351 SEMINOLE RD RES21-0312 ''-U',y,\ Building Permit Application Updated 10/9/18
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• f, City of Atlantic Beach Building Department **ALL INFORMATION
+ HIGHLIGHTED IN GRAY
-�jj 800 Seminole Road, Atlantic Beach, FL 32233 IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us c
Job Address: 3.9% S€NI)' O1 Q, rid Permit Number: KE S Li -a3 I
Legal Description - 151 5 16 - 7-S - Z 66 RE# i 1 /3439 -000,5
Valuation of Work(Replacement Cost)$ 1'0, 000 _ Heated/Cooled SF � i0 L(.j Non -Heated/Cooled I Q Z.6
:). 7Q(
• Class of Work: ❑New ❑Addition ❑Alteration epairrtOMove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑ComESmercial esidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes filAo
• Will tree(s)be removed in association with proposed nrnfp�*2 r'Yes(_must submit separate Tree Removal Permit) lao
Describe in detail the type of work to be performed: s no- - r u;if i (,y 6.,e-JS- Ft bO,i:f ,Jf
I ND E-2 t o(Z. RE.rv`.o E. C_..
J/ rte%
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name C-c!igiuy, 3-0 vi-i A9S II C Address 13301 ge4th OW 1010" 714 Jtu0 1-7-
City
.City -3� State 1)-1.-- Zip 3-L Z Z '1 Phone 909 ejS 44 5'11 `3L Z2t�
E-Mail 2 J �i Cr iblu)! . tot-i
Owner or Agent(If Agent, dower of Attorney or Agency Letter Required)
Contractor Information
Name of Company Ascnl r tnov,v11.etC Qualifying Agent Ito v/C J 1I1 oNq s
Address MO CoAvc49 4r-J %,.s''4 (cit City TeAy" State FL Zip ,3 z z/d
Office Phone goy - 423 -34,73 Job Site Conta t N�mber - y Z -' ' '3
State Certification/Registration# 64,0530Z-0 7 E-Mail kw COlf;}r44 . fl L M 43. (nM
Architect Name&Phone# r✓
Engineer's Name&Phone# lZ
Workers Compensation Insurer Ev CH T t OR Exempt q/Expiration Date Cl/I 7/ZOL?
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 manageme t districts,state agencies,or
federal agencies. CJ , 5 ' 1C)/6/Zi
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work wilt l z ---1=—
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 YOUR NOTICE OF COMMENCEMENT. /,0 M
(Signature of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this Pi day of Signed and sworn to(or affirmed)before me this a day of
0 CAL , 2_69..I,by<��pt 0000- , Lott ,by Uwai 1 CMaetQs
ii
~v(Si:na ur- .f .. . (Signature of Notary
�/ Notary PuHiio SON d Florida �M Hotary Pur Skis d Florid.
�r„wt�r+o�Giknon + Lawrer� Giknotr<
[ ] rsonally Known OR • My Cotrxnata^HH 100925 [ •
]Personally Known OR • F: My Commission NH 100925
[ Produced Identificatio
Egon 004025 [4Produced Identification �at+� Era«ea 03I04IZ025
Type of Identification: Type of Identification: •,.. W../'r"
NOTICE OF COMMENCEMENT
State of f ly Tax Folio No. f 70 q 31-i --O 0 0 5
County of .T,)U vct 1
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 stated in this NOTICE OF COMMENCEMENT.
Legal Description of property being improved: 1 0 - 15 1 b -Z. S - 2_ (o b
E it "Z s A-1- TA-.z It Q , LOT % 7 7 _
Address of property being improved: 3 s I Seo;A, lc ►O 44-1441.i( i3 ecC h
General description of improvements: . M,J t1 D Ct'I 0 ?Gi11'+, (A b:A(4S/ Fico,,' y ()r)/ aq it
Owner: (xi t)Vy 5QIU},,:u.9S 1 I (, Address: ib (33 ell 8e icla 5iJ OA;f 711" J-154(
Owner's interest in site of the improvement: ikr r S F(, ✓ 3 zz-vi
Fee Simple Titleholder(if other than owner):
Name: 04'011
i _
Contractor: l-rq{M t V CnO11'I11 o.1S 1 1(0 04' 11v� �tn1 t M01 I)
Address: ?1 ( 7 0,ttvi,y) \ ; 1 Uhil ) 011 ,d)( -j 3 ZzJ /
Telephone No.: CI 09 -9 23. 367 3 Fax No:
Surety(if any) iiiW
Address: Amount of Bond$
Telephone No: Fax No:
Name and address of any person aking a loan for the construction of the improvements
Name: J[
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: Ail Al
Address:
Telephone No: - Fax No:
In addition to himself, owner designates the following person to rarai,,o -, - pa a 2289, tion
713.06(2)(b), Florida Statues. (Fill in at Owner's option) Doc#2021264271,OR BK 19948 9
Number Pages:1
Name: /J Recorded 10/08/2021 11:06 AM,
Address: PHILLIPS CLERK CIRCUIT COURT DUVAL
COUNTY —
Telephone No: Fay RECORDING
JODY $10.00
Expiration date of Notice of Commencement(the expiration date _ ,_, ,,.u, !Will we Gate of recording unless a different date is
specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
Signed: % --I Date: Oct. O . 20 2 f
Before me this day of in the County of Duval,State
Puywenesbes Sarr!d fiaida Of Florida,has personally appeared 0 , a 0
C
Giwt Notary Public at Large,State of Florida,County of Duval.• •44P4cAllrYL ss4On HM 100915 My commission expires: f`•(Or-LM '1 24.�J E> 03/04/2025 Personally Known: 7-1) _or
Produced Identification: .10