392 -396 4th St RES22-0203 f.-, Building Permit Application Updated 10/9/18
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City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: 3 ( � 4P ,( cris_ 1 (4 i Permit Number: R _-_. 2.Z — 0203
Legal Description J/ 9 `/73 -;.?„(1.',:, _g. t+.., A'"1"4. r;,j^r./c. 'PE le-:-.` `,4 RE# .,/ (-1,g. . - 0 i too
Valuation of Work(Replacement Cost)Sf/p— ; Heated/Cooled SF '+
C� � C.) N911-_Heated/Cooled aC
41
• Class of Work: ❑New ❑Addition ❑Alteration Lv' epair ❑Move ❑Demo ❑Pool ❑Window/Door 1 iy-c;,,,,Rix," ` .
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• Use of existing/proposed structure(s): ET/Commercial E 'P, sidential --cry r'k j-.. r " ''''' f'-' `F' IC "` "*,ff "' ;
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• If an existing structure, is a fire sprinkler system installed?: ❑Yes kff‘lo
• Will tree(s) be removed in association with proposed protect? ❑Yes(must submit separate Tree Removal Permit) l o
Dssr..rip9 irviet@il t e type of work to,b ormet (.p/ :(i ' �— (-4---'
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Florida Product Approval# tl ) ; for multiple products use prod
PropertyOwner
Information ' _El—
CityName 4L- T) t 1&) /� ' Address 3L Z LrILLI &S)ZL "-
City G /, id ?—� statT_.4__ _Zip :s 213 S Phone 9 oit 91.1.2 C'ero
E-Mail r. '1' A l I I b C- & JL• C.vM
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company �o c 41 ';3 v14,JW-6., (, Qualifying AgentftG-L)50")
Address., X111^) 4-0 P1 City P rIy9i4-f-ie State L_. Zip 3-2-2-3
Office Phone ( ct'&/) Com{3 13 L 5 3�
Job Site Contact Number 'k4-(4- ii-el i-
State Certification/Registration# E-Mail 6L'? . . i,LConJ (. 73 eThat f4,(&. d ,At
Architect Name&Phone#
Engineer's Name&Phone# _
Workers Compensation Insurer /Expiration' - - OR Exempt xpiration Date e-P 7- 0 -
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 T ICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TOO: . . A CIN , C' SULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
: ' ORDIN `O 41' NI TIC •F'COMMENC MENT.
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Ty. :Lure 0 Oar• Agent) (Signature of Contractor)
e and sworn^to(or affirm�)before this //t day of Signed and sworn to(or affirmedADefore m; his tday of
it, R.• . . 7' , - o1otar e n traieasIc'ndaMy�M�UGG945276 Roeemane C rExprM 0108/2024 lay Conynma an GG 945276
[Versonally . . • w• • [personally Known OR O••` Expr�•0108x2024
[ I Produced Identification [ ]Produced Identification
Type of Identification: Type of Identification: