415 SEMINOLE RD RESO21-0087 Building Permit Application Updated 10/9/18
` C. , City of Atlantic Beach Building Department **ALL INFORMATION
\, � v 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
,� IS REQUIRED.
Phone: (904) 247-5826 Email:
Building-Dept@coab.us
Job Address: 4(7 S �PG(1 -v (,C /�Bo p+ iQ �( Ill j Permit Number: Rt._, -.--, ,.__ , c)08 - 7
Legal Description /0-ic / -Z -Z/ Ca Z rtnr4// Jot /S/ RE# I -U (-I/O -oaa0
Valuation of Work(ReplacementmCost)$- p/ 00 v Heated/Cooled SF Non-Heated/Cooled
• Class of Work: I tQew ❑Addition DAlteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
E
• Use of existing/proposed structure(s): DCommercial Residential
• If an existing structure,is a fire sprinkler system installed?: DYes ❑No >v'✓A
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) ❑No
Describe in detail t e type of wor o be perfor ed:
0-trl eel ,,-) r- cAciCyci\:c (/(
Florida Product Approval# for multiple products use product approval form
Property Owner Informationt-m77 7
Name �A'e''-- Jct 0 TSU/`' S Address 1�� f<!i'1,,•'7 f( � 7c,/'//113 I-C )G(�l2
City State Zip Phone
E-Mail r`JcnvAfc_) Z,C P Gwlat,"/ (0'x'1
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information__Name of Company l -tve f i-)Alea/d//' Qualify-ng Agent ?(A-1 l t ►\
d- (1)
Address ,F6 f 3 P47-/47 //J 7 S City,/(,.i(,///�'67(tState G Zip -527 ('
Office Phone %77 �T— 7d� Job Site Contact Number fa( 37 — ' -v 4-.7--
State Certification/Registration# Z/'0 .7(J' E-Mail p k i(I QrVCr 5%4,/e`.,lo//C S- ('o .-vi
Architect Name& Phone# N/#'
Engineer's Name&Phone# N(19
Workers Compensation Insurer (7 ss 5fs OR Exempt❑ Expiration Date
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 YOU • N•T CE •F COMMENCEMENT.
----11.Mb... 0 ' '''' A_..7"--
(Sig ature of Ownerl Agent) (Signature of Contractor)
Signed and sw9rn to(or a -o-d,before me this 3 day of Signed and sworn to(or affirmed) before me this day of
A)'Ji!eik1( , 2 b :: :41.a. A 1 e. _imp ,by a \ .g 'C ,
( sgna'r � �P ,,,a'.r,(Signatur • tary)
4off\°L. AB NoISA Y E
• �; Notary Public-State of Fonda;
.. ,e1= Commission#HH 110420
[ ]Personally Known OR 1)Personally Known OR My Comm.Expires May 25,2025
[ ]Produced Identification Jrr/'T,-Produced Identifica� o �•
Type of Identification: �r / Type of Identification: ��f ._t
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