179 Pine St Fence Submittal Building Permit Application Updated 10/9/18
r ` City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: NL c Sf- /7� Permit Number:
Legal Descriptior 10-(a 16-ZS '2(c _ Cc`i 11(-6v c- ti VZ (,Q{-(,77 RE# (7J 3S— c3O?(
Valuation of Work(Replacement Cost)$ /C90 U Heated/Cooled SF Non-Heated/Cooled
• Class of Work: iiiKew ❑Addition ❑Alteration Repair ❑Move ❑Demo DPool DWindow/Door
• Use of existing/proposed structure(s): ❑Commercial 4-Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes o
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit)-bNo
Describe in detail the type of work to be performed:
Florida Product Approval # for multiple products use product approval form
Property Owner Information
Name {�.�rc e.( LC 1 S , Address / 7(l
City 7/-4( {'c lar State Zip 3 2 2- 3 3 Phone lex(- c) 2 (- (OC'"z
E-Mail /4. (c c c-(/7 cZ (cam) c3-7 c,
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 Nur ser
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 th- ork and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and t•: 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 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
RECORDING YOUR NOTICE F MMENCEMENT.
��� (Signature o Ow, r Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this /(12day of Signed and sworn to(or affirmed)before me this day of
J 1) L`I , 2021,by ✓ /i`c L,e ( I c%c cr,'r. by
1 ,
(Signature of Notary) (Signature of Notary)
[ ]Personally Known OR • CHRISTIAN¢IQESonally • own OR
;;ia•• •�.=;
[produced Identification0; jar ;«: MY COMMISSION tl pfbt131631 I ratification
Type of Identification: Ft, 17L +.'.'*.'P EXPIRES:Apr1fy"i2011r{entif tion:
` ` TWwsbu'Public Underwriters
•L'tr�„ Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
` City of Atlantic Beach Building Department GRAY IS REQUIRED.
i
V° 800 Seminole Rd, Atlantic Beach, FL 32233
`' t)II9." 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.
1 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: 1701 i I mac. SIC 4 0 t`6,- 3 2 2 3 3
Owner Name: PI iC. in c e(� ( t1-7 cll.i\� n Phone Number: goy- �z /- 1002
Mailing Address: ` 7y t' i t, L .c-t- City: A-6 State: FC Zip: 3 Z-Z 33
Notarized Signature of Owner 7Z1
/
7/
The foregoing instrument was acknowledged before me this )(2 day of J VLy , 20 , in the State of Florida, County
of bUVfl1.
Signature of Notary Public / ' /lam!
CHRISTIAN GILES [ ] Personally Known OR [ Oroduced Identification
.z.: ! , ;.: MY COMMISSION#HH 117153
EXPIRSS:April 13,2025 Type of Identification: rL q f
4.2,,,M1�P' Bonded Ttru Notary Public Undenrilets
Updated 10/24/18
BOUNDARY SURVEY
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SURVEY NOTES
CONCRETE DRIVE CROSSES THE PROPERTY LINE ON WESTERLY SIDE OF LOT
., N J _o a
E ` 1 F_'1'_C' e o
��P �r � ,/`TARGET
° No.6415 y SURVEYORS CERTIFICATE
‘...
. . I HEREBY CERTIFY THAT THIS BOUNDARY SURVEY
ISA TRUE AND CORRECT REPRESENTATION OF A SURVEYING,
.. SURVEY PREPARED UNDER MY DIRECTION. U V i�Y .oma
"• a• NOT VALID WITHOUT AN AUTHENTICATED ELECTRONIC LB#7H93
STATE OF . SIGNATURE AND AUTHENTICATED ELECTRONIC SEAL,
P'04 F� o R l o f oP ORARAISEDEMBOSSEDSEALANDSIGNATURE. SERVING FLORIDA
'( 8 V qV E+ Kenneth J.
Osborne Digitally signed by
Kenneth J.Osborne 6250 N.MILITARY TRAIL,SUITE 102
":".. .."----
WEST PALM BEACH,FL 33407
Date:2021.011.1522:50:31 PHONE (561)640
(SIGNED) -04'DO' STATEWIDE PHONE (8000))22
KENNETH J OSBORNE PACF 2(W 21 ArCFS STATEWIDE FACSIMILE (800)741-0576
PROFESSIONAL SURVEYOR AND MAPPER 4E415 I� I I T]: I) WEBSITE: httpJ/targetsurveying.net
..0-Ant, Fence Addendum Updated 1/14/2021
City of Atlantic Beach Building Department
V 800 Seminole Road, Atlantic Beach, FL 32233
-raw. PERMIT#
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: Date:
12I'v? 07 /AV 2 /
Property Type: Lot Type/ Features:
Of Residential eOne Street frontage (interior lot)
❑ Commercial 0 More than one street frontage (corner lot,through lot,
etc.)
0 Swimming Pool
Fence Material: Fence Height (select all that apply):
Wood 0 Four Foot(4ft)
❑ Chain Link %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)
tN o
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.