555 Selva Lakes Cir Deck Submittal ,•s
:- _,;., Building Permit Application Updated10/9/18
rCity of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
,1 9',-- IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: ......6:7‹ . ' 10"Q L/-e5 C/."C,/e Permit Number: C
Lega Des ption --- i -c y3 is I S' RE# t 7 ZO Z. /— S SZ v
Valuation of Work(Replacement Cost)$ •s <-01 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: JXNew ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial ®Residential 'JECElE
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No = AUG 1 Z 2021
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit{eparate Tree Removal mit) J11\lo
Describe in detail the type of work to be performed: ••y,
criu rd' ,— ?2 �
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name .Jc/7n >a/ ea/7i- Address .S .--5.....S4"/,‘,- Za/ ....s (ii.e//e
City x]776,->7L State l'6- Zip 3"2.z._ . j Phone 4oy .>yi - >7/J A ( 7 i ,
E-Mail ' r / ,..i-v -2G 3 y a of • ('or!.
/
Owner or Agent(If Agent, Power of Attorney dr 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' stallations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all wor, ill be performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a separ. - permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS,POOLS, FURNACES, BOILERS, HEATERS,TANKS, . d 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 OF COMMENCEMENT.
j (Signature of Owner or Agent) (Signature of Contr. .r)
ned and sworn to(or aff -.)before e this Zda of Sighed and sworn to(or affirm before me this day of
��tl) - ,1 ,b 7h 'i. !11 e4L1 b
Sigpature o IV= _, (Signature(Signature of Notary)
MERGER
ti�pY PUg,�, 1'Oidl G;NdLES,
;i�•• c N#GG353178
[ ]Personally Known OR : Lk :�:[�� tglaylPniOrP23
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[ ]Produced Identification C \ :-..--.,,.. .....ii-[ ]Rrb rcr4 `r[i�}inn iters
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Type of Identification: `,•• '-��-
Owner Builder Affidavit **ALL INFORMATION
:rf ���� HIGHLIGHTED IN
', City of Atlantic Beach Building Department GRAY IS REQUIRED.
•
800 Seminole Rd, Atlantic Beach, FL 32233
fe 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$5,000 PENALTY UNDER FLORIDA STATUTE NO.455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE
OWNER SHOULD PHYSICALLY SEE THE COUNTY"CERTIFICATE OF COMPETENCY" OR THE FLORIDA"CONTRACTORS
CERTIFICATE"TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904-
247-5826 OR BUILDING-DEPT@COAB.US) IF IN DOUBT.
V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I
COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT.
Job Address: .1.75-V '/ 4 Aes C44-C'/e. &/Ztv11Z ' 1% /L
Owner Name: ,✓ 6 16i i �} Phone Number: .k/-- 7/6_c
Mailing Address:f5s/J 5i// /'ti2'c (;;41e€'- City:070,,`1j4 •Q;r0.4 State: / . Zip: Z2,2 73
Notarized Signature of Owner ‘G
MgThe instru ent was cknowledged before me this I day , 202,(n the State of Florida, County
of
Signature of Notary Public
[ ] Personally Known OR [ ] Produced Identification
Type of Identification:
wanm+mxcai:aas
TONI GINDLESPERGER
MY CQi$"a1I$SIQN#GG 333178 Updated 10/24/18
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`ANVdl4OD AIMV IVno nrIJ.IL Z21VMILS `Sx0Vf 'a aLLVx `NOLAVrlo 'a aItoaosu :OJ, aaiai iao
NOTICE OF COMMENCEMENT
State of Tax Folio No. 7Z OZ 7- S 5 20
County of _ 9rc^r-,t
To Whom It May Concern:
The undersigned hereby informs you that improvements will be made to certain real property, and in accordance with Section 713
of the Florida Statutes,the following information ii state4l.jn this NOTICE OF COMMENCEMENT.
Legal Description of property being improved:P j o Y6 p`7, It /I Q a 4 /1 13 Ldr62
Address of property being improved: ...3-5< SEa _
General description of improvements:
Owner: Jc9( (96,1 eci % Address: ;C5 L 1 ���� ic-g s Orel
Pe-3i'Owner's interest in site of the improvement: i"E"L'--3i'c��,✓` '
Fee Simple Titleholder(if other than owner):
Name: r) i. 'l er
f t J —
Contractor: 1�O/,-, �"r er _
Address:
Telephone No.: Fax No:
Surety(if any)
Address: Amount of Bond$
Telephone No: Fax No:
Name and address of any person making a loan for the construction of the improvements
Name:
Address:
Phone No: Fax No:
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may
be served: Name:
Address:
Telephone No: Fax No:
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section
713.06(2)(b),Florida Statues. (Fill in at Owner's option)
Name:
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is one(1)year, ot44.4,date ofOrliflogNtiteBeWERa diff3rent date is
•
specified): { „: MYCOMMISSION#GG 353178
t ,r.. F
.- .y; EXPIRES:October 6,2023
THIS SPACE FOR RECORDER'S USE ONLY OWNER I, °F" Bonded Thru Notary'Public Underwriters
Doc#2021209534,OR BK 19861 Page 1137, Signed: A//// Date: 7
Number Pages:1 Befo ,me this .2 da • a in the County of Duval State
Recorded 08/12/2021 04:14 PM, ,�
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL Of. .
orida,h. personally ape & _ , - •_ en L
COUNTY Notary Pubic at Large,State.f •rida,Cif • i uval.
RECORDING $10.00 My commission expir- .
Personally Known: m . a- •_. or
Produced Identification: