469 ATLANTIC BLVD 13 SIGN24-0007r- ; BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
41111' City of Atlantic Beach Building Department
PERMIT# St GNI Z4Jbbd
u-; 800 Seminole Road, Atlantic Beach, FL 32233
ALL information required to process
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Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address L.4 b0 NIcko-01,-\C 1StVcl 13 RE#
Legal Description 4 O-1 6 21-2g- 2c& E. o,- ' ,tS C 3 1,.k5 N-to ^C'o 8-16.
1 838 -To etio
Valuation of Work(Replacement Cost) I,f ZOO Heated/Cooled SF Non-Heated/Cooled SF
Class of Work: New 1=1 Addition Alteration Repair ID Move 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\ 5-ak\ sign fog- e '-E'(?o s ?i&6S E--- . .E'S f1Iv2A i [
Florida Product Approval#For multiple products use Product Approval Information Sheet)
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Property Owner Information Name p jo•Y'r`orsc 9- o.\ 5\ale P cope,c le5 Phone
Address G S—1—A- Lo u o 2_ 5 City -Ck'5csiNV t Il c State F L Zip -3"?...-1_1(.,
Email Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information Name of Company i\c‘01e-sco r.yAvuL40 `tnc, Phone cko N- G2ck 8s83
Address -q-()Li , "GcAzPo-4-1: ic-1 `-3 r -to4_-tgt City -1o..c1c54,.,V tUe State FL Zip 'a L1s(D
Qualifying Agent State Certification/Registration#G c 15 05 8,6'O
Email Y`no-.c o D 0-4e.bcoc0^S C`•ucitior•.0 ore-. Job Site Contact Number
Worker's Compensation Insurer OR Exempt Expiration Date
Architect's Name A//11 Email Phone
Engineer's Name Ai/b 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,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
ATTORNEY BEFORE RECORDING YOUR NOTICE 0, .0 ME k ' .
WO s-7;tlitfrSignatureofOwnerorAgent) Sign. . e of • ractor)
Signed and s orn to(or affirmed) before me this 2 H day of Signed and sworn to(or affirmed)before me this 2 Y day of
j)-J 2, 27 by )Ose M 5;.,,--5,--5;., ,, 7Dc.4 1 ZZ t G e,e -'
1U )Signature of Notary ji Signature of Notary f
Personally Known OR [vj'Prolduced Identification Personally Known OR [ • oduced Identification
Type of Identification: ft,L Type of Identification: 06
4P,N.', Notary Public State of Florida
usT°4 Notary Public State of Florida Luz Adrian Santamaria
Luz Adnana Santamaria 1 c_ , My Commission HH 107252
a;My Commission HH 107252 11,0,
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