715 SEMINOLE RD RES22-0135 Building Permit Application :,;,
..: t; City of Atlantic Beach Building Department .-ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
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Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED,
Job Address: r7I CJ' 5aci i d. A-� 1 _ ___ --Permit Number:1).„.....
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Legal Description_ Q-- : r� l RE tt_
Valuation of Work(Replacement Cost) Li,.boo Heated/Cooled SF Non-Heated/Cooled
• Class of Work: DNew CAddition OAlteration Iklepair :Move [Demo OPool ( Window/Door
• Use of existing/proposed structure(s): OCommercial r sidential
• If an existing structure,is a fire sprinkler system installed?: [Ver.esu' UNo
• Will tree(s)be removed in association with proposed project-; ' 'yes,(rr,uyt submit separate I c:r,Ri:I e i ?rrrmit) :Ncj
DSo l��detail �� of work to be performed:•�1 j \� ruV\ -VVI 1\ be -�p ‘rw„ �
e2d a c\ N Q Cl 3 A 0 bQ e ptc c C1 h-fi
riorida Product Approval# Ni rel _ for multiple products use product approval form
Propert Owner Information
Name e r ! _ r Wiwi aar' . � I
CO ► ,I �C-
��_� State '�I, ='hone �� �� Ci —
E•Maii 01 ( ._ + `(`( , CO
Owner or Agent(If Agent Power of Attorney or Agency Le ,:,Required)
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Contractor fnformation
Name of Comparry ,__,t ,oQ ej• Q er INE Ce Qual fying Agent NAV(
Address 11301 --3,i 3" t'i 41ti7'rl Aye E city eltpk56t\v1l Ve ,:iate R z i, i_.
Office Phone q&-i1•.2.ci 2. . b`=Y-5- job Site Colt.-w-Number
State Certification/Registration NIA F . jeA 'Sk'tSt arv-k tl, C-b rkt__
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer t►°G 71- e 01.1111141 AMIAaL4 Q OR Exempt C` Expiration Date OL,•b&, ,21)9.-3
Application is hereby made to obtain a permit to do the work and installations as indicated.I certify that no work o' Installation has
commenced prior to the issuance of a permit and that ail work will be performed to meet the standards of all the laws regulating
construction in this jurisdiction.I undersand that a separate permit must be secured for ELEC I RICAL 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
1.'. _RING YO - , ICE OF COMMENCEMENT. .
-,pnator. c`Caw ui :T,Cnt! . ignature of Cr,ntr;- tori-Std-h
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S' ned and sworn to(or affirr •. ; before r 3 i� day 'Sin an sworn to.(or aftirme• - .re •,j this day of
V ZC]_ y w 004 1 - 1 - -'91-0 aa.,by._. .. �1..._41 Cf'
Si y atureMiraft,A. 1t4+s/*r✓,
11 7 „, ,,,It,,, R
L(OMMr.SIY\
( i Personally Known OR (vf Personally Known ORF,XNIRt S f of„;
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( )Produced Identification ( j Produced identification t,,,,,._ ,,„,.•,,,�.s ,,,,,w•
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Type of Identification: l - L Type of Identification: ____
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TONI GINDLESPERGER
MYCOMMISSION#GG 353178
� EXPIRES:October 6,2023
Bonded i hru Notary Public Underwriters
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