351 Seminole Rd RES21-0312 Revised App Building Permit Application: .....( Updated
City of Atlantic Beach Building Department **ALL INFORMATION
J
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
�� IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: D5 SEMot.)cCE (20 Permit Number:
/C Legal Description ^277 70 2_ '(-//f.- RE# i 701434-"coo5
Valuation of Work(Replacement Cost)$ 009,CD Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New 4dition ❑Alteration DRepair ❑ ove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Residential
• If an existing structure, is a fire sprinkler system installed?: DYes 13No
• Will tree(s) be removed in association with proposed project? DYes(must submit separate Tree Removal Permit) .No
A Describe in detail the type of work to be performed: •A l/v�A., //(571 , r '-r?c �z.oO'-'( 17(,j
-
/ 1 ootc AJ (etre_ I c > r
Florida Product Approval# for multiple products use product approval form
Property Owner Informationf( 2
Name (,ri{oQaX S°\�kf,o '^� Address 133 ("Lk i. ctAcC-t tL1,a . .(t.k
City Toc\,e_SQ j iRt State F( Zip 32.221.& Phone 9ti ( 321 6 41-Z. '$
E-Mail 7 e is Z Cy" \o•Rv.y._ • C0.,.�
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Corn any ( /k-C- Qualifying Agent ��0'f 2- z.A-A- -Qc
Address C�j' `77�t-k-t011iefl City Q it>6 ��'-�State 'Ft_--�� Zlp . 2_"2-5T
Office Phone -� Q Job Site ontact Number // ���� ((2�
State Certification/Registration#C1, j p E-Ma QUt 21! Ul (7 ' 1X rC€ '
Architect Name& Phone# �CJJ
Engineer's Name&Phone#
Workers Compensation Insurer 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 PRI 'Ef TY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LEND OR A A, r ORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
I
(Signature of Owner or Agent) ign. - . ractor)
ySigned and sworn to(or of irm d)before me thZ- day of Sigped and sworn to(o .' d)be ore me.t d y of
1 O✓ ,z0Z ) wir:_,,y, Pt N 0 c! , /• ='041" my 1r /Cy
--Ns w a .
;o<�YP�a TONI GINDLESPERG
,,[--115e rso n a I ly Knouiin OftNv.p. .,, TONI G!NDLESPERGER [ ]Personally Known OR ,*i i .c MY COMMISSION#GG 30
[ ]Produced Identificati• [ ]Produced Identification ^..o` EXPIRES:October 6,2023
��� c, MY COMMISSION#GG 353178 °.-.1 4P' Bonded Thru Notary Public Underwriters
Type of Identification:,.,-.A::cEXPIRES October 6,2023 Type of Identification: `
;-'q;?: Bonded Thru Notary Public Underwriters