113 4th St Shingle Submittal g " ic Building Permit Application Updated 10/9/18
s\.
j **ALCity of Atlantic Beach Building Department
L INFORMATION
v 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
�o;:it)r IS REQUIRED.
Phone,:/(904) 247-5826 Email:�� Building-Dept@coab.us
Job Address: 7/.3 OZ ,4 2)1ZG L'Grlc,fi/ - 3.3 Permit Number:
Legal Description 5"-- 1/ /6 - s- ie.io klidrz r,a6V/ rffer(e4)S° r�lxc' RE# /70/6/"CCa7
Valuation of Work(Replacement Cost)$ //� 017 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New DAddition ❑Alteration ❑Repair ove ❑Demo ❑Pool ❑Window/Door 40(
• Use of existing/proposed structure(s): ❑Commercial E esidential
• If an existing structure,is a fire sprinkler system installed?: DYes No
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) Xo
Describe in detail the type of work be�pe�rmed:
K/`Gtr
Florida Product Approval# A /6.3.�.7 a7. �3' / for multiple products use product approval form
01
Property Owner Information 5fl�)&e- v ��m /
Name (//40f/M t�iVa. // //,3 �f/ - -1-
Address /
City L ./ , i_; , State /�� Zip , 33 Phone (e) o y- .231/
E-Mail 1S/fl 0d/ 1nif4L-ror/111-4-/M
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information ////��""
Name of Company /✓. 54 ��L„j1t- Qualifying Agent �C YZ/d ,�rlrr
Address /3Sa5 �,J/ 4L9 City fkAadi//f/;&.” State 4 Zip 3'7?
Office Phone (9x/) 378"8605 Job Site Contact Numb, r do g - pc
State Certification/Registration# lC.-1: / 0/,2 E-Mail /3,5AiLi7..b Ka, c G 'li 'TT r
Architect Name& Phone#
Engineer's Name& Phone# / '� //
Workers Compensation Insurer /� /-1/i/P4 l�,rrI' /
OR Exempt D Expiration Date / ,A:
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 : ' : ATTOR EY BEFOR
RECORDING YOU OTICE OF COMMENCEMENT.
(Signature of Owner or Agent) 'of Contractor)
Signed and sworn to(or affirmed) before me this ±5:5- day of Signed and sworn to(or affirmed)before me this /Sr day of
X V tt Y- ,207—( , by-7744 f/,44fiI,L4- .,,(tele, %T? 1 , by Wit; 5.0f
e icli-e _ lik(O —
(Signature f Notary) (Signature of Notary)
� :; WILLIAM L.POPE
_ %;:c WILLIAM L.POPE
,. ,i�_ .,,: MY COMMISSION#GG 348645 Personally Known OR "Q•
XRersonally Known OR .vt '0n, ,a,, • = MYCOMMISSION#GG348645
="yr-'�gQ EXPIRES:October 19,2023 ] produced Identification '*i •,f.
EXPIRES:Odober19,2023
[ ]Produced Identification :FbFi�o.; Bonded ThruNotary Public Undervrt'tors •.-%• • •o,c I
Type of Identification:_ pe of Identification: ,.c?fS Bonded ThruNotaryPublicUnd
NOTICE OF COMMENCEMENT
State of ((Cleat/ Tax Folio No. /70/61 -0000
County of
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 proper y being improved: -6Q /6- , 5-( i9e- ICS
i i& Lof /(' 7usv )
Address of property being improved: /13 /7/ 5 q�[ /.l�rtC ,Cioal 3c3' 3
General description of improvements: iee /'AGO/
Owner: --/---//1642-/V /4/9/i2 Z Address: /13 1 i C,4
Owner's interest in site of the improvement: c> 2 -- 33
Fee Simple Titleholder(if other than owner):
Name: /) _
Contractor: ,6 j/7f',�
Address: /35;7( 3/90 `L IR/VC
Telephone No.: (Qou) 378-a05— Fax No: 4)(1) 378-tStd6
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#2021308542,OR BK 20022 Page 806, Signed:
Date: /t —W
Number Pages:1 Before me this i$ day of t LDeitto 2_ in the County of Duval,State
Recorded 11/18/2021 04:23 PM,
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL Of Florida,has personally appeared r4
COUNTY Notary Public at Large,State of Florida,County of i Iva 'Yei WILLIAM L.POPE
RECORDING $10.00 My commission expires: / —/ -2 I . MY COM, ., : •:,.5
Persona�iJ�s _ L��1 �': s•` EXPIRES:•K..,�,:
Produced Identification: •••"_, BondedThruNotary Public Underwriters
/I/c261— f-/ll�i
,ifir' PRODUCT APPROVAL INFORMATION SHEET FOR THE CI OF ATLANTIC BEACH, FLORIDA(*REQUIRED)
*Project Address: /13 547! '-7, C ,�i�C/7c.
y /1/ C Jas 33permit#:
*Owner/Project Name: /714/n4;-(( /eUI�(..,r
As required by Florida Statute 553.842 and Florida Administrative Code Rule 61G20-3,please provide the information and product approval number(s)
for the building components listed below as applicable to the building construction project for the permit number listed above. You should contact
your product supplier if you do not know the product approval number for any of the applicable listed products. Information regarding statewide
product approval may be obtained at:www.floridabuilding.org.
Category/Subcategory Manufacturer Product Description Limitation of Use State if Local#
A.EXTERIOR DOORS
1.Swinging
2.Sliding
3.Sectional
4.Garage Roll-Up
5.Automatic
6.Other
B.WINDOWS
1.Single hung
2.Horizontal slider
3.Casement
4.Double hung
5.Fixed
6.Awning
7.Pass-through
8.Projected
9.Mullion
10.Wind breaker
11.Dual action
12.Other
Page 1 of 4 Updated 06/21/21
Category/Subcategory Manufacturer Product Description Limitation of Use State# Local#
C.PANEL WALL
1.Siding
2.Soffits
3.EIFS
4.Storefronts
5.Curtain walls
6.Wall louvers
7.Glass block
8.Membrane
9.Greenhouse
10.Synthetic stucco
11.Other
D.ROOFING PRODUCTS
1.Asphalt shingles / k spec / / (G to
3 /
2.Underlayments ( J ceZA4Or
Koo Fc a53.3
3.Roofing fasteners
4.Nonstructural metal
roof
5.Built-up roofing
6.Modified bitumen
7.Single ply roofing
8.Roofing tiles
9.Roofing insulation
10.Waterproofing
11.Wood shingles/shakes
12.Roofing slate
13.Liquid applied roofing
14.Cement-adhesive
coats
15.Roof tile adhesive
16.Spray applied
polyurethane roof
17.Other
Page 2 of 4 Updated 06/21/21
Category/Subcategory Manufacturer Product Description Limitation of Use State# Local#
E.SHUTTERS
1.Accordion
2.Bahama
3.Storm panels
4.Colonial
5.Roll-up
6.Equipment
7.Other
F.STRUCTURAL
COMPONENTS
1.Wood
connector/anchor
2.Truss plates
3.Engineered lumber
4.Railing
5.Coolers-freezers
6.Concrete admixtures
7.Material
8.Insulation forms
9.Plastics
10.Deck-roof
11.Wall
12.Sheds
13.Other
G.SKYLIGHTS
1.Skylight
2.Other
H.NEW EXTERIOR
ENVELOPE PRODUCTS
1.
2.
Page 3 of 4 Updated 06/21/21
In addition to completing the above list of manufacturers,product description and State approval number for the products used on this project,the
Contractor shall maintain on the job site and available to the Inspector, a legible copy of each manufacturer's printed specifications and installation
instructions along with this Product Approval Sheet.
I certify that this product approval list is true and correct to the best of my knowledge.I further certify that use of different components other than the
ones listed in this document must be approved by the Building Official.
*Contractor Name(Print Name): �/JC;G�� (f� *Contractor Signature: "v •
*Company Name: / SST// A (-1 1
*Mailing Address:: /35,?S Sffi✓GST /(O/rig
*City: ga` 1 -zzC *State: / L //�� *Zip C�o-de:: ..�b
*Telephone Number: pg0'-/ 378 �60� *E-mail Address: 00,1)/ 'S/�?S�/e00t) qtr .d 1
Cell Phone Number: /07 3766O5 Fax Number: 378- g6c6
Page 4 of 4 Updated 06/21/21