175 15th St RES22-0059 revision 3-8-22 Revision Request/Correction to Comments * ALL INFORMATION
'
�. HIGHLIGHTED IN
p 1' ' City of Atlantic Beach Building Department GRAY IS REQUIRED.
/1/ 800 Seminole Rd, Atlantic Beach, FL 32233 RLs z z -cos9
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Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
❑ Revision to Issued Permit OR ❑ Corrections to Comments Date: t,2
Project Address: 1 7s 1Si/h ST
Contractor/Contact Name: \ tSv '- CO't 1 t. rf--*--,_
Contact Phone: CIO I( cYC2CC Email: �C� C-- (c( gCo n(1 &A ( CZ7 rY'
Description of Proposed Revision/Corrections:
I a c.c. �� ("24 I i Z— affirm the revision/correction to comments is inclusive of the proposed changes.
(printed name)
• NI-proposed revision/corrections add additional square footage to original submittal?
No ❑ Yes (additional s.f.to be added: )
• WjLl-proposed revision/corrections add additional increase in building value to original submittal?
17_1No ❑*Yes (additional increase in building valu •$ ) (Contractor must sign if increase in valuation)
*Signature of Contractor/Agent: �� ':... . ...e...-az----
(Office Use Only)
❑ Approved ❑ Denied ❑ Not Applicable to Department Permit Fee Due $
Revision/Plan Review Comments
Department Review Required:
Building
Planning&Zoning Reviewed By
Tree Administrator
Public Works
Public Utilities
Public Safety Date
Fire Services Updated 10/17/18
-A`jr4Building Permit Application Updated l0/9/18
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City of Atlantic Beach Building Department **ALL INFORMATION
�p� �/ 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
art IS REQUIRED.
7S IPhone: (904) 247-5826a Email: Building-Dept@coab.us
Job Address: 1 !5 /C111 - 1S % �I'�kiti7c en Ck fl--rN33 Permit Number: R ES 2. 2- Cja
Legal Description /4)7 3 131-)< ( Pl E MNO ALA' ) Cp I 7 (g
Valuation of Work(Replacement Cost)$ QVO Heated/Cooled SF 4`b4E Non-Heat . o0
• Class of Work: ❑New ❑Addition ❑Alteration KiRepair ❑Move lifiDemo ❑Pool (8Windo /Door
• Use of existing/proposed structure(s): DCommercial giResidential
• If an existing structure, is a fire sprinkler system installed?: OYes fiilNo
• Will tree(s)be removes) in association with proposed protect? ❑YesImu_st submit separate Tree Bernina'Permit) SQNo
Describe in detail the type of work to be performed: R(,f'l l(- N-----.? ) FIZt ' M p 5 ,
Florida Product Approval if for multiple products use product approval form
Property Owner Information
Name Il MAP( u j ri4Est;_ ,f 04A'.9:v.) Address 175 IS Ili "j I2/�
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City °4Ti.AN --' t-'�i:'(Ac'14 State rt_ Zip 33)-'x'-) Phone '01-/ oileA Ji-c)43 IF 7o y4.;jCyOsi�
E-Mail /'V) okin Sv-) ),a & vCYylr;}, L )"'1
Owner or hent(If Agent, Power offAttdorney or Agency Letter Required)
Contractor Inform•.tio f I P.� Ili
Name of ompany 'Co
r (i Qt l 1 l Ie - Quali ing Agent C 1 hi�I�b 8
Address a �� S" City :;�% �MA!1
Office Phone 0 ' - ( .Mt Job Site Contact Number 0 _ •
State Certification/Registration K 4' •�� a E-Mail . 4 C.. ikeriff rr,a t . re+
Architect Name& Phone$$
Engineer's Name&Phone K SA130 l�/t1 o-r tik/- 114=r— 501 7 j 7,s'"--,;
Workers Compensation Insurer OR Exempt Er 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
RECORD) c YO R OTICE OF COMMENCEMENT. GPli
(°is a. n• of a net or Agent)
/I-- (Signature of Contractor) /
Sired and sworn to(o affirmed)before me this L Y0 day of Signed and sworn to(or affirmed)Lbefore m�e,this f - day of
►`1't a;`.1 t/, 2 L i 1 , by Oki• i `, .11'4,.. r♦ 1•(./i f ;. / , 201 Z--,by 1 ��fp �. I fi�'�+S5` �-
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`• L J(Sigrt ture of Notary) Li)(-"(�gnat/re of No[[�ry) •
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_��..� MELISSA;Cahn DAMS ,�i o` . M;_SSA JOANN DAVIS
V1Personall Kn 4(1`; Notary Dub':,c .State of Fiorlda x:� ' Notary Public•State of Florida
Personally Commission x GG 956245 (‘j-Personally Known OR Commission I GG 956245
I I Produced Ide My Comm.Expires Feb 14.2024 ( I Produced Identificaho �• •a� My Comm.Expires Feb 14.2024 I
Type of Identifica n: Bonded tnrou h National Notary Asir Type of Identification: laded through National Notary As`* 1