940 ORCHID ST RERF17-0157 NEW CONTRACTOR ^•,',.:5�'1%'i 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
Phone: (904) 247-5826 Email: Building-Dept@coab.us I7S REQUIRED.
Job Address: Qb/O O,QChI/D ST Permit Number: R EJEJ-
-- / - 0 I S7
Legal Description If-J.' /7-.2S-deli- Set 014 4mq4/7-/c ea, sot y, /4/.7,, tors gig is& RE#
Valuation of Work (Replacement Cost) $ QTc Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo [Wool EWindow/Door
• Use of existing/proposed structure(s): ❑Commercial Residential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes EINo
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) KNo
Describe in detail the type of work to be performed: f'• Nc p i RE-_Cm Z(:),1 7 per (r1, -{- /ry c-( c..
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name /Qp)/ ,1/ 4'h44" Address 4:8 5 61/LL 14D&E TEL
City PONT vi-ORA do/. State FL _ zip lac r72. Phone 90V- rql-07-77$
E-Mail fay. acaroman g .'r f. fol
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required)
Contractor Information 1/
Name of Company ac f/}�NE$ CONSTQG/C71On/ Qualifying Agent iBR/At✓ NINES
Address/09S•0-60 -ti,.isctse BLVD. #" .78.7 City SACKs0Nvii LE State FL Zip .1'02,2 2_3
Office Phone goy - 903- 7886, Job Site Contact Number
State Certification/Registration# CCC. /33OO.Z a E-Mail brc 1,yne_s 9 m tt.t I . Co net
Architect Name& Phone#
Engineer's Name&Phone#
Workers Compensation Insurer ZuRly/-4/7IE2IC4A/ /NS. CO. OR Exempt o Expiration Date /./.�//.Z OAA
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 ATT RNEY BEFORE
RECORDIN YOUR NOTICE OF COMMENCEMENT.
(Signature of Owner or Agent) (Signatur,,of�.fctor)
//,I✓ I t
Signed and sworn to(or affirmed) before me this (O day of S�i nI�ed!ad sworn o(or affir led)before me this lt� day of
APR it- , 90a ds by RA = i# Q ,i ' bySNOW" di, _S
4rrture of .•.: gRANDI MCKINNON (Signat`re of Notary)
rate•` ,
Commission#HO 5872
Notary Public State of Florida .* :" rilS
S. Brian H nes .��`! �1E61ISho pf 81nInsurance8003857019
(Personally Known 0; My Commiss on "��. , °�.
✓[']'Produced Identificat; 1 HH 20292+ 1 �r iA • �� ��'—xp�+,-Zei�v
Type of Identification: Exp.121t712025 LCD
Type of Identification: \ L