10-10-22 Attachment B - SCM Minutes - SSS
(6;) oU� CQ� S o
Building Permit Application t,f,J:rrrd,U�11F
City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@ au IS REQUIRED.
uwr K= u Perm RES022-0026
Job Address: -]
1 `-K. ._A+ �Atr jct L t` Permit Number:
legal Description Lef .� 4-i P' ►.., j, t t.t`r1) V ' REI! -
Valuation of Work(Replacement Cost)$ ( Heated/Cooled SF Mr''r Non-Heated/Cooled
• Class of Work: DNew DAddition DAlteration /Repair//OMove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): I liCommercial (31 esidential
• If an existing structure,is a fire sprinkler system installed?: [(Yes (' No //
• Will tree(s)be removed in association with proposed project?EJYes(must submit eparate Tree Removal Pr *N
rmit i • o
Describe In detail the type of work to be performed: �v�� ji4 q,,, icr cA/Y%7
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name +�tr. _. �^ Address '7)5 �+�6[f`v..
City x-11 . 1rr. , • -- State FL Zip 3)- -.3) Phone V1- 303- `7"?L9
E-mail n, •n .:tf.'1:•1 16 c,l,'tn( .c.M
Owner or Agent(If Agent,Power dAttomey or Agency Letter Required)
Contractor Information
Name of Company_ /v A' _ - _ Qualifying Agent
Address_..... — City.__ ____.—.._..... State tip_---._
Office Phone Job Site Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone if
Engineer's Name&Phone ft
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 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.
-
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(Signature of Owner or Agent) - (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
MGcI ,aoa))- ,by aih F kn , by
dCtr • , ip¢.Irtg4b9• (
7579 (Signature of Notary)
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,` EMPIRES:October 21,21)24
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. MAP SHOWING BOUNDARY SURVEY 01RECEIVEO +NJrrA. t 1•u1
LOT 10 BLOCK 5 ACCORDING TO THE PLAT OF
r,OYAL PALMS UNIT ONE
AS RECORDED IN PLAT BOOK 30 , PAGE(S) 60 AND 60A OF THE CURRENT
PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA.
CERTIFIED TO: JOHN BRANDON FANNING AND KELLY CASSIDY FANNING,
FIRST AMERICAN TITLE INSURANCE COMPANY,
FIRST INTERNATIONAL TITLE, INC. AND
UNITED WHOLESALE MORTGAGE.
1n
N N ' I I LOT 21
N a vwE oN BLOCK 5 LOT
9
¢' ASSOC. I S 85'20'02" E 80.55' (R) •
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i//y ` 3846 BLILLE, FLORIDABOULEVARD LORI OTIK mMOT KAMM�>IuA T NM SUPPWKO,M A m1o1M<n uu.Y
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I HEREBY CERTIFY THIS SURVEY WAS DONE UNDER MY a maawrt t K110ILT IC) 0/A •1fo1 RAT
DIRECT SUPERVISION AND MEETS THE MINIMUM TECHNICAL ' C'ot Mrtr'"cA° 0 • c1 IO'PIPS 01 Maur
STANDARDS FOR LAND SURVEYING PURSUANT TO CHAPTER 5J-17.050 can cavoes •A11DC PRY a U 6411
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BY: •LE_ B. HATC IER FLORIDA C���ICATE NO. 3771 �ry n _ vv.,,, MROM ICE
C • 3- L STARUNG FLORIDA J•TIF1CATE NO. 4579 Pc POINT Cr a t mar-ovattAo mil'
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