150 ARDELLA RD RERF22-0042 Building Permit Application Updated 10/9/18
1 City of Atlantic Beach Building Department **ALL INFORMATION
7 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
�o;tiu� IS REQUIRED.
Phone: (904) 247-5826 Email:// Building-Dept@coab.us RER
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Job Address:/Id / cq/e//o. j d �>ther;TQC dt cX7 ,/I.Z.73 Permit Number: � 22`cL/4
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Legal Description /9-/e /,f-?9E•/96 •fin^rrs• �� /orter- rT� 96F/ RE# /7.2/)9 d42m
Valuation of Work(Replacement Cost)$ (✓/3C6 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial [1.126dential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes
• Will tree(s)be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Permit) INo
Describe in detail the type of work to be performed:
6Srr� .;f
Florida Product Approval 4`/0(.'7 J�/��n�/ � //�� //I ''`''r'' multiple products use product approval form
Property Owner Information
Name -7-ciiriirti Ly/f3' Address /.??,A. //cc •l< j,•),.7f Ari(
City State / / Zip s-) 2 Phone 9e--57 �a/�5 Co C 4;1-
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company /1"k0-/,&o C J/rut in)-i Qualifying Agent J'- ,iL /?/146411)
Address/6875 /7Ppk_ oti.. Tr(2,1 Citysc.ic State /el ZipjJ, /4
Office Phone 96"y7c T) 3s Off' Job Site Contact Number
State Certification/Registration# Cc-c• /23,9 4'2- E-Mail sv44J'krr.t 1•0%7JItu,cI,n44eQ tia.i/ r.>N-
Architect Name&Phone# V
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt Ipiration Date//It:18�.2,-�
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 OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
otr— /M. (-
(Signature if Owner or Agent) (Signature of Contractor)
S' ned and sworn to(or atp.- •= o_- me �ay of a and sworn to(or . ed)before me his L-day of
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--�—.._.:._-- ure o Not. ) 4111 -- (Sig •tu - • otary)
12'��"�` - TONI GINDLESPERGEP,
MY COMMISSION#GG 353178
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••, o•,,, o al � ber6,2023 [ ]Personally Known OR ,•�;n�Pv'••.,, �"—
_.:_ ti:�Ua4�0 Nit ;lic U . ers [ ]Produced Identification `.' , : TOM COMMISSION#GG 353178
•
Type of Identification: !MIL Type of Identification: -
°p", Bonded TMu Notary Public Underwriters
NOTICE OF COMMENCEMENT
Permit No. ifrA rf;-'Oe*g Tax Folio No.
State of nedsx_ County of /(,,,,g/
To whom it may concern:
The undersigned hereby informs you that improvements will be made to certain real property, and in
accordance with Section 713 of the Florida Statutes, the following information is stated in this NOTICE OF
COMMENCEMENT.
Legal description of property being improved:/9"-/ /7 'at 1= Sri •/94
JOnners .4/fPr L0"7-02 P i e- gal r Gd T U A6 6
0/13 -1-24,0 - 7,Fr eel,/c
Address of property being improved: /rO 14ra'G/l4m /39/
,4f/Qpic, 8P c ,fG 3J233 n
General description of improvements: gerats
Owner T) rnj Ly/at
Address /34 At.,,Ierwoval A61 ��cC Jf S2 2 ZS
Owner's interest in site of the improvement
Fee Simple Titleholder (if other than owner)
Name
Address
Contractor L�P✓.,,. /nail,1,.c,
Address LDY7S .R1®/C p/oclai4,... 7-1-u-i1 _AIL) ,&J 37-�.I f
Phone No. Fax No.
Surety (if any)
Address Amount of bond $
Phone No. Fax No.
Name and address of any person making a loan for the construction of the improvements.
Name /J//
Address
Phone No. Fax No.
Name of person within the State of Florida, other than himself, designated by owner upon whom notices or other
documents ma be served:
Name /v �I
Address
Phone No. Fax No.
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in
Section 713.06 (2) (b), Florida Statutes. (Fill in at Owner's option).
Name /y4
Address
Phone No. Fax No.
Expiration date of Notice of Commencement (the expiration date is one (1) year from the date of recording unless a
different date is specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
Signe DATE Z ��°
Before me this , day of . A l AC-r L 2.p Z 2- in the
County of Duval,State of Florida, has personalOy appeared
—0►.-/ "ycc.,, 2., jLt;Z herein b
himself/her;lelf and affirms that tiRSTdlTlfx�`e1�W' y
are true and accurate rot"•Y'�e< .: KATHERINE PERRY
Doc#2022055441,OR BK 20165 Page 1718. , 1
Number Pages: 1 ,f i�����i ,.; Commission#GG 280740
Recorded 02228/2022 02:33 PM, .,;,;,.77Pa` Expires February 6,2023
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL
',0`F`0'' Bonded Thru Troy Fain Insurance 800.385-7019
COUNTY
RECORDING $10.00 Notary Public at Large, Stat ri021-1ck . County of 1J v c�
My commission expires: 02-04,120 23
Personally Known or
Produced Identification s=i 61. L L/ID Seob 3 c. 3(f c-b•
6l /z5 / z`/