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122 6th St Int Remodel Submittal : ''' . Building Permit Application Updated 10/9/18 J� ...._.! City of Atlantic Beach Building Department **ALL INFORMATION 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY -Enti IS REQUIRED. Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address: /r u1 yZi,(,(it.ij 0 -- Permit Number: Legal Description 5E 9 t -Z-5-Z5, "C 4-''[ZC `=AC EJ/2 Lcq-C> RE# Valuation of Work(Replacement Cost)$ it°-G E Heated/Cooled SF `' ?0 Non-He,,ated Cod b ' • Class of Work: `Jew ❑Addition ❑AlterationRepair ❑Move ❑Demo ❑Pool ❑V bow Door • Use of existing/proposed structure(s): ❑Commercial C9(sidential JAN 3 1 2022 • If an existing structure,is a fire sprinkler system installed?: ❑Yes Effio Ry. • Will tree(s) be removed in association with proposed project? EYes(must submit separate Tree Removal Permit) do Describe in detail the type of work to be performed: .` tat LAW2A - 12411ALi - C t.),t. - f QL.c,CE-- iL(1.-C- i . C.:-N-3 t 1.C__--TS Florida Product Approval# for multiple products use product approval form Property Owner Information cl Name �t darer , -A-U)J_- Address /(D City I/.Qlj/1.rim J3 _LLL State 7"/ Zip 3 a ;3 Phone 71 --7 5 -3 3 j E-Mail 0 `a wp4 a R cyy 1 P e'ryyi r Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Contractor Information /�Name of Company _ ik-40�� ©1- FL-Qualifying Agent C[LD K-[.L51fZ 0 Address (( ( S 9 -2k Of 0Q ,? City /&X SC&JVILLf State F L Zip -j LZZ CI Office Phone c-( 0 + — 3 g 6 w '''C 4- Job Site Contact Number State Certification/R`egistration#CLC (51 8 t (4 E-Mail FcLo? kf-3)a 'S of L(' (i b--C-&t L- • Cg2)(-•-i Architect Name&Phone# Engineer's Name&Phone# Workers Compensation Insurer OR Exempt 0 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 O AN-Aid;; ► EY BEFORE RECORDIG YOUR TICE OF COMMENCEMENT. _� 11- , j• GE Esp�'f'�g�ature of Owner or Agent) Ai , (�*7:ature of Contractor) �0 ... .. .''' '- ei 4Glig 'and swcpx r�ffirmed)before me this 13 day of Signed and sworn to(or affirmed).before me this 4 day of : 'y�vt-Q`` 1 Sy (,dntce tcOi/ �}ACVUAI°1 , 2027 ,by L1�(S � 1CLOM _ i�`s�Na Gg6 S O ignature of Notary) (Signature of Notary) a�6-•...FeroG sC;: -3- ' PVe�:<,\, _...e:;:.:;. ,C 1 YP CHRISTIAN GILES ��i,[ ]4@rf'g0,011Y wM 0' ["]Personally Known OR S ,,, � MY COMMISSION#HH 117153 r' de I 'l.titron ['1 Produced Identification tf uQlIUr" Lr NJ Type +�1�P EXPIRES:April 13,2025 Type PI Mi i anon: C S T e of Identification: Fo';'�. . ..._ ri?ers Fl,- p 1 _