1545 MAIN ST SIGN22-0014 - " Building Permit Application Updated 10/9/18
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City of Atlantic Beach Building Department **ALL INFORMATION
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\\ 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept(a�coab.us IS REQUIRED.
Job Address: I S 9 S Mk.,- S�-^eG A- ; /-0,.,,�,-, Ze.c t,t 1= L- Permit Number: ���
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Legal Description I .4- 1.S - a 7 t' 6. Li ti pT Ce Ot/T (.07 M 12cic0 ofa RE# 17Z.23 as e-e kO
Valuation of Work(Replacement Cost)$ 2 l 0 (gyp Heated/Cooled SF /"/(4 Non-Heated/Cooled AAA,
• Class of Work: XNew ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): [ commercial ❑Residential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s)be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Permit) kNo
Describe in detail the type of work to be performed: I 'J /� /�l`
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name PC,v- I?rn L- 13 Address P. O. tax 33 O 1 7
City A-}Icv14,'c Re-c-c k State t=L- Zip 3 VZ33 Phone 50'4 -,::.(-/6- CI30
E-Mail Gv-c,is /4 ¢ Se.,04 1 . (u"-, I
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) 'e< o...d
Contractor Information
Name of Company 4Cc..c..-..( 0cy (e••,:c c C•••i., Qualifying Agent R VA/. Z: (p,`.,t
Address (S H 0 i'ae....,,;- C4- City -.a�cGcca.r,..'((r ate 1:4-- Zip Zz o b
Office Phone Cl oM ':355--4:3o Job Site Contact Number
State Certification/Registration# ES(Zoo 143o E-Mail ri.-._v Q St,,,,r...! 5:g.., 0•-J:t,e . Cow,
Architect Name&Phone It
Engineer's Name&Phone It C 11 wk14.,.'4,•, (..... 1 6 8S - Z?) -3 113
Workers Compensation Insurer (..o.1 1 r.s.-vc-r.(c C'0 . OR Exempt ❑ Expiration Date I l(/Z;
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
RECORDING YOUR NOTICE OF COMMENCEMENT.
7Z . . ,e<
(Si ure f Owner or Agent) (Sign ntractor)
Signed and sworn to(or affirmed) befoAp me this/Play of Signed and sworn to(or affirm ) Wore me this /f day of
75741 -
4.-41,4- Ogo%cy Cbpdii-Al AdoZ'a,by . (e..01.7)51.(4.3
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(Signature of Notary) (Signature of Notary)
ios4.%Y Pae(,c DEBORAH S.GOSS
2o`!a °as.` DEBOR H S,GO$ ersonally Known OR * i.`j „ Commission#HH 175673
Personally Known OR Expires January 7,2026
[ ] Produced Identification a x� . Commis On x HH 17SS?3 [ ] Produced Identification "� I w`
Type of Identification: ji ao� Expuas.l.3nuary 7,201 Type of Identification: �f/!�� � �4�9e4N041y$Mavv
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Letter of Authorization
To: City of Atlantic Beach
800 Seminole Road
Atlantic Beach, FL 32233
RE: Letter of Authorization
To Whom It May Concern:
This letter authorizes General Sign Service Corp. as our licensed sign contractor
(or agents or subcontractors) to secure permits, variances, and perform sign installations,
removals, or maintenance at the property located at:
J
Sandar Industries- 1545 Main Street-Atlantic Beach, 11,32231 I
By: (i4e."'"
A.A.)4.- sw s
Title: 6-s4✓ yz A u 6-z
State of Cid( .11- S44.—o ft.t v )t3 /gee.
County ofD046-1
The tiregoing i► stnimenty/as acknowledged before me this orth day of JAL' ,
204,x, bye n; ,Jas (sziwa.J j( of vrdal u its Flor+da,
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corporation,o►f behalf of said corporation, who did not take an oath and who:
Is personally known to mei.
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Produced current f for driver's license as identification:
�,r'"41 Plotuy PubYc Shl*d FIo ids
5 Deborah J Douglas
_.� . ✓/iirr y My Commission GG 323508
•otary Public
of „pc Expifes 04/15/2023
Seall/�/Stamp _
Name of Notary printed: rGt��•J 4.S
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