569 Camelia St RERF21-0235 App -- Building Permit Application Updated 10/9/18
_ City of Atlantic Beach Building Department **ALL INFORMATION
i 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: 5(0i CIONouA '�r PM v? rt,. •jC7*t,t4327<33 Permit Number: R ERF - (�Z 35
Legal Description % —3 ( 1 7 - S 'd`-c? t C, // ,SEL /d RE# /7,5??'Dg 60
/`V �rctTLa: a 8 /23
Valuation of Work(Replacement Cost)$ 700 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New DAddition ❑AlterationRepaiirr��OMove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial 'esidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes Aeo
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separ to Tree Removal Permit) ❑No
Describe in detail the type of work to b performed: 0
9 - 2 ( s 1 rt �`vhi NQ �►
coo ,6/Y
Florida Product Approval# I O 7 q , 1 /---1---1-1 L, -- for multiple products use product approval form
Property Owner Information
Name ,472-4'+1-/G jeCS a/•!--4r7 Ce4)4, J Address ,2-4r .2/4.10 ePU-E` A)
City c7;1.-,4_ 6e-)1644 4 State fl- Zip /2:2-6Z Phone 701- 6713 Y- 7-1'/1
E-Mail e_bo_/-r1 o s.54.6 721X-14,--4- r /- l.r3N^v
Owner or Agent(If Agent, Power of-Attorney or Agency Letter Required)
Contractor Information ,/ ,� //
Name of Company lax (Sf'�LtevtliOr 'Tt' Qualifying Agent K.e✓1 -. (tij/vCfsbA/
Address As\ �rtiV4 S�?'tyl i�4 �% 32230 City State Zip ,3 2 i-.�
Office Phone 613 $if 13 Job Site ContaactA Number 96'1'19 3 ,
State Certifica n/Registration# Ce-C-1,33 66 to 1 E-Mail # ac_oyt-t "y`._c y��'
Architect Name& Phone# /Lp9
Engineer's Name& Phone# /44
Workers Compensation Insurer OR Exe p Expiration Date ? )7 LT/
Application is hereby made to obtain a permit to do the work and installations as ind ted. 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
RECO Datil • UR N�l.f OF COMhVIE C lVl NT.1 .)
7I..Si �f JU1 )I,c �eS ; A `Jr+(' ' uV
,' gnature of Owner or Agent) (Signature of Contracto
Si
;fled and sworn to(or affirmed)before me this•JD�day of SSiiinnedd nd sworn to(or affirmed)before m- l iu.9ay of
Q 1 I / e /
I 7)0
ature '
ori I at Q� IN BECOTTE (Signa u c'Q Notary) •• •
r Commission p GG 262134 _ ;My Comm.Expires'N
* -;(A)? * qugust 25.2025
N, illi o� Expires October 19,2022 = No HH 169672
Personally Known OR +rFof0°a Bonded TTuuBudgetNol.ryservkas [ ] Per ally Known OR
I Produced Identificationroduced Identification ] f� �'•.,•PUgL��:••'•Zj`a�
Type of Identification: Type of Identification: J "� �i �o • •"' • 0t\•��
r •
NOTICE OF COMMENCEMENT
State of cA00 .4 dew Tax Folio No.
County of � v�L
To Whom It May Concern:
The undersigned hereby informs you that improvements will be made to certain real property, and in accordance with Section 713
of the Florida Statutes,the following information is sated i this NOTICE OF COMMS CEMENT.
Legal Description of property being improved: / —3`t I,7 ✓2-S b A RA/v nc ivat b4 55Z'
N ôPT 1,07- 3fJLk - (2-3
Address of property being improved: C(41/ 0444 0.--).A C�� 'FLA ibly-A tt 3ti233
General description of improvements: 6 XUOr Si L/ 1:L.-
-Owner: ,4TZA c— (24C o . a__ Address: 5 61 CN(V16 t 4 ,7i /++44,41c,k .260 331,3
Owner's interest in site of the improvement: /00
Fee Simple Titleholder(if other than owner):
Name:
Contractor: K L V Cron 5••Nt V C()A l c.
Address: (qs‘ OCfGf� ���ti6 Svv-rkt P►t A Si&AL `SEP(. 4 3 USS
Telephone No.: (WY) 613 gG /3 Fax No:
Surety(if any)
Address: Amount of Bond$ _
Telephone No: Fax No:
Name and address of any person making a loan for the construction of the improvements
Name:
Address:
Phone No: Fax No:
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may
be served: Name:
Address:
Telephone No: Fax No:
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section
713.06(2)(b), Florida Statues. (Fill in at Owner's option)
Name:
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a different date is
specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
Doc#2021257270,OR BK 19938 Page 362, 1 ((ff
Number Pages:1 Signed: - `-�• A1C Date: 7 .�
Recorded 09/30/2021 02:36 PM, Before me this & day of in the County of Duval,State
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL Of Florida,has pe onally appeared / Cn I p ,51-1)
rl I
COUNTY Notary Public at Large,State of Florid, ggunty Q! IVANN BECO
RECORDING $10.00 My commission expires: r°�. •��' Cpmmisslon#GG 262134
?ersonallyKnown: f•. , . , rxplfASOctober19,2022 or
Produced Identification: r"1E0fc," Bonded NU Budget Notary Services