1657 SEMINOLE RD RES22-0092 A ,,-, 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';9Y IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us (�
Job Address: /1 7 , 3Z2 33 Permit Number: 1 2 Z ! 009
09. 2s• 9E-//
Legal Description ocE�.✓ �¢.� k�„T / S/4 P7~ RE# /6 PSL�-vt33a
1-0 7' / / .4-0— 4 - q
Valuation of Work(Replacement Cost) $ �i�'o • Heated/Cooled SF '4 Non-Heated/Cooled �b l
• Class of Work: ❑New ElAddition."Nareration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial esidential
• If an existing structure, is a fire sprinkler system installed?: [Nes to
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) Vo
Describe in detail the type of work to be performed: �,�
.� A--ro.�c_. A-64a4 D 4 ,A.....-/A7,7 STS T'H
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name 12-cr:a$ Ftrvt'-L Address /6•x'7 `S'e /*"-/1 '��Q--(
City >'4-r-c---.4,./1/L EP1C-1 - State fa- Zip 3z-z-33 Phone - 22 • 31.7 /
E-Mail R.)i-ItdrCLEN �?�( MA1t_.(i�;� kco •_; i �f 1/
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company-Bc 1--1—1 1 L r--%C. Qualifying Agent W f 1--t 0 f•
Address 2--' Kt''t4 3b,�r— Q� City kii_v c4 State Cc.- Zip 3-2-04.1S—
Office Phone `1a4-Z'S - L t t0 Job Site Contact Number %b.4. 44q - 1 49 3
State Certification/Registration#ICS 13 Z--6 SZ-B E-Mail bc ca rJ e_ A 0 C• c_o�4
Architect Name& Phone#
Engineer's Name& Phone#
Workers Compensation Insurer OR Exempt Expiration Date S(4¢/21:'73
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 A —rs • EY BEFORE
RECORDIN I d R NOT CE OF COMMENCEMENT. -
ignature of Owner or Agent) (Signatu -of'ontractor)
Signed and sworn to(or affirmed) before me this aVhday of Signed and sworn to(or affirmed) before me this2Dlay of
Vsaec , Zoiz , by ^°6 T_ __` • KW/in207/7/ by�i. I Il 1 Solt
nitTIRII
,!gn@kfriEP9tiNottjtyy of Florida ;=u«v:�yc 1 . •' I VER
Commission#HH 106510 ft Commission#GG 366355
•
'lova ` My Comm.Expires Mar 21, 2025 Expires August 15,2023
Bonded through National Notary Assn. • ` F,",:'• Banded Thru Trcy Fain Insurance 80A•385.7019
t•
[1roduced Identification [/Produced Identification
Type of Identification: I'fv{�4'. �(;cfreic 1.4 c.c.--._r•.. Type of Identification:F1/DV. f3150-144)-(//-100-0
NOTICE OF COMMENCEMENT
State of
PL-0 9-41:1.a- Tax Folio No. /L 95-4 V. oo.36
County of
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: /&---22- 09'. Z5 - 29 E, � ,e'er&
C-4-#.0,7 i S'1/4b P r� Lo r // .34-44-
Address
L-M-Address of property being improved: I L. S&t-i t..!et-E-- 37--a.3
General description of improvements: 12-e of FSA w BA'T 1 - `T h-4 A a-c&/L3,0-Tb3..,
Owner:7--""�* —1/4A-1 Pi s-1 Address: t LS-1 S e-Ez
Owner's interest in site of the improvement: - _
Fee Simple Titleholder(if other than owner):
Name: _
Contractor: o L.tti es•I Q-e t.I C
Address: 2-o 1L.-,,.J 19 1+1 �oK 1�J -t ob 6 oLA PJCIC- PA 3 z
Telephone No.: 9°4-44-et - 6443 Fax No: LD 4. 2-15-. L t to
Surety(if any)
Address: Amount of Bond$
Telephone No: Fax No:
Name and address of any person making a loan for the construction of the improvements
Name:
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 may
be served:Name:
Address:
Telephone 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 Statues. (Fill in at Owner's option)
Name:
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is on year fr the datd or ing unIOSaft/ltfievitQt date
specified):
+ •, Notary Public-State of Florida]
:, ; CV111111i])NI,W MN 1065111—9 oFr� My Comm .Expires Mar 21,2025 P
THIS SPACE FOR RECORDER'S USE ONLY OW E I Bonded through National Notary Assn.
Signed: Date:MA( 2 ` 2 2-
Before me this day of Malt 4. 2012.in the County of Duval,State
Doc#2022078759,OR BK 20200 Page 2029, Of Florida,has personally appeared 2d6by S4`( t, k/e 4
Number Pages:1 Notary Public at Large,State of Florida,County of Duval.
Recorded 03/29/2022 01:36 PM,
My commission expires: 2. L rrL
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL
Personally commission
exp Make '� r
COUNTY or
RECORDING $10.00 Produced Identification: 'i.is.A iri %leaf L.r c•C w j