175 15th ST RES22-0059 application t 'f'r' Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
\ ;, 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Jit , IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: ' 75 'Srid -s Z rI t1Ai4ctf39•a-�3 Permit Number: R ESZ Z- oc1 5
LU
Legal Description 4 3 1-3n< , I' L p\cIr o.A-ND A y CIP
Valuation of Work(Replacement Cost)$ H 04)O Heated/Cooled SF Non-Heated/Cooled
• Class of Work: DNew ❑Addition ❑Alteration ft Repair DMove giDemo ❑Pool .Windo /Door
• Use of existing/proposed structure(s): ❑Commercial ipResidential
• If an existing structure,is a fire sprinkler system installed?: DYes giNo
• Will tree(s)be removed in association with proposed project?(=Yes(must submit separate Tree Removal Permit) 18(No
Describe in detail the type of work to be performed: RL---f-LBLE_ (jLAMS / FRi ,
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name W I?KC c1-j e'RE- --J 01-(A) Ni Address )75 I S rIf 1011-7
City A TL AN ne_ .i-e6,1.4 State tC_ Zip 33.3,),) Phone /O Z/ �t('- n'043 H 70 Li Oj D`/09 )
E-Mail YV1)o h r)5t2r1 a & 5 r y yl t-+. ( J YvN
Owner or Kgent(If Agent, Power of fAtt66rney or Agency Letter Required)
Contractor InformVio 1 Name of ompany _ t t 1eioU1 Quali ing Agent
fZip
Address 0? t–� r, City ` , State • Zi
Office Phone 16 9 _ 1 � 3 Job Site Contact Number 0 - • . ' t
State Certification/Registration# $ OS 11 53 E-Mail ,SSG,G l • ep M 4. . c 0.r'^
Architect Name&Phone#
Engineer's Name&Phone# SP130dN-r MeP/P&— /C / 7( 7
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 PROPERTY. IF YOU INTEND
TO OBTAIN FINAN ING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECDYOI�ICOF CO
MMENCEMENT. "
0 a r �of Lner or Agent)
(Signature of Contractor)
Signed and sworn to(o affirmed)before me this tSO day of 5• ned and sworn to(or affirmed) .efore me this 1 4o day of
Kbrue.,'It 26 �,by ►)'1�J•Ss� - <� ,j c.4—v�;:1 , ZeLz,by '-• Air ',,4. AI;ss`?km v
(ignrture of Notary) , �( gn re of o
.4:0°4:-. MELISSA JOANN DAVIS jr r�'-., Mc�155A JOANN DAVIS
�Personall Kn 4, -,, Notary Public•State of Florida .`�" 4F` Notary Public State of Florida
y Commission#GG 956145 In-Personally Known OR i Commission#GG 956145
[ I Produced Ide f) My Comm.Expires Feb 14,2024 ` [ ]Produced Identificatio ar My Comm.Expires Feb 14,2024
Type of Identifica n: Bonded through National Notary Assn.' Type of Identification: Eond•d through National Notary es r.
. 00.111PNIP.t