725 ATLANTIC BLVD UNIT 15 - CHANGE OF USE (7
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''.;1‘ ‘''j riBuilding Permit Application /\., Q�
Updated 10/9/18
r ; City of Atlantic Beach Building Department �—Q **ALL INFORMATION
t V 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Si IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: .a5 f(f(a.ry/(C- 131VA1 L.n1-1- ( - Permit Number:
Legal Description RE#
Valuation of Work(Replacement Cost)$ Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window C E I VE
• Use of existing/proposed structure(s): Commercial ❑Residential JUL 2 0 2021
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree ReMbv&Permit) ❑No_.__
Describe in detail the type of work to be performed: Ck' -ccje_in use—
Florida Product Approval# for multiple products use product approval form
PropertyOwnerInformation
Name Fitt.krl Vi-?'1Y\ U.L- Address 1() C&')IA-1iI '(j`1 i t t '1
City �'+C.ttcp)4 Mt' 1�.)LLALi State r Zip `..6/.1-451.) Phone -tU.I ( 'I J1l,)
E-Mail V-ii kkAliflviCit 0(C'✓I @, cc Witt( .t ISM of C�Ccia-k?..Ctl�A��.0-4�Yv\
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
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``''ar Information cloy--54S--7-1'i'
Cc�afi „.,. rtis dlW �s�cMR �j'�c12 i.+�✓
Name of Company ` t 3, ,rs,C� 1 Qualifying Agent ca hvtartint2
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt 0 Expiration 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 YOAR R PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAI F$AN ING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORD, /i!UU ' NOTICE OF CO 4 u CEMENT.
/ (Signature of Owner or Agent) (Signature of Contractor)
Signe a sworn (or affirmed fore me t 'sp�� Q�c,ay of Signed and sworn to(or affirmed)before me this day of
, ZIJ24 ,by run D iCWi , by
/-
(•irnatur•.f otary) (Signature of Notary)
BRITTANY FAYE DRIVER
Personally Known OR MY COMMISSION#GG975700 [ ]Personally Known OR
[ ]Produced Identificati.. EXPIRES:April 28,2024 [ ]Produced Identification
Type of Identification: Type of Identification: