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1021 ATLANTIC BLVD 1011 COMM24-0029LAN:,,,, BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY f ' , City of Atlantic Beach Building Department si PERMIT# 800 Seminole Road, Atlantic Beach, FL 32233 ALL information required to process ars P Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address ib2( 4.17.4rierk EzAM . 4/ /O/(RE#e orybryi Z-1-bvZ Legal Description ei PQOOH'( Valuation of Work(Replacement Cost)Heated/Cooled SF ,4 45. F Non-Heated/Cooled SF Class of Work: New Addition Alteration ®Repair Move Demo Pool Window/Door Use of existing/proposed structure(s): [1ICommercial ['Residential • If existing structure, is a fire sprinkler system installed?:Yes AT No Will tree(s)be removed in association with proposed project? Yes (Must submit separate Tree Removal Permit) IN No Describe in detail the type of work to be performed: SMG au6K &-y1571,76 5:P.44c6 /IaQuc ie CAAAES RF©uli26't /c&SMic °MI? Florida Product Approval#For multiple pr ducts use Product Approval Information Sheet) Property Owner Information Name , 'P/ P.,er,11 LLC l N?%//d Phone 8/3. 30Z. Zij3 j Address /621 4 I/C $UJA , f/O// City 47(A //C State F. Zip 3Z 33 Email n/a_/f A4 2t$ 4.(L_(in7Owner or Agent(If Agent,Power of Attorney or Agency Letter Required) Contractor Information Name of Company 4/4 Phone Address City State Zip Qualifying Agent State Certification/Registration# Email Job Site Contact Number Worker's Compensation Insurer OR Exempt Expiration Date Architect's Name Email Phone Engineer's Name Email Phone 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 city/county, and there may be additional permits required from other governmental entities such as water management districts,state agencies, orfederal 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 YOU PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE SITE OF THE IMPROVEMENT BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. ignature of Owner or Agent) Signature of Contractor) Signed and sworn to(or affirmed)before me this I' day of Signed and sworn to(or affirmed) before me this day of Jvli 2.13 Ly by g I( by Signature of Notary , Signature of Notary Personally KnAP O111? •roduced Identification Personally Known OR [ ] Produced Identification Type of Identification: Type of Identification: i'`/.'.. GRANT GARRETSON I ffray Notary Public-State of Florida1:,®!.1 Commission#HH 403616 4 ° rt','' My Comm.Expires Jun 3,2027