195 Main St Fence Submittal Building Permit Application Updated 10/9/18
i City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
.cno9'• IS REQUIRED.
Phone: (904) 247-5826 Email: Buildin -Deptecoab.us
Job Address: 1q�J M0;(1I��jjCA-):-Permit Number:
Legal Description1.--04-4A t-�Irr)Ck 89 A}1 . ' • 5<(-- RE# (S —^ 1 ' 3
Valuation of Work(Replacement Cost)$ 4) 55 D • J Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration Repair ❑Move ❑Demo ❑Pool goggIVE
• Use of existing/proposed structure(s): ❑Commercial Residential) ! JUL 0 9 2021
• If an existing structure,is a fire sprinkler system installed?: ❑Yes tivo
• Will tree(s) be removed in association with proposed project? ClYes(must submit separatA1'r' o
Describe in detail the type of work to be performed:
Re puCE-1)(1e n 6* cold c c;-E-=k-En -ie nC-C--
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name Kenne- �1 T-1�L' j1 Address es( ,� �E
City A- 1/4 C .ea tate , Zip Phon `
E-Mail C-N-SPI A 1 7 I-)0 e.3 o
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❑ 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 maybe 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
RECORDIN YO Rl� NOTICE OF COMMENCEMENT.
(Signature of Owne o Agent) p (Signature of Contractor)
Signed and sworn to(or affirmed)before me this / day of Signed and sworn to(or affirmed)before me this day of
Jul}/ , 2.0 21 , by \<e-,.met11 �J \i , by
- a
;f. - • otary (Signature of Notary)
.."'' Coals bn•ooua8l$
Apill 29.2073
[ ]Personally Known 0 .'k K'i lowT� Faii mow 006,30mig [ ]Personally Known OR
[4-Produced Identifica.•• [ ]Produced Identification
Type of Identification: FL. Dr. Type of Identification: -
- .Jvi Owner Builder Affidavit **ALL INFORMATION
Vise `',, HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
s r, 800 Seminole Rd, Atlantic Beach, FL 32233
``no— 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: I (•s5 \i\ I _` , 1`1---(an-I ► k ' . . 3 25_5
Owner Namele,(1Y1e 11 I CIQPhone Number:
A r
Mailing Address: \ 5 in ,f ee-f- City: `A j,4 CIifjc jr State: -0 Zip: 32Z 33
Notarized Signature of Owner
\--VA'16/CH
The fq�egoing nstrument was acknowledged before me this da of Jv L I , 20 21, in the State of Florida, County
of Cr...) //��
Signature of Notary Public
in/tec/1
� .�•' CHRISTIAN GILES Personally Known OR [1.4'froduced Identification
:! 1.1 MY COMMISSION#HH 117153
:+1. w°' F 13,2025 pe of Identification: L V�
Bonded Thru Notary Public Und«wden
Updated 10/24/18
Fence Addendum Updated 1/14/2021
>> City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233 PERMIT#
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 3i.:a 33 Date:
fr a.(tr 44-
Property Type: Lot Type/ Features:
1�J Residential ❑ One Street frontage(interior lot)
❑ Commercial More than one street frontage(corner lot,through lot,
etc.)
0 Swimming Pool
Fence Material: Fence Height (select all that apply):
IV Wood 0 Four Foot (4ft)
❑ Chain Link t/Six Foot (6ft)
❑ Vinyl 0 Other
❑ Block/Stone (Plan details required for footings and/or
retaining walls)
❑ Other
Fence Location:
Please submit an accurate and current boundary survey 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?
0 Yes (must submit separate Tree Removal Permit)
4(No
Conditions of Approval:
• Roll off container company must be on City approved list. Roll off container cannot be placed on City right-of-way.
• All old fencing and debris must be removed from job site by contractor or homeowner.
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.
MAP SHOWING BOUNDARY SURVEY OF:
LOT 2, BLOCK 84, ATLANTIC BEACH SECTION "H" AS RECORDED IN PLAT BOOK 18, PAGE 34 OF THE
CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA; TOGETHER 'WITH A PART OF FORMER MAIN STREET
(AS CLOSED BY THE CITY OF ATLANTIC BEACH RESOLUTION NO. 65-75-5), ALL BEING MORE PARTICULARLY
DESCRIBED AS FOLLOWS: FOR A POINT OF BEGINNING COMMENCE AT THE SOUTHWEST CORNER OF SAID LOT
2; THENCE N.89°00'15"E. , ALONG THE SOUTH LINE OF SAID LOT 2, A DISTANCE OF 91.30 FEET TO A
POINT ON THE SOUTHWESTERLY LINE OF THE AFOREMENTIONED CLOSED PORTION OF MAIN STREET; THENCE
N.54'37'00"E. , AT RIGHT ANGLES TO THE CENTERLINE OF SAID CLOSED PORTION OF MAIN STREET, A
DISTANCE OF 25.00 FEET TO SAID CENTERLINE; THENCE N.35'23'00"W. , ALONG SAID CENTERLINE OF THE
CLOSED PORTION OF MAIN STREET, A DISTANCE OF 43.48 FEET TO AN INTERSECTION WITH THE EASTERLY
PROJECTION OF THE NORTH LIME OF SAID LOT 2; THENCE 5.89°00'15"W. , ALONG SAID NORTH LINE OF
LOT 2, A DISTANCE OF 87.64 FEET TO THE NORTHWEST CORNER OF LOT 2; THENCE S.O1°17'45"E. , ALONG
THE WEST LINE OF LOT 2 (THE SAME BEING THE EAST LINE OF A 50 FOOT RIGHT-OF-SWAY NOW KNOWN AS
MAIN STREET), A DISTANCE OF 50.00 FEET TO THE POINT OF BEGINNING.
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r"----%, "*-1,,,... NOTES ".
-z- 0•,'0` BEARINGS ARE BASED ON THE EAST RIGHT-OF-WAY LINE OF MAIN
rte- 49STREET AS BEING S,OI.17'45"E.
4/,- NO BUILDING RESTRICTION LINE BY PLT,BUT THERE MAY BE
( -��''.,z-,
1, RESTRICTION LINES OR EASEMENTS THAT AFFECT THIS PROPERTY
I ?i �' BY ZONING OR RECORDED IN THE PUBLIC RECORDS OF THIS
COUNTY THAT ARE NOT SHOWN ON THIS SURVEY.
THIS PROPERTY LIES IN FLOOD ZONE "X" BY FLOOD MAPS
REVISED 4/17/1989, COMMUNITY PANEL NO, 120075 0001 D.
KENNETH W, a KAREN E. HOLIDAY :
I HEREBY CERTIFY TO:HABITAT FOR HUMANITY OF THE
JACKSONVILLE BEACHES D/B/A BEACHES HABITAT : ATTORNEYS' TITLE
INS, FUND, INC. : HAYWOOD M. BALL, ATTY.
THAT THIS SURVEY MEETS THE MINIMUM TECHNICAL
STANDARDS AS SET FORTH BY THE FLORIDA BOARD OF
PROFESSIONAL LAND SURVEYORS, PURSUANT TO SECTION
472.027 FLORIDA STATUTES AND CHAPTER 61G17-6
-,:; FLORIDA ADMINISTRATIVE CODE,
DURDEN LAND 'i&%fL,_
SURVEYORSINC. PROFESSIONAL LAND SURVEYOR 4707 F RID
---:-\-- \--„ H. BRUCE DURDEN, JR.
DATE: NOVEMBER ZU, 19 3`5
1103 SOUTH THIRD STREET SCALE: =20'
JACKSONVILLE BEACH, FLORIDA 32250 .
(904) 249-7261 FAX.(904) 241-1252
THIS SURVEY NOT VALID UNLESS THIS PRINT IS EMBOSSED WITH THE SEAL OF THE ABOVE SIGNED.