1386 ROSE ST RES22-0172 IA,--- Building Permit Application Updated 10/9/18
1- lk : City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
'''.,..)-711:?,?' IS REQUIRED.
Phone: (904) 247-5826 Email: Buildin -Det@coab.us
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Job Address: i . ..511 Le /r�[�� M--- �IC.Lr'�f� , / ermit Number. 1l
Legal Description f Q,_ ( 7 - �1 /. fits; / RE# /7/t,U -'-Oc Ob
Valuation of Work(Replacement Cost).' "eated/Cooled SF 1 Non-Heated/Cooled G-
• Class of Work: LI New ❑Addition Iteration ❑Repair ❑Move ❑De o DPool ❑Window/Door NYz-
• Use of existing/proposed structure(s): ❑Commercial %Residential 5) ,5- N
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• If an existing structure, is a fire sprinkler system installed?: ❑Yes1No IJL ,13 Lk-
• Will trees) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) ]/V0
Des,Des ,ri e in detail the type of work to be performed: J �//_if n-�'
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Florida Product Approval# for multiple products use product approval form
Property •wner Information
NameAigis �"- -� >� ,/' ' Address P - I " i;i- A_. ) �-
City + C-1 i State 1'V Zip 'hone c Dag• �j
E-Mail Cu-i f'h(,acc 1 ginc,1 ) , 101�-- �/- `
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required) 1,1--n-C..-K--
Contractor
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Contractor Informatio
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Name of Ca �} !!if . �_A � 1/ Qualifti ing A_e t it__ rn _
Address J Yr . City `1 r�St.te Zip Y.
Office Phone L ' �(D✓,(-/-4-411 Job Site Contact Number
State Certification/Registration# tes-6-ZR E-Mail ni i'1 CYC • rove---- , T
Architect Name& Phone# (1 Li l/
Engineer's Name&Phone# K--)[CV
Workers Compensation Insurer OR Exempt Expiration Date
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 ATTORNEY BEFORE
RECO YOUR NOTICE OF COMMENCEMENT.
I/ l4 � /L—
r 1 (Signature of Owner or Agent) /(Sign. •re of Co actor)
Si:fled and sworn to(or affir{i • before me is(v day o Si ned and sworn to(or�af`fir e• before me this/ 3day of
eci-- tAcIfi
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,�;�YP�'•-, TONI GINDLESPERGER
= MY COMMISSION#GG 353178
..,:; a''• TONI GINDLESPERGER
::. -; 4 :Gct4 6,2023 PersonallyKnow QR°' --
' '''•'F OF ,ff�so � pwr� [ ] if; . MY COMMISSION#GG 353178 '
o u o,a u li Underwriters :R
[ )Produced Identifi •ll,is EXpIRES:October 6,2023
Type of Identification: ,LType ofldentificatio �rn�, a�n� hryNozNa,bucUn.do' tos