1628 W LINKSIDE DR ACC21-0061 - :1-- Building Permit Application Updated 10/9/18
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' �� City of Atlantic Beach Building Department **ALL INFORMATION
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, 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
of IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us nn
Job Address: /(.p Z$ L-4"n4-5 uIE �. \-E- -7-- Permit Number: aQ azt - (Doc, I
Legal Description if7-XS-"/ 7- -ZS-29 E CFI VA 1-00►c5ilE ltNrrZ 2-or /33 RE# /7 Z3 — (oZ43S—
Valuation of Work(Replacement Cost)$ Z'S✓00.In0 Heated/Cooled SF Non-Heated/Cooled )C,
• Class of Work: ❑New ❑Addition Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial (Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes 'b'J.No
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) 141No
Describe in detail the type of wog(to be performed: cmc'-i'" , '4# Fr' e.0 :,--)4‘37„•.'1.. / T I /'t'At /-ii /r7%f; I'-L
^JEW' — 4JEAZ vi/r rHi _S' ,"E. / -ice +✓T_
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name Atiy t-u1�„N •-d eD[tl,-) IK• K rti8.veo Address itoZg 1--'tov. iQE ,ba.... 'Y r
City j7 L-, ric.- c H State / � Zip Z az2' Phone 9 ” 95S---07-co
E-Mail Q.M`(@ i-ltvof te-5er✓`_iEa4..5_ CrPri-1.
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company At.--vhf !'—• Qualifying Agent _1 hao )-(ot_c.or•4411
Address Z STF:•.442T ST= CityATA-4--Inc- Acr.} State Vt - Zip E33
Office Phone 904 - 'S3 --(p5"-Z Job Site Contact Number �•to g7-31-4'Z
State Certification/Registration# *( —Zrf`tgCr i E-Mail ciWi(c; (..1 �c�wC, Co,4t
Architect Name& Phone#
Engineer's Name&Phone# /
Workers Compensation Insurer-/ / E a. i oj) 0" AOR Exempt o Expiration Date 3/0//z2_.
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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 FINA CIN , CONSULT WITH YOUR LE ' ' O' ANA RNEY BEFORE
R -7IIN2yO ;TICE •FCOAIy MENCEMENT _OS__ ••
M.4 • : P . ,..,..-)
/ (Si:.•ture of 0 ner or Agent) (Signature of Contractor)
Signed and swo to(or affirmed)before me this I O 'day of Signed and sworn to(or affirmed)before me this U 'day of
1)« , 1.Ct I by W l_t_ v o v T De c , 'zo Z l ,by liJ l c l +,IU&
(Signature of Notary) (Signature of Notary)
[ ]Personally Known ORP [ ]Personally Known OR pro•ii, Notary Public State of Florida
?Produced Identificati.. j°� Notary Public State of Florida roduced Identification 'p 1 t; William Vogt
.: William Vogt y d My Commission GG 178525
ype of Identification: t My Commission GG 178525 Type of Identification: Ne,,,, Expncs 01/24x2022
'Po„,d' Expires 01/24/2022
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