOMMISSION*GG356196
Bonded Ttru Publk
Notary Signature
My Commission expires 11-17-
04 VEGETATION AfftOAV11 03.Oi20i8
POOL20-0040
mEE & VEGETATI ON AFFIOA vrr
City of Atlantic Beach
Community Develo pment De partment
800 Seminole Ro ad AtJ a ntic Beach, FL 32233
(P) 904·24 7-5800
FOR INTERNAL OFFICE USE ONl Y
PERMIT# ______ _
SI TE INFORMAT ION
ADDRESS LI I (R~ 32233
SUBD IVISION BLOCK 15 LOT )1 C.
D RESID(NTIAL D COMMERCIAL D OTHER
AP PLIC AN T INFO RMATION
ADDRfSS L/ I tt,b ~-l, 32'2-.1.3 ((11 t q()l{ t,b3J -52:J?Pt
un AtbA+tc. 'bO\ SlAll P( ZIP (OD[ 3~
fMAII _lc_ed~/:>(l). a.ol . ~ !xi OWl~E.H IJ l EGAl AUTHORl7EO AufNl
\
I affirm that I have reviewed t h e p rovisions of Chapter 23, •Protection of Tr ees and Nat ive Ve g etatio n•, of
t he Municipal Code of Ordinances for the City of Atlanti c Beach Florid a and/or I have participate d in a p re-
application meeting with the Administrator of those regulations. Subseque ntly, I affi rm t hat no regulated
t rees and no re gulated vegetation will be damage d, d e stroye d and/or re move d fro m the a b ove-described
property and/or adjacent propertie s including right-of-way.
I HEREBY CERTIFY THAT ALL INfORMATlON PROVIDED IS CORRECT: Signature of Property Owner(s) or Au t horized Agent
SIGNATURE OF APPLICANT (2) PRINT OR n'PE NAM E
Signed and sworn before me on this crH> day of J)OC'ev\b6r
b(\~hl!P-flo\
'7o2D by
DATE
Stateof _....__l-'------
County of J:>tAvaJ2
Identification verifled:--l£r,1{,.:_ ____________ ~-----
~ ~ ~ oath Sworn: O Yes
NotAry Signature
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