290 Magnolia St RERF21-0255 App �.'`-''f',`� Building Permit Application Updated l0/9/18
,) City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
�,'t 9� IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: gdU 0 410Vu. S'3, Ri1ai��+c, 624,A, vi- 32 an Permit Number:
J
Legal Description 10-$ 1(o-a5- ME catko6t Sec 1 Lot gen RE#
Valuation of Work(Replacement Cost)$ $)300 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration /Repair ❑Move ❑Demo ❑Pool ❑Window/Door (2..•f:>G.9
• Use of existing/proposed structure(s): ❑Commercial DiResidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes 6No
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) YNo
Describe in det ii the type 9f work to be performed: (er.v.v¢- tkna (cew.ic- ek•',I•n Sri Nit_ loA' l..1.e,1 X4 (› zk u,VAe,'d avrki./ 44 Al CAAitetkiott 7h,43►C.
Florida Product Approval# FL 067/�- IS E Ft-1G(5O"f�1a for multiple products use product approval form
Property Owner Information sati i *^6 i`t fi
;,.
Name kb2:i H►11;'7 Address %5L. 114 S-.
City I'1t1044.t. 9z.u.r2ti State FL Zip 3 3i Phone log-7U, -90(cO
E-Mail Bob ti h'ilk rQ A:.4.5.(-°^Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company E0.3-A gv,L1a4
; V1drINA Qualifying Agent 1 o5eek Id .„.1,,
Address aC,SJ`Z IZo5',11le- Si-. City J•.cKkAv,1(C- State F` Zip 1 za.,-f
Office Phone 90 - '398- IuHN Job Site Contact Number g56-766/ -iICic.
State Certification/Registration# CCC /32 Oa, E-Mail ,:Ait;Ol00.ee. ree`�rp5.c.a/
Architect Name& Phone# 1 11
Engineer's Name&Phone#
Workers Compensation Insurer lo s.t,iihr5' `/ E/(44,/160, _ OR Exempt❑ Expiration Date 7 . ,A3 • 0-
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 YQj ► •`� a COMMENCEMENT. -
�'Gr.�LGa ! �t�utuuiNr� „AO"
(Sig
��� iii—
(Sig : re o own\�ydt� 6}N VASTO nature of Contractor)
•
S n d a savor to r affirm t •• = d sl, rn to or affirme. 2
C _. �a �•day�f Sign-. . ./ ( •-fore me this day of
O� bid U` �S ...ffi* I✓� e �2� •. by a _WAST . lss ' r
3 10HH 067322
$1/N4t4 e�fNotary)\.�•••(Q` (Sig ature o Notary)
% 1 nded tt' o.'
�-• '''blit Undo`'i .*5)\��� STANTON WELCH HUDMON
•[ ]P rsonally Known OR / 8�� STATES�����\ [ rsonall Kn. ,.1� Notary Public-State of Florida
[ oduced Identification 41111111110" y +'` Commission K GG 933446
[ i Produced Iden fi .,;•:".7,.. My Comm.Expires Mar 16,2024
Type of Identification: Type of Identifica •n: Bonded through National Nota Assn.
1111-20-171—(0 -30—b
Doc # 2021282757 , OR BK 19978 Page 1395 , Number Pages: 1 ,
Recorded 10/27/2021 08 :51 AM, JODY PHILLIPS CLERK CIRCUIT COURT DUVAL COUNTY
RECORDING $10. 00
NOTICE OF COMMENCEMENT
(PREPARE IN DUPLICATE)
Permit No, Tax Folio Ip I7O53O -0016
State of FL County of Is.
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, p
Legal description of property being improved: 1(1-0 1(o"as-a!t S.1* c Sec LA.
1 p
Address of property being improved: 2'10 (11a51401'0.., 9 . �t')(l0.^�j3a133
'' II `
Gen al description of improvements: iTeNwve_ Oi'.Q7 f t IaLC, e v-)l 511,ti 1.L.
(os pt i Ptd i c.\. . Lhk erlarer anc� ikOrt�� �,rtl S ;�lc4
Owner Rd�ef4V 14,1115
Address 15 . prof 4. fal/y�
la,k,c. 1,Zrh t h— 32233
Owner's interest in site of the improvement WO
Fee Simple Titleholder(if other than owner)
Name
Address �c^— t�
Contractor x 5v-Alt v5 O �1 cI6�i 410.
Address 2q A 90ssei�1rGl �t. �1ckSo tvt1�C. 3;L2oti
Phone No. /O1- 39?J- lO"/tt Fax No.
Surety(if any) ki
Address Amount of bond S
Phone No. Fax No.
Name and address of any person making a loan for the construction of the improvements.
Name
il
Address iA
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
i\f/A
Address
Phone 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 Statutes.(Fill in at Owner's option).
Name NA
r�Address
Phone 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 ••
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eero me Th s da o _,�� DAT o \\ ��,EEN V.A.sto4",�,
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himselV herself and affirms that eU stateme an d orations herein ?o j,.••
are true and accurate �4�
2: i1HH 087322
O •21 r0�• Q�
Notary Public atLarge.Slate of �].County of y-iv�l i9.;•. a�dUn a .4.1.
My My commission expires: i
Personally Known
(r'.�7* ef1Cf1STATeC �Podeiato N 117 L(') ill