1071 Atlantic Blvd COMM20-0023 1 of 3 permit application_1Building Permit ·Application
City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab .us
Up da t ed 10/9/18
"ALL INFORMATION
HIGHLIGHTED IN GRAY
IS REQUIRED.
Job Address: I Of/I 11-t1~.fi c. 51 v-d A+/o,vrht 13th , rl Permit Number: ______ ~-
Legal Description 38~~s-;{q£ laS! (j,sfro YFerre r'GIUL ,-,f RE#. 171'-11/, aDtfo
P I R EC. V OJ R r·7 5.-0 '7 ~J ;;J '7 I
Valuation of Work (R eplacem ent Co st) $ (,£5, 0 00 Heated/Cooled SF 1'90 C> Non-Heated/Cooled, ____ _
• Class of Work: DNew DAdditi on ~ion DRepair DMove D Demo DPool DWindow/Door
• Use of existing/proposed structure(s): ~mercial D Res i dential
D Yes ~ • If an existing structure, is a fire sprinkler system installed?:
• Will tree 5 be removed in association with ro osed roOect? D Yes mu st submit se arate Tree Removal Permit
Describe in detail the type of work to be performed: /111 <-<>o/k ,', B ~ IOr -'
Florida Product Approval # _________________ _
Owner or Agent (If Agent, Power of Attorney or A ency Letter Required) ___________________ _
Contractor Information .~\!;--i2~JQ4t'l!4-14:.a.!ktId/t£f__"YJ.~c..~ Qualifying Agent 12., ci a.& iarHl eC -
_-"'-''--''-!i<"'-£:<.Lla.,f--''''"''-L _________ City )"""".8c.h . State eL Zip J:2Z--S (l
Office Phone 'loCf-£= Job Site Con t act Numbe,"-r._-,2<;-;C!(22-:!4~S;-~f~0"TF'_-;r-_____ ~
State Certification/Registration # c.&.12-S0 ii9 o/ E-Ma il lid,' CQ",s7 ru-c-/",o.; @L<, 7l ,.qe-f
Architect Name & Phone # _-<-D=S"<2;rC!c;;:=-___ c-_~----=----------------------
Engineer's Name & Phone # LQ U-> g <:;f r q do",?,. h e . ,
Workers Compensation Insurer __. . m •••••• •.••••••• •. I ... . OR Exempt ;;?'Expiration Date _ .tIL ~bo~
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 Y UR NOTICE OF COMMENCEMENT.
-~.
~YPlJ.9. .,0 •••• _._'~ PAMELAD.HOIV.\RD
~ Personally Known OR • ~. MYCOMM ISSION'GGOl886!
[ ] Produced Identification ~ ;:c EXPIRES:August17202O -:9'>.:'::' •
Type of Identification: ~o !,"C:\,r;),~ BondedTh-uBud;e!NO!:i!rrSeMces
"''""Iv. ?AMELAD.HOWARO
!>!'Personally Known OR .,~ MYCOMMISSION .GG018861
[ 1 Produced Identification * * EXPIRES:Augtlst 17.2020 ~ ~ So 'cos
Type of Identification: ___ -.C·~jto"'r"!!\l!:0~=-~""'=.'.::ThN=B"2''':...'N_''':...~_M_