1846 SEMINOLE RD RES22-0195 REMODEL '`'-'.,;'.i, Building Permit Application Updated 10/9/18
,j ...,a,.1?% City of Atlantic Beach Building Department **ALL INFORMATION
---:-.{-un� / 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
i IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 1 €J L) ` e f1.C\C) f t ,\3C fl' CI Permit Number: R�`> 2._--b( 95
Legal Description ' (V - /4�n�-' 04/1 / L& �
7 ek_
itRE# 112'4'74 - 06-7g
Valuation of Work(Replacement Cost)$ t'Z. Heated/Cooled SF /6qVg- Non-Heated/Cooled_4 'r1 y
• Class of Work: ❑New DAddition DAlteration IvRepair EMove ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial IiIResidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes 9oNo
• 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:
ell i>oft-ke, (7)C-Piea-' Fecok3-.., elyi —rze /-; i'-- (1;01----)
Florida Product Approval# 44- for multiple products use product approval form
Property Owner Information _
Name 1`n().f Vs. 1\, �i.>pc Address Y'I k glen \ I n Olii
e Rd ,
City L - ' lk - --1_ C 1 State k Zip 3223 3 Phone 904 - 3`13 -` 1 3 Z.
N'
E-Mail lotr 1Vc N .0 L::..c.). -C•
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information r
Name of Compan�yl4/445l+•I� 6"y %.l1L Qualifying Agent I(4.1 r./J A Li"Ait
PA Address le/T I-aptik /310d k S City / { j''a^ /.State r/ Zip��j?-;?-j7-i
Office Phone 116 $3e 75-6, Job Site Contact Number qDy it,-; 74.- 3
State Certification/Registration#4e125/1E-Mail Sd•hg.4k')f I3ti4,4(s'. epyiil• Gf'y',
Architect Name&Phone# `� l
Engineer's Name&Phone# "'—
Workers Compensation Insurer OR Exempt/1 Expiration Date l 23
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work r 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
RECORDIN YO NEI!'' OF COMMENCEMENT.
(Signature'of O ler,.r Agent) (Signature of Contractor)
ed and sworn to(or affirmed)before me this day of Signed and sworn to(or affirmed)before me this day of
V IN<- ,.9%024 , by—TtCkeSein 5UA12_ , aa9a, by U. .L...,iw _ vt n
ti s,.t�.� : .s � r`,, _.se!IIMi�!<BIoft�V�Jjda
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.1 < Commission#HH 26464
Commission#HH 264164 �� 8
''?pr... My Comm.Expires May 12,2026 1 My Comm.Expires May 12,2026
[ ersonally Kno n OR Bonded through National Notary Assn. ( [ Personally Kno OR
[ ]Produced Identification [ ]Produced Identi" . o
Type of Identification: Type of Identification: Bonded through National Notary Assr