1941 Francis Ave FNCE19-0116 Submittal Sltiy J; City of Atlantic Beach APPLICATION NUMBER•
1111:4141:6
rBuilding Department (To be assigned by the Building Department.)
� 800 Seminole Road F-11 l9 _ t (
,�� r Atlantic Beach, Florida 32233-5445 C
Phone(904)247-5826 • Fax(904)247-5845 ! /Z.-7I
" E-mail: building-dept@coab.us Date routed:
t
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: CA 4 \ FR ANDCAs C Dpartment review required Yes No
Build •
Applicant: l! C-)-D Planning &Zoning
Tree •s . •r
Project: a) I FCe Public Work
ublic Utilitie$.
Public Safety
Fire Services
Review fee $ Dept Signature
Review or Receipt Date
Other Agency Review or Permit Required of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Approved. ['Denied. ❑Not applicable
(Circle one.) Comments:
BUILDING G�
PLANNING &ZONING Reviewed by:_21 Date:
TREE ADMIN. Second Review: I 'Approved as revised. ❑Denied. I 'Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: I 'Approved as revised. ['Denied. I INot applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
To,:Ly; City of Atlantic Beach APPLICATION NUMBER
i" (To be assigned bythe BuildingDepartment.)
ti �- Building Department g p )
'i 800 Seminole Road
_, Atlantic Beach, Florida 32233-5445 �w CE'�� _ I `
Phone(904)247-5826 • Fax(904)247-5845 ! /lc)
F- on g%' E-mail: building-dept@coab.us Date routed: ` /z...-7
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1 CA 4 \ 1` R ptN�,i S Nf CDepartment review required Yes No
(Buildi.•
Applicant: c)
LAD tv&CZ 'fanning &Zoning
Tree '• - '-
Project:
"Project:
t 1------ ce Public Work
ublic UtilitieD
Public Safety
Fire Services
Review fee $ Dept Signature
Review or Receipt Date
Other Agency Review or Permit Required of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Approved. I 'Denied. I of applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by. Date: /0— Z—/9
TREE ADMIN. Second Review: ['Approved as revised. I !Denied. I 'Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ['Denied. I INot applicable
Comments:
Reviewed by: Date:
Revised 05119/2017
riyLy2,,: City of Atlantic Beach APPLICATION NUMBER
iS Building Department (To be assigned by the Building Department.)
'i 800 Seminole Road �jv �_ ( _� ' t
' " Atlantic Beach, Florida 32233-5445 C
Phone(904)247-5826 Fax(904)247-5845 l Z7
J � E-mail: building-dept@coab.us Date routed: `
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1 CI.4 ` FR ANDC S C D partment review required Ytey No
(:-Buildi
Applicant: U3 NGaL anning &Zoning`
Tree •• . •r
Project: LO Cr--- cePublic Work
f ublic Utilities .
Public Safety
Fire Services
Review fee $ Dept Signature
Review or Receipt Date
Other Agency Review or Permit Required of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: (roved. I (Denied. Not applicable
(Circle one.) Comments:
BUILDIN1.
PLANNING &ZONING Reviewed by: Date:]6 -3.-)0/7
TREE ADMIN. Second Review: ❑Approved as revised. I ]Denied. ❑Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ['Approved as revised. ❑Denied. ['Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
,:1''''.. Building Permit Application OFFICE COPY Updated 10/9/18
ia\
AtnBdDe **ALL INFORMATION
800 so latic Road AtlanticBeachuil
ing Beach FL partment 32233 HIGHLIGHTED IN
RMATIOGRA
°i{if
�r City IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us i Q
Job Address: 4 It 11t f'0.c'Q. S SI Permit Number: 1—NC' C, 19 t'I
k C42
Legal Description p T .1-c4 i Rec-ct. 0/R. 7 E O" 32-( RE# 17Z09.9 - 4-5 1 5
owlvG( _ . Simez„,
Valuation of Work(Replacement Cost)$ 8d�—Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ElMove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial ❑Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• 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:
6 FeN e e-
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name MO..t 9 Rei,F3-\ ( )0tzrrci[\ Address I R 4 L t-aACA S P,v e.
City Dtkt,a"`-t.C(.Ses_e-fr. State L_ Zip 37,7_3 3 Phone 904 -37Z --7L 7 a
E-Mail IVB L)
Owner or Agent(If Agent,Power of 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 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 0•,
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS, 0
WELLS, POOLS, FURNACES, BOILERS,HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirementf this (1
permit,there may be additional restrictions applicable to this property that may be found in the public records of this countyand N M
there may be additional permits required from other governmental entities such as water management districts,state agensl*smor,J 2 ,
federal agencies. J U QO 3
o- O F %
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance witalIW 0 tii
applicable laws regulating construction and zoning. 01:01,:-.: Z F-
UU8 o
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT M/ V i"1 < o
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INT 0 a
u.
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE ! cn
z
RECORDING YOUR NOTICE OF COMMENCEMENT. 0 ua. a la
,4-vi cz41,1 ea t,u (W U=;- N. pO a CO UJ
(Signature of Owner or Agent) (Signature of Contractor) W f- 3 o
/
. Ucwi� w w
"Wed and sworn to(or affir before me th's Z(iay of Signed and sworn to(or affirmed) before me this of L W
f'r ,ZO ,by_01• Oii _d'C0 is , , by W -
cc cc
TONI GI DLESPE' S" t
1'Y COMMISSION#FF 924 , • (Signature of Notary)
EXPIRES:October 6,2019
,:
cad Tin Notary Public Underwriters
[ ].PersiliaNyfC WirtYf "'"`-'`-'" [ ]Personally Known OR
[ ]Produced Identification [ ]Produced Identification
Type of Identification: 0-5 g v--3g- fp Z+4-Type of Identification:
Owner Builder Affidavit **ALL INFORMATION
s rs�'��ri;r. HIGHLIGHTED IN
'J "' City of Atlantic Beach Building Department GRAY IS REQUIRED.
"" j800 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 ATA 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 WITHI-ALLTHE REQUIREMENTSUIFOR THE ISSU NCE OF AN OWNER-BUILDER PERMIT.
(
Job Address: `L 4 1 (-Q , 0 cS
Owner Name: in\ QL\Ct g�0t_t)R Phone Number: `l o4-37z - 7 ( 7Z-
Mailing Address: VG-<Y) •--2.____ 44/1..
City: �CLL[�G1 State: r-L Zip: 6 zz,35
Notarized Signature of Owner /hi(A,.v�l -6 ti^' Z'1 '����
The egoing ins rument was acknowledgedbeforeme this day •'�_ 0. , 2019, in the State of Florida, County
of e (/�Q
Signature of Notary Publt 1114
�� c/-1111\ _
[ ] Personally Known OR [ ] Produced Identification
od
Type of Identification: u--� V
Tai,C4NDLESPEACIER Updated 10/24/18
kilt COMMISSION#FF 921951
xFIRES October S,2019
,-).;cd1n:JPNc ar PublicIJndern'i(crs
,i • Sep. 12. 2005 4:22PMNo. 5082 P. 21/22 .
MAP SHOW-121k;W121 BOUNDARY SURVEY OF'
A PMT OF GOVERNMENT LOP 2, SECTION 17, TOWNSHIP 2 SOUTH, RANGE 29 EASE', AND MORE PARTICULARLY
DIBEa•AS FOLLOWS: BEGIN AT THE SOUTHWEST C70'RNER OP. YAI',2, : • , ON THE EAST LINE OF
'PRANCES AVENUE, AS SHOWN ON CONNER'S REPLAT RECORDED IN RLAT BCX)K PAGE 16, OF THE CURRENT.
PUBLIC REOORDS. OF DUVAL COUNTY, FLORIDA, RUN 500TH' ALONG EAST LINE eF FRANCES AVENUE, A DIS-
TANCE OF 86.00 Atxr FOR THE POINT OF BEGINNING OF DESCRIPTION OF THE LAND,HEREIN CONVEYED;
THENCE SOCJPH•ISN THE EAST LINE OF SAID FRANCES AVENUE'48.00 FEET; TFENC E EAST 176.00 F't.WT; .;I -
ENCE NOR'IIIERLY PARALLEL TO SAID FRANCES AVENUE 48.00 P'r'rii' THENCE WESTERLY 176.00 rtrT,MORE
OR LESS TO SAID'EAST LINE OF FRANCES AVENUE TO POINT OF BEGINNING, SAID LOT BEING A PART OF
THE PROPERTY KNOWN AS THE (SCHOOL LOT) AS'SHOWN ON THE ABOVE MENTIONED RECORDED PLAT.
1
•
LOT2 '
DONNER'S REPLAT FOUND cm•� •
CROA/DELL •
8L OCK. 1 1
• , .
X . P.O.O. •
•
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•
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NUMBER IBI • y i
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" � ' NFLY, Dts
m ' dCG ,.1 oCRITE ORIVE CCi fAtlantic
Beach
Z 1 ENCROACHMENT oning Departmenti .
7 Plannin
„ 1 hi„ +p^rcva! verifies compliance with aDDI =•
e "°
•
.:r i,.n �bdi,�is,on and other local t2nd' '
"'vat'-f'''''1 egulations, but does not can �(ute
NOTES: iuva' Inr the.issuance of permits. Comp!{ice
I. ANGLES ESTABLISHED IN THE FI6<�D,�1
B.FIELD WORK COMPLETED 0/ID/3s. •:ill. r"In:ida Building Code and all other appli able
local Mate and Federal permitting require enta
rnut be verified by signature of the City ofAt antic
o' 10. 4O' gach Building Official prior to the isauan of a
Ilding Pernlit�
roved 8 '^
oRAPWic ■ u/
I. .. Jo' 1ti1 D y'• • C . e
Date; '
1.Co` J ,O to•:."••" atrector
REVISED cEATIFICATIDN$e/l7/11 ,,.,,.,• ,
P Y. 1'11tMN.Utl NE.FENFNC€ PnINl ,, etANY Of*INTERSECTION P.C.c. POINT Of COVPOUND CURVE T L MO.CENT
P...•P. rft leMANEN1 (ION IN14.PtIINT" * •Y RICHT OF MAY • A/C AIR CONDITIONER P DELTA AMR;
P LC, i‘.Ail! r{ I •.r.11HC1:MY.NT ,,. sd•rICIAL RECORDS,VOLUME P,T• POINT,,.TANO.NDY R RAl:ull6
P..,J1. 1'140 t.T bbuINNINO O.d. IJIAD BOOK N,D•VA:NATIONAL GEODETIC VERTICAL DATUM DLR.YLOCK
P. t'.,u;T OF CURVE PU PACE " R.LS, REOIS1ERED LAND SURVEYOR
P• I •.T r,F Id VERS! dJRVE ' L.9. I O�NSI DUgINESS 4
City of Atlantic Beach a. APPLICATION NUMBER
BuildingDepartment (To be assigned by the Building Department.)
p SEP 30 201 Fig 1� _0 11
800 Seminole Road C
c.f Atlantic Beach, Florida 32233-5445 e.
y Q
� �.- Phone(904)247-5826 • Fax(904)247-5845_' /Z-.7
/l 1�!�,i 9r E-mail: building-dept@coab.usDate routed: ( 1
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1 —t`-t 1— R P&D,t s ( s-It C Dgpartment review required Yes No
/Build'.•
Applicant: UD NE—(L 'fanning &Zoning
Tree s • - •
Project: Public Worms!
��� lic Utilities ...)
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: t /Approved. ['Denied. ❑Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONINGReviewed byi- � ,,ice' -i .1a:". .f.
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied. ❑Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ['Approved as revised. ['Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017