3 Composite - Building Permit Application;,;; AMANDA JACKSON
`' "ar. State of Florida -Notary Public
Commission 4t GG 205328
My Commission Expires
April 09, 2022
Building Permit Application
City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233
Phone (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 342 19th Street, Atlantic Beach, FL, 32233 Permit Number: RERF20-0153
Updated 10/9/18
**ALL INFORMATION
HIGHLIGHTED IN GRAY
IS REQUIRED,
Legal Description 36-64 09 -2S -29E SELVA MARINA UNIT 12-A LOT 5
Valuation of Work (Replacement Cost) $ 13000.00 Heated/Cooled SF
• Class of Work: ■New DAddition Alteration ❑Repair ❑Move ❑Demo ❑Pool
• Use of existing/proposed structure(s): ❑Commercial I_✓ 1Residential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes �No
• Will tree(s) be removed in association with proposed project? ❑Yes (must submit separate Tree Removal Permit)
RR 172020-1242
Non-Heated/Cooled
■
Window/Door
Describe in detail the type of work to be performed:
reroof, 27 sq, 6/12 pitch, shingles FL10124-R26
Florida Product Approval # rL,1(ila,y,-- 9,2,w
Property Owner Information
Name Donald Maclean Address 2 PETTIS ST.
for multiple products use product approval form
City LAKE GEORGE
E -Mail tombourdon7@gmail.com
State NY Zip 12845'
Phone 860-874-1941
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Reliant Roofing
Address 4230 Pablo Professional Ct#155
Office Phone 904 657-0880
State Certification/Registration # CCC1330615
Architect Name & Phone #
Engineer's Name & Phone #
Workers Compensation Insurer Policy #: WC 196-49725
Qualifying Agent Cameron Shouppe
City Jacksonville State FI
Job Site Contact Number 904 712-3111
Zip 32224
E -Mail amanda@reliantroofinq.com
OR Exempt ❑ Expiration Date 11/20/2020
Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 Yglaill N TI OF COMMENCEMENT.
(Signatu of Owner or Agent)
Signed and sworn to (or affirmed) before me this 3 day of
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(4ersonally Known OR
[ ] Produced Identificati
Type of Identification:
(Signature of N
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(Signatur
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Signed and sworn to (or affirmed) before me this
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4$ersonally Known OR
[ 1 Produced Identification
Type of Identification:
(Signature of Not
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AMANDA JACKSON
tate of Florida -Notary Public
Commission # GG 205328
My Commission Expires