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751 Atlantic Boulevard COMM24-0034 BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY 1` tt' City of Atlantic Beach Building Department PERMIT# COMfy\ ZQ-` Dr 800 Seminole Road, Atlantic Beach, FL 32233 **ALL information required to process Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address 7 5"I 14+-i l C.f (411( is k/cL I4t4V lC.seociA Pl'3223-5 E# 1 ! 7( 4 5 -0060 Legal Description 3S -Zs-z°E Z. 14 B D . CAs Te© 1 Reel) o/ . Valuation of Work(Replacement Cost) C 3 Cc, 3 ©� Heated/Cooled SF Non-Heated/Cooled SF i 6138-1777 •Class of Work: ❑ New ❑Addition ❑Alteration ❑Repair EMove EDemo ❑Pool ❑Window/Door • Use of existing/proposed structure(s): ❑Commercial ❑Residential • If existing structure, is a fire sprinkler system installed?:❑Yes❑No •Will tree(s) be removed in association with proposed project? ❑ Yes (Must submit separate Tree Removal Permit) ❑ No Describe in detail the type of work to be performed: r f\` e_r t o r hut (0 o c 1' -- n d C h A-lt e 40(y., c_1 o rc_J--\ Florida Product Approval# (For multiple products use Product pprova formation Sheet) Property Owner Information/� Name 61,_\)0(f 3fj 1 j J\/ S pG V) �Q ( Phone c tf t--(( )77 —L 7 3 Address 1 S ( 4+1 Cd✓1'�'-(L ( City i4(CAvt�IC jCV1 State .F Zip 32.233 Email bObb'r@ beocrk€5\C)'I finer oTr Aent(If Agent, Power of Attorney or Agency Letter Required) Contractor Information Name of Company Phone Address City State Zip Qualifying Agent State Certification/Registration# Email Job Site Contact Number Worker's Compensation Insurer OR Exempt ❑ Expiration Date I� Architect's NamEG efal Gt t \d,e 1/1 Email N.) eV10l1rC,lnt�tG�e t'a-'PR�ne'0 M cC)LJ Engineer's Name Email Phone 1S4.-127,6 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, 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 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 ATTOR Y BEFORE RECO DING YOUR NOTICE OF COMMENCEMENT. (Si nature of ner r Ag t) (Signature of Contractor) Signed and sworn to(or affirmed)bef me his IS --d\ay9f,, Signed and sworn to(or affirmed) before me this day of AU4".0 by 0.' ` by Signature of Notary c--- Signature .f Notary [ ] Personally Known OR [ ] Produced Identification [ ]Personally Known OR [ ] Produced Identification Type of I t!t?1T"""� . Type of Identification: TONI GINDLESPERGER `' mn MY COMMISSION#HH 407122 �.7� EXPIRES:October 6,2027 FOf F�: