488 SKATE RD RES22-0079 new application .!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
r st IS REQUIRED.
Phone:aa (904) 247-5826 Email: Building-Dept@coab.us n
Job Address: `/U U SLUk Quad Permit Number: RES 22- 0079
Legal Description 314%2 Vi •ZS'ZRFR m. Zy
�-(P P�' o� (tap( Palms Unit Btr�19RE# 17151.,p-7- d()OC�
Valuation of Work(Replacement Cost)$ 1 ,000 Heated/Cooled SF I OS] Non-Heated/Cooled , 2 7 z
• Class of Work: ❑New ❑Addition ❑Alteration Repair ❑Move !.1.emo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Jesidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yeslo
• Will tree(s) be removed in association with proposed project? EYes(must submit separate Tree Removal Permit) o
Describe in detail the type of work to be performed:
awl' 0A-r) ;-t-bleu,_ ✓IA4c., ()wed (rnk,ar- Wa!/) r�t_o/au dra- Dan �n S��cvu+
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name Adek\ vv.1t'7 Address q(6b S t1Q (Rxtd
City (-�}\fano-:t_ 6too-, State it Zip 32233 Phone (1k-i '442 3803
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company P(PLb WiC1+ gUZL-DER_ Qualifying Agent Charl(5 OiXOn
Address 1 3 q 1 StU PrC,tII)L LFrt•J City Jnf_IL.'t)n Jt u, State FL Zip 3222+-I
Office Phone C101 • 2,y t- 1 U L i— Job Site Contact Number q bL • 33.•4- I 2-01
State Certification/Registration# Nix.„ O4 23 c10 E-Mail 1- tI )tnS [Otaults C boco-, 0(9
Architect Name& Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt Expiration Date 1-1/151 23
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 TTORNEY BEFORE
RECORD!, G YOUR NOTICE OF COMMENCEMENT.
AP'
/�xCE? Z� �1.'�� of -:e' "
(Signature of Owner or Ag (Signature of Contractor)
Signed and sworn to(or affirmed)before me this 1V day of Signed and sworn to(or affirmed) before me this /5day of
IY1arth , 2. -2, ,by Ade II W•le marCk , 2-021- , by to-lit D;x on
tyiL-7 1 1-- AQti4(t se_ VI/mi. ✓t/a..,- ______
.
J(Signature of Notary) G U (Signature of Notary) I
siviii ."" JOYCE MARIE FREEMAN 1 i✓i°o"' JOYCE MARIE FREEMAN
`�• Notary Public•State of Florida C• T'' Notary Public•State of Florida
Vi Personally Known OR � [✓f Personally Known OR
'° $'e! Commission#HH 092628 ';% ' `� Commission#HH 092628
[ I Produced Identification ''t tid` My Comm.Expires Jun 10,2025 [ ]Produced Identification ..,a e. My Comm.Expires Jun 10,2025
Type of Identification: .Bonded through National Notary Assn. Type of Identification: I Bonded through Narinnai Notary Assr.