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1636 ATLANTIC BEACH DR RES22-0067 w . . 4YCity of Atlantic Beach Building Department °ALL INFORMATION 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY Phone: (904) 247-5826 Email: Building-Dept@coai } IS REQUIRED. s. Job Address: ICI 3 ti: ki t44M i"I C R?a b(i 1H, Permit Number: � -SZ Z —OC)�, 7 Legal Description La+- 15`+, iktl ii . 3,,,,,h. 6c4tt(To (..k. ,JA 4 I RE# I Lt1 S"dr_ I 1 10 Valuation of Work(Replacement Cost)$ 4, COO . " Heated/Cooled SF Non-Heated/Cooled • Class of Work: ❑New ❑Addition ❑Alteration ®Repair DMove ❑Demo ❑Pool ❑Window/Door • Use of existing/proposed structure(s): ❑Commercial EfResidential • If an existing structure, is a fire sprinkler system installed?: DYes DNo • Will trees) be removed in association with proposed proiect? DYes(must submit separate Tree Removal Permit) & No Describe in detail the type of work to be performed: /;;:‘ I: i w;..-c. •j,1,1,.,,,..q... 1,/r4.,1 r L`Y lL.A. f iii.5 fu..i( iltc,+. r t I t, • -+Lb .-f-10 V©c),D Florida Product Approval# for multiple products use product approval form Property Owner information Name &INt- I1$)i I Ic4 S.J 1 it 3. //J.'k c Address Ito 3t.' A-1-i. (t'I'7 c- (,?{a.c. ._ 0 i'�i u - -N�t�v City 1-1-4-6.0.41 L.. 11[G cJ'l�/� State Fl. Zip - ,A-2-33 Phone +fes -10.1- g b's13 E-Mail Si-1.IKCS ISG ti c ( .C_4 +-1''t Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Contractor Information Name of Company SC& IC,CtI ?<Ski,l+"C01Str14-+-l". LAG Qualifying Agent 1.-16& ptWKe' Address 1 i I t3i'ac, R-VivL City tlfIa.vt`ha, g[ac State FL.. Zip 1 Office Phone C 04 - S 2. I - I-1-?5--7 Job Site Contact Number 104 - 025--SDC`State Certification/Registration# C C- 11C-3,1 lbE-Mail >C'G:ltJtl ii.,' � 104)64. 9rnai i . cm' Architect Name&Phone# Engineer's Name&Phone# Workers Compensation Insurer OR Exempt Expiration Date 5 I r 120 :a. 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 RECOR , NG YOUR NQT C OF COMMENCEMENT. f' r / ' f... , /f L.d1---. tib (Signature of Owner or Agent) (Signature of Contrarct ) Signed and sworn to(or affirmed) before me this?30 day of Signed and sworn to(or affirmed)before me this I 1 day of i.:ti .'7 , ,crr), ,by )vS�/' I,4J;IA c SVOAU(tirt,i ,_i-ti :L , by I.\CI tit i LC t.1 (Signatur 4f Notary) , (Signaturesof otary) S i •:. ZACHARY KAHALY ., CAROLINE J.SCHROEPFER [ ]personally Known OR ��: Notary Public State of Florida [ ] Personally Known OR �. ,.. °.= Commission N GG 366355 Commission#GG 924046 I l Produced Identification °77 [.)('roduced Identification _o�J ExplreSAugust 15,2023 My Comm.Expires Oct 20,2023 •':Eof Bonded T Troy Fain Insurance 900.395.7019 Bonded through National Notary Assn.