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350 4th St ROOF22-0043 application rit, Building Permit Application Updated 10/9/18 ,k-I City of Atlantic Beach Building Department **ALL INFORMATION L 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY err " / IS REQUIRED. �.aj1 Phone: (904) 247-5826 Email: Bulic.+in -Dept a-}coah.tis Job Address: ,3.50 S tI y� c Permit Number: 8 I Legal Description S l 9 /4, ds '- f 4 tiff/7 lJ Ay � vix s RE# 0 � , �'0 Valuation of Work(Replacement Cost)f at-ES° Heated/Cooled SF ?/ Non-Heated/Cooled • Class of Work: DNew DAddition OAlteration DRepair DMove DDemo DPool DWindow/Door • Use of existing/proposed structure(s): DCommercial DResidential • If an existing structure, is a fire sprinkler system installed?: DYes ONo © Will tree b- remov-d in a sociation with •ro•osed •ro'ect? DYes m st su•mit -• •r. -Tree R=movalPermit ONo _ _ Describe in detail the type of work to be performed: L-O'T )4- •-i c rC ✓ j#k , Florida Product Approval# F-71 'AO. / for multiple products use product approval form Property Owner Information/ Name /n CSrec.- /MP Address 35C 4' ,;y A- City [Y J. State f Zip 793-3.3 Phone let, v 7c `(it 73 E-Mail Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Contractor In f,,La-tion Name of Compan' ,[► a.el• 0 siu,i 'a.....r •es ualifying Agent hC?./1/1L4pi1-,tQ e16. Address 1'5 L \ V t 1 • ity�? '.—State Zip Office Phone OA). (Q - �q Job Site Contact Number) YS H. tAWII . , , 0 State Certification/Registration# 1'('p kit-04 ) '„gee,E-Mail Architect Name&Phone# Engineer's Name&Phone# Workers Compensation Insurer l OR Exempt ❑ Expiration Date S 1 lei 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 0: • • ORNEY BEFORE RECORDING YOUR,NOT,ICE OF COMMENCEMENT. Y'na-),), v-z_k_,� c - l � / /" (Signature of Owner or Agent) Signature of Contractor) Signed and sworn to(or affirmed) before me this d y of Sined and sworn to(or affir -• before me`t is day of i!};x�;5r , 2`'Z�by `1 o.i(' c,( � i � 1���� ')r , � - —may � . , J /(Signature of Notary) - (Signature of Notary) •ersonall Known OR 41•-•'•: f v°q., v:C:HOLAS:OS,-;Lia.BROWER [ )Personally Known OR Yo.., Y ,votary colic-State of Florida �► ¢. vICHOLAS JOSHUA 9ROWER )Produced Identification oi Commission 4 HH 186068 Produced Identificatiot� — ap.' �: ,votary?ubiic-State of Florida ? "i' :CHOLAS Expires Feb 1,2026 Type of Identification: '' `? �+ "o Type of Identification: °F F`' Assn. '. .!p,' My Comm.Expires Feb 1.2026 — — — —