940 MAIN ST RERF22-0037 Building Permit Application Updated 10/9/18
f--__ City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email:
au
Building-Dept@coab.us IS REQUIRED./�
Job Address: /4O ,main /u-' ai t.�7C Aeac(Permit Number: 1 `e- Rp ZZ-OO �!
Legal Description A-3q 38-01S-4,1-9E SEC k aJ/- 9G(. Lvfs 213 a/A•*# /109k4- 64710
Valuation of Work(Replacement Cost)$ $,CCO Heated/Cooled SF Non-heated/Cooled _
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door ge-470
• Use of existing/proposed structure(s): OCommercial Residential
• If an exictina ctrurYure is a firp sprinkler system inctallerf?• rlYec I1Nn
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed: .c-4/.16.. , piv
Florida Product Approval# &//F / /04,?-v-r for multiple products use product approval form
Property Owner Information
m •
Name ( Y
Address
City n17�cad. State P1- ZipI33 Phone 40f , 3 Y3 • 0690
E-Mail /
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information /, /f �,
Name of Company ��" Qualifying Agent /�O /6 _ _
4-tut /. & yyL1d rLtC �o�..• t'e�" .
Address j 7-441 G Q City en k tate - Zip 3���b
Office Phone 47(0Y 6i%.aigI Job Site Contact,�^ Number gam" /Lt=*
State Certification/Registration# CLC d2f6fi�s3 E-Mail res L-€�"y9//c e'Li/i 6.fi7
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer A2i
,
. ns. co/Le/7t7Y7 S OR Exempt❑ Expiration Date 51/A01—
Application
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 FINANCITcCONSULT Vt/ITH YOUR LENDER OR AN ATTORNEY BEFORE
REC• ?SING Y R NE COM ENCEMENT. j �
rail? te, oAi,
1tureofOwner Ag t * (Signature of Contract r)
/64
Signed and sworn to(or affirmed) fore me this` day of Sigma,,Land sworn to(or affirmed)before me this day of
F ?O d-by tt /ri.Ond t;� [e6 , r�a�by ten . a u(4./4-t-4.1,-
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,44.014 U .� �J % . j c
"•" (S'g` dA�VA( A r DICHEV i•natu - of Notary)
•,•.• ,,,
L___________:;�•� MY COMMISSION#HH 182457 ANNANIK,M OIAEVNADICHEV
:,,�,,. EXPIRES:January 29,2026 ,: MY COMMISSION#HH 182457[ I Personally Known '•dofFtp,: Bonded Thru Notary Public Underwriters [ Personally Known OR (( I Produced Identifica [ ]Produced Identification ' Bonded Thru EXPIRES:January29,2026Type of Identification: Type of Identification: Notary Public�nderM�ltero
Doc#2022041587,OR BK 20144 Page 1458,
AFTER RECORDING-RETURN TO: Number Pages: 1
Recorded 02/10/2022 10:34 AM,
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL
COUNTY
RECORDING $10.00
PERMIT NUMBER:
NOTICE OF COMMENCEMENT
The undersigned hereby gives notice that improvement will be made to certain real property,and in accordance with Chapter 713,Florida Statutes,the following information is
provided in this Notice of Commencement. (, �q
1. DESCRIPTION OF PROPERTY((Legal description of the property&street address,if available)TAX FOLIO NO(PCN).: It •f 3 9 3s-25-2 ` I
• Legal Description S r C 1 ( -t'1 c&.M. 1 c- 5 cm L1/4-.. L o-t s 2 i 5 I K 1 6 7
2. GENERAL DESCRIPTION OF IMPROVEMENT:
3. OWNER INFOON OR�,LESS NF TION IF THE LESSEE CONTRACTED FOR THE IMPROVEMENT:
a.Name and addressP `� 1�` 0 , ' V s±, Aiillo-c-E4c-i--\
b.Interest in property:
c.Name and address of fee simple titleholder(if different from Owner listed above):
4. a.CONTRACTOR'S NAME: R C S C.f t.. is
C ROC r t o it
Contractor's address: / 1 /..._, -c.Q c\ P J A x r--(...... 2 ,-f 6
2 Z /..._, b.Phone number: 9 C� 4 ^ pc CD 6 t I 9 -7
5. SURETY(if applicable,a copy of the payment bond is attached):a.Amount of bond: b:Phone number:
c.Name and address:
6.a.LENDER'S NAME:
Lender's address: b.Phone number:
7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7.,Florida Statutes:
a.Name and address:
b.Phone numbers of designated persons:
8.a.In addition to himself or herself,Owner designates of to receive a copy of the Lienor's Notice as provided in
Section 713.13(1)(b),Florida Statutes.
b.Phone number of person or entity designated by Owner:
9. Expiration date of notice of commencement(the expiration date will be 1 year from the date of recording unless a different date is specified): ,20_
WARNING TO OWNER-ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER
PAYMENTS ER CHAPTER 713.PART I.SECTION 713.13.FLORIDA STATUTES.AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR
PROPERTY. OTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN
FINANCIN ONSULT WI Y LEND'' OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR OT10E..RF COMM CEMENT.
4 r � _ �-,Apr Wo N .VA
(Signature ner or Lessee,or Ow MI's .11ssee's )c".
(Print Name and Provide Signatory's like)
Authorized Officer/Director/Partner/Manager)
State of re Cr;c(G'.- County of ALI/CEP
The foregoing instrument was acknowledged r� before me by means of Qphysical presence or °online notarization,
this ° ' day of U ,20 C#- by a,, ^ 'yPay,,,, '��y�
` D�
n (name of person)
as 11 w — for ---- .- NIKOLAEVNA ----.
(name of party on behalf of whom instrument was executed) (type of authority...e.g.officer,trustee,attorney in fyl t) r►'••.,, ANNA
ICHEV
`: MY COMMISSION 0 HH 182457
PersonallyKnown or Produced Identification '�►�� `' EXPIRES.January u'2026
O Type of Identification Produced 9 .''!oi M1OP;