1058 BEACH AVE ROOF22-0026 -S'-'�'r,,, Building Permit Application Updated l0/9/18
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City of Atlantic Beach Building Department `4C'U�"Z **ALL INFORMATION
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800 Seminole Road, Atlantic Beach, FL 32233 Z HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.us k IS REQUIRED.
Job Address: 16 ET 13i=,4cr4- AI /4-1.-/4 4..4-,..--t 8e-cc. Permit Number: ( ll;,
Legal Description LOT to /Vk 4a RE# 11O Z)c, -0000
Valuation of Work(Replacement Cost)$ <9.,LJ cQ. Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial 1 dentia)
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s)be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performDppd: 11 1 [ 7
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Florida Product Approval# FL. . ..4.-- -3 for multiple products use product approval form �„ cC
Property Owner Information
Name 0_1-1-kii 416vt r✓JE3 Address po iLX 33J Q 4 -
City 6+6 t'-- )3E,9Cft State & Zip 3,44_ Phone
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company 6. Xe'bZ Rieorrnt. LtoKr,u rvi S Qualifying Agent 4 �C�tl7T�fit/ISE-✓t
Address 7.0)..q-1.3o
-/.3 (' wvvct.l.�
tvitp4/{-Lc 74-V' City J4?C State FL- Zip 3? ,9.O
Office Phone c7Lcf - (,,3/-7 told 3 Job Site Contact Number 9OY-L/43-3113*
State Certification/Registration# MC i3 Isf,-I C(e E-Mail O.r ',e>e 6ge,i sl,x .0 8v4
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer .S�tvt rvt.4- OR Exempt 2r-Expiration Date /X-q- )-2,
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 OBT A N Fl ► '' NCING, CONSULT WITH YOUR LENDER OR A ORNEY BEFORE
RECO��''i Ii�i' '1"•UR NOTICE OF COMMENCEMENT.
L�.��
(Signatu e o Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this k da of Signed and sworn to(or affirmed)before me this I,,t day of
M C i, 2_C CYl r 1 S 1--Vo0 16 c S� t'iGk,k-k Z2 y k SoTen Yl
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- (Signature ofNota
iQ`•''�Y°`• t�.. BETHANYSALCAN ,•;;ar BETHANY SALCAN
:*. ,. :* MY COMMISSION#GG 317919 '• ,., ••,. MY COMMISSION#GG 317919
\>�Personally Known&. EXPIRES:Ma 11 2023 Personally Known OR *=
/ roduced Identifi ti rwF.V Bonded Thru y i/] =+,���P°= EXPIRES:May 11,2023
NofaryPubllcUn,ie�wrltere roduced Identification •,tr io,- Bonded lbw Homy pubic umervai i
Type of Identification: Type of Identification: