1811 SELVA MARINA DR RES22-0263 (-‘:;-''
- Building Permit Application Updated 10/9/18
,.,. ';, City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
will)/ IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us• ,�
Job Address: l�I '' t V1 i Ma/rt {� ti� Permit Number: \ES �C -CY--67-`�
Legal Description 7jlp-(o t Ds 25--24E/00;4- 1 /it t 1151/2 Lot-2- RE# 172020-0761-t
Valuation of Work(Replacement Cost)$ i// ( Heated/Cooled SF "2-S-187 Non-Heated/Cooled
• Class of Work: ❑New DAddition PJAlteration ❑Repair DMove 19Uemo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial 121 sidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes VVo
• Will tree(s)be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Permit) lEi1Vo
Describe in detail the type of work to be performed:
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name (41 ue (�ll.l(b'L°,v]ii,--etI Address ft& I _�ivc -n Kvi ( jVe___
City At'Ia_,i'l.'j1ZGjGik-I State F' Zip "32,-2.:3R Phone fig, --2..- 1-- ' CcZs
E-Mail 3c'jj9'$lI dr s" -
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company � �
VY Qes% oe. ..tied ban--din }ua i mg Agent I -✓✓
Address ---1-1----1-1-"/-"/ IL) 51 - City if (�1, 1 -I tate IL Zip3212133
Office Phone 1-4-0t-(—7S9-e-j 7?3 Job Site Contact Number 4b'- --7"a,c— 'p
State Certification/Registration# Cf2-e i97232)%12---1 E-Mail 1G,✓Ya-f w., "t'cx 90--a4 I - GGA l
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt lia--l`xpiration Date
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
RECORD NG„BYO R NOT�F COMMENCEMENT. �'(Si at r of wner o�nt) �iOMAL(z/V.01A-47t
Si nature of Contractor)
-fined a d sw to(or of :)before me this 1 day of Signed,and sworn to(or affirmed)before me this( ►day of
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.' Y" TONI GINDLESPE-- •,I �/
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, '!t ;_ MYCOMMISSION#GG 353178 1 :r at R •ta 1 (Signature o�tary
J L EXPIRES:October 6, •: 41-
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