85 W 2nd ST DEMO22-0014 Building Permit Application Updated 10/9/18
I ', City of Atlantic Beach Building Department **ALL INFORMATION
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J HIGHLIGHTED IN GRAY
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� 800 Seminole Road, Atlantic Beach, FL 32233 u.itiy,c IS REQUIRED.
Phone: (904) 247-5826 Email Building-Dept@coab.us
Job Address: U 1 (A)e- + yod s+ Permit Number: t I v r/�n\O 22 - 3( 4-
Legal Description SIP k. SJ( 7 nOtr)(Y.5f-6-_'1i 42 4G '- f RE# / -7083 Ti- OOC 0
.,t G--r. , toYT1' d $1 /
Valuation of Work(Replacement Cost)$ 3//Cx) Heated/Cooled SF 0 7o Non-Heated/Cooled �j l�
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ,emo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Residential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes ro
• 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 performed: Deno 44-0,-, ors ger?CtiQI a 4 hop-7e.
Florida Product Approval# for multiple products use product approval form
Property Owner Information / /
Name -r o++1 d S eOek W Address S. S dt-A d Sir c --
City 111' L b-Li- State FL Zip 3 4,Z, 33 Phone YD it S6 rr 07 2-.)..
E-Mail I'is,/ 0 rook $ :4.11 6 Q hot" rpt,-,1 co Iv-
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information /
Name of Company —3CI X t(�'�(vtirk_I- QualifyingAgent `��,�ria-r-/�G//c I7-7dc
Address l/c ,it/et fy /J1 City A /rrr};7 - r41 State Y L! Zip 1 7 3 2
Office Phone G S . ( ,9£/ Job Site Contact Number . I 7C •
State Certification/Registration#(G( / 4 07t/ ..38 E-Mail .r-7C,i)r),(-6i . `-Seix .D,- t,,,,i 1lcc, (6r-)
Architect Name& Phone#
Engineer's Name& Phone#
Workers Compensation Insurer 13074/,-+ 4 (Cort,/{-, OR Exempt❑ Expiration Date ///77,3
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or inlation 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 ,bbU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNE
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RECORT2,tri N� OF COMMENCEMENT. ;
(Sig ature of Owner o"Agent) (Signature of Contractor)
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Signed and sworn to or affirmed befq t fs lII day of Si: -d and swo to(or affir e•)before me this% �� of
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• �... NN5 :.�^ - Y 10/29/2024
<ersonally Known OR ''
.•NO. �\,: y.}PorsonaIly Known OR ▪ No.HH 58645 Q-
[ )Produced Identification .0i�i • �.U�'' �,��` [ I Produced Identification N2' pUg`�G,:..C
Type of Identification: '4`1,7-E IOF` �s Type of Identification: i,'9T ......, n
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s--L`-rc, TREE & VEGETATION AFFIDAVIT FOR INTERNAL OFFICE USE ONLY
�� f City of Atlantic Beach PERMIT#
31 Community Development Department
800 Seminole Road Atlantic Beach,FL 32233
�J;; 9'�' v (P)904-247-5800
SITE INFORMATION rADDRESS v , �- /r/ -g
SUBDIVISION BLOCK . / LOT 3r G/
RE# ( 70 7 Cb00 "TRESIDENTIAL ❑ COMMERCIAL ❑ OTHER
APPLICANT INFORMATION
NAME HOCO/CI J I?ooks PHONE# -) 6. 6 7,D
ADDRESS g--(n� (,/es + , /,,j S '� CELL#
441
CITY . 0,1 1-1L 6 ea ar, STATE r L ZIP CODE 3 7a 3
EMAIL plgriWNER ❑ LEGAL AUTHORIZED AGENT
I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation", of
the Municipal Code of Ordinances for the City of Atlantic Beach Florida and/or I have participated in a pre-
application meeting with the Administrator of those regulations. Subsequently, I affirm that no regulated
trees and no regulated vegetation will be damaged,destroyed and/or removed from the above-described
property and/or adjacent properties including right-of-way.
I HEREBY
CERTIFY
/THAT ALL INFORMATION PROVIDED IS CORRECT:Signature of Property Owner(s)or Authorized Agent
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SPet4NPPLICANT PRINT OR TYPE NAME DAT
SIGNATURE OF APPLICANT(2) I r..\ PRINT OR TYPE NAME DATE
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Signed and sworn before me on this 1 (-\ day of`-C - ,__ by State of C(
III County of WV CAA
Identification verified: ```o l i i i,,,,, �� .
Oath Sworn: ] Yes ❑ No `• R.NN B Cy��' (�� �/`'jki\A/01 —/
My�mm ExPlres•.yZ Notary Signature .\
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04 TREE AND VEGETATION AFFIDAVIT 03.0 �/••••pUg\: ' Q.O
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