1672 Atlantic Beach DR RESO24-0086 Application Building Permit Application Updor8d1019
City of Atlantic Beach Building Department --ALL INFORMATION
800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
/Ph/�o/1ne:/((904) �2r4t7-5826 Email: Building:-Dept0coab.us /l IS
REQUIRED.
Job Address: r472�y ATI-riI�nI1I� btAq DDiyt Permit Number: m - \JOND
Legal Description 4461/2 eke_l'yclagtowtg , &1 REp //. J
Valuation of Work(Replacement Cost)$ 2J 5 0 -L74 Heated/Cooled SF MP Non-Heated/Cooled lu n
• Classof Work: ❑New OAdditlon XAlteration ORepair []Move []Demo OPool OWindow/Door
• Use of existing/proposed structure(s): []Commercial '*esiden4i\al'
• If an existing structure,is a fire sprinkler system installed): Oyes IDNo
• Will trii,$)be removed in association with proposed proiect?Eyes Imust submit separate Tree Rennova'.
Describe in detail the type of work to be performed: -rL,`¢P CA;6rD&I Gq4 6a, Ii
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Florida Product Approval g _ I for multiple products use product approval form
Property Owner In rmation. L J
Name , 9 Q A Address 2 t RdN,
City r L , State Zip Z7- Phone D
E-Mail h1G d �9�!/H •ram
Owner or Agent(If Agent,Power of Attorney or Agghry Letter Required)
Contractor Information
Name of Company Qualifying A$$ent / eK� ✓C�s•v/
Address ID2 N - City ff(�/�rd.� L Statet, Zip����
ORice Phone - lob Site Conga Numper 'e
StateCertification/Registration g.�" E-Mail IlJ I1U49 J 41 r2 '7 u ✓1'
Architect Name&Phone g y
Engineer's Name&Phone g
Workers Compensation Insurer OR Exempt o Expiration Date
Application is hereby made to obtain a permit o do the work and installations as indicated.)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 maybe additional restrictions applicable to this property that maybe found In the public records of this county,and
there maybe 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 PROPER . IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ITORNE EFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
(Signature of Owner or Agent) (Signatu'01 contractor)
Signed and sworn to(or affirmed)before me this_day of Signed and sworn to(or affirmed)before me this(rte day of
byT
(Signature of Notary) (Signature of Notary)
I I Personally Known OR I I P ¢anally Known OR
I I Produmd Identification mduced Identifcati
Type of Identification: Type of Idemificatum
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MV ODMMIggIDN M HH 116065
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Building Permit Application Vp.wdaww 1,
] City Of Atlantic Beach Building Department ••AtLWO ATIOH
800 Seminole Road,Atlantic Rrarh, 11 12233 mpaRAV
Phone: (904)247-5826 Email: — @_rnah lr, BSO'
Job nddre,u _(4.72 ATIeM(1L_ th QWYL
Pemgt Number:
legal LtessTiptbn
VNuatiptra Walt(Replacemem Corti S.-Zl.S - fiR Ilartad/Ceetadas u o_New,"Nalseliciallandi
• L1a55 of WedC ON. OAddltimi yAlterNlon ORegaair OM'we Oceans Opea Gaindo./poor
• Use of exhsIrg/000Rd eA000. (sl: OCommerclal TsnewmW\I
• If an existing Awdure,is a fire wonder system InstaINOR: Uins; 6.
Oesctl6e In detM Me type of work to be performed: Iv6AI 2v -
S
Rtf C v Npl, Jlld r.ota:e, a rl a ver
Honda Product Approwl I for multiple padu[ts/u�spe produd approval form
Namer rl toe tle ALdfIe Add. 11
city Ste, np orIN.
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E-Mail /vr
Owner or Agent(if Agent,Powers Attorney orAg platter Reefulnedl
cpntraccw In(amatbn y
Name Of Company U� 1{'2� pudRyiwh t 14(( / r•
Acidness 2 N city 5 t P1, EP-3 CA&OsiO
Office Phone lob Sets,Cnistv Nu er
State Certifintion/Registration R� EMaI O Y
AnIldivt Name&Phone d
Engmae/s Name&Phone Y
Workers C000eaosadonlnsuferl OR Exemist0 Experaden Dat D
Uplintion is hemN made to obtain a permit 0 do the work Rod installations as indinted.I ter"that no work or installation has
cornmenced poor to Me issuance da padmis and that all work will be,performed to meet the standards of all the laws nauMdng
sonstrucdon in this jurisdiction.I understand Mat a oneste permit must be secured!for ELECTRICAL WORK PLUMPING,SIGNS,
WELLS.POOLS,FURNACES,BOILERS,HEATERS.TANIG,ed AIR CONDITIONERS,etc NOTICE:In addition to[herpuimnentsa Mls
P,mi%then may be additional000obns seellcaae to this -.p"the may befound m the public rtcondsof this county,and
thane mry be addMtwl permits regrired from ober governmentN enties suM az watr management drtdm,sate ageneses,w
!Heol whimsies.
OWNER'S AFFIDAVIT:I owdh that all the foonong iammation is accurate and the all work will be time in Onmphaore with all
aep,ogN.a.regulating cunstmction 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
RECOMNO (OTIC FIOMMENCEMENT.
;sga ureaownw orAsal ola wuwpfcpmraxtN
SI arM swornw Ibefose this a 9gllse and sworn to(or aavmh)beLaa me Ni,_data
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to-P"-Al,mown OR 1 7 PwrxwdN aleem ca
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