1810 SELVA GRANDE DR RENC21-0096 ze.",! Building Permit Application Updated 10/9/18
F.:
City of Atlantic Beach Building Department **ALL INFORMATION
r� , - HIGHLIGHTED IN GRAY
���, �,,; 800 Seminole Road, Atlantic B ach FL 32233
Phone: (904) 247-5826 ETIl: Building-Dept@coab.us IS REQUIRED.
Job Address: /F/O .5' VA 644icz9'1 1�✓L, 12P-8 Permit Number: t �� ( ' 00 1(
Legal Description 5 .( I'4 D L)'LA- Z,® 7-- 9-- RE# /69 191 , SGG
Valuation of Work(Replacement Cost)$ -g 9 2co Heated/Cooled SF Non-Heate t E gI ' 2.
• Class of Work: ❑New ❑Addition ,Alteration ❑Repair DMove DDemo DPool DWindo oor
JUL
• Use of existing/proposed structure(s): DCommercial (Residential 4 2021U
• If an existing structure,is a fire sprinkler system installed?: DYes I'JtNo BY
• Will tree(s) be removed in association with proposed proiect? DYes(must submit separate Tree Removal Permit) ❑No
Describe in detail t e ype of work to be performed: / 4.)coo ieZi V 4v AC •L 36-o r'_F"
Florida Product Approval# for multiple products use product approval form
Propertywner Information
Name k/(l9/ L- C--4-12 - Address /J/U ` 1 I/1 Cli2-4A-47 2A
city /)-1- TYL 5 )) State A1 Zip 3)..,,2 3Phone ja / -3-- S — J 1-r—
E-Mail b c:&4-. Sc7,1,0=)? 7o 6 laboa) i_r i}.
Owner or Agent(If Agent, Power of Attorn y or Agency Letter Required) ,c J2-Q
Contractor Information / //t�,.,,
Name of Company SCO 1-1 V I/1(r-9i / c Qualifying Agent--401 " ,T'i k-,“
Address 2 ,2 S .51- -737))1.2) (�.//'� __ I- City 7/ Gwll i )te• State /•'C Zip 7)..)2 Y(p
Office Phone 76Y— 307- b7 2 )-- Job Site Cont.• Number
State Certification/Registration# E-Mail
Architect Name& Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt o Expiration Date
Application is hereby made to obtain a permit to d• he work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit a . that all work will be performed to meet the standards of all the laws regulating
construction in this jurisdiction.I understand at 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
RECORDI U:001.bTICE OF COMMENCEMENT.
'Sig"of wner or Agent
,� ) (Si! .ture of Contractor)
-
ned n. swo'to(o yi �d before me his/ day of Signed and swor• o(or affirmed) before me this day of
O�" ,ZUz/,by'&k i� O� .by
' na . �11� : (Signature of Notary)
Al-Personally Known • 2:0:4-*;,,, TONT GINDLESPERGER� [ ]Personally Known OR
• • MY COMMISSION#GG 353178
[ I Produced Identifica : `'� +: [ ]Produced Identification
Type of Identification: ';+,:.. ,e,= - ars Type�n`�id- EXPIRES:October 6,2023 T e of Identification:
01A, „, Owner Builder Affidavit **ALL INFORMATION
n
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 HIGHLIGHTED IN
"'r 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: IS-lo U' &#+2/ 6liv .. P/t. 46-
Owner Name: e/c27 C. Yx-! c q
/ Phone Number: /� -sys-- I' s
Mailing Address: cct_`()'e, City: State: Zip:
. e
Notarized Signature of Owner v
�
•
The`f regpin ins tru ent was acknowledge) .efore me this(`-' day . 11! ,AZ , in the State of Florida, County
of J J V
i
i
Signature of Notary Public —_ • a
[,]-Personally Known OR [ ] Produced Identification
Type of Identification:
trK•v•Poq''.. TONI GINDLESPERGER
r. .. Updated 10/24/18
n. :,: MY COMMISSION#GO 353178
'vim' �,° EXPIRES:October 6,2023
1l p
'4', ;f;;,•••oBonded Thru Notary Public Underwriters
�j:
Fence Addendum Updated 1/14/2021
x, ' 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: Date:
I /e 5C-L (14 6 &)-)opfi 3 yz... 41 "—r-s 3 /it7)b(i.22_)
Property Type: Lot Type/ Features:
(Residential 4 One Street frontage (interior lot)
❑ Commercial El More than one street frontage(corner lot,through lot,
et
i''❑ Swimming Pool
Fence Material: c Ince Height (select all that apply):
si(Wood ❑ Four Foot(4ft)
❑ Chain Link i Six Foot (6ft)
❑ Vinyl ❑ 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)
[t3,4Vo
Will tree(s) be removed in association with proposed project?
❑ Yes (must submit separate Tree Removal Permit)
*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 SHG WING BOUNDARY Su RVEY OF
LOT Z BLOCK — AS SHOWN ON MAP OF
1 cE-L_.A,r,=-- ---ri�247--
AS RECORDED IN PLAT BOOK 38 PAGES - aOF THE PUBLIC RECORDS Of DUVAL COUNTY. FLORIDA
CERT1FIED FOR: tLic..+ - L y • Joa" 1L Cr R-C'e n- Po V a►�JaTlo...0 4
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NOT VALID UNLESS D(BOSSED MMTH SEAL OF THE UNDERSIGNED. BEARINGS BASED ON re--f+--T UNE AS SHOWN
THE PROPERTY SHOWN HEREON APPEARS TO LIE WITHIN FLOOD HAZARD ZONE AS SCALED FROM FL000
INSURANCE RATE MAP 0001FOIR THE CITY OFA-ri_.. 12j , FLORIDA. DATED 4- r'7-SG . AND
IS SHOWN AS A COUR/L.NY ONLY AND DOES NOT CONSTITUTE A CERTIFCATTON OF SAME
TRI-STATE LAND SURVEYORS, INC.
8411 BAYMEADOWS WAY SUITE 112, JACKSONVILLE, FLORIDA 32256 (904) 731-7235
LEGEND
I HEREBY CERTIFY THAT THE ABOVE'LANDS WERE SURVEYED UNDER MY
•°01"61"'" RESPONSIBILE SUPERVISION AND DIRECTION, THAT THERE ARE NO
•RCN°0t ENCROACHMENTS EXCEPT AS SHOWN AND THAT THE SURVEY SHOWN
M""'w I
`s""I HEREON MEETS THE MINIMUM TECHNICAL STANDARDS SET FORTH BY THEun".1 ,1A
oPINCE (7 ) FLORIDA STATE BOARD OF PROFESSIONAL SURVEYORS AND MAPPERS
moN cotTZ
PURSUANT TO SECTION 472.027, FLORIDA STATUTES.
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LILL 111/1119 ICSTIOCTION II(
carr WO/NT LARRY G EDDY. P.LS No. 4744
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