136 BEACH AVE RES22-0289 ?F N
iro
r IBuilding Permit Application Updated 10/9/18
City-of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
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Job Address: (� ,K /`t 'i' (.0 ��C'. - Permit Number:
Legal Description "(Oe} I(. -aS-,d l J 'RE# (ice 2-O - 00,0
Valuation of Work(Replacement Cost)$ (O/COO Heated/Cooled SF lg 'i Non-Heated/Cooled
• Class of Work: ❑New DAddition ❑Alteration ,epair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): DCommercial VResidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes )1No
• Will tree(s) be removed in association with proposed proiect? DYes(must submit separate Tree Removal Permit)XNo
Describe in detail the type of work to be performed:
()•Ri\ZING Sic iv & } b 200\c.,INi: 1.-k-3 c-- LJ«vou5
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name pe`\T S1 All( .Si-cN Address jeep \ c 1. -C \ AJe
City . t.NAC-3-T1Q.--- --- AC 4 State Fl- Zip '3'a.a"<3 Phone
E-Mail l
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company P T2_ic Ls'JN\--:-Q..(' Cf t Qualifying Agent IC(-V-A4Z.b -1-2,GlMA�L
Address Ci ti(VAY Pj 's IPS_ City ---S-N(jKSCN\catt State 1`-L Zip -?j L' L "?j
Office PhoneOL4(-1/5( Job Site Contact Number
State Certification/Registration#C)2.C. 1-2)-2-5. 9-78 E-Mail �kCI4 ePETR IN't-c vv
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt[Expiration Date 9- (2"J`-c)-0.A
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
Ipermit,there may be additional restrictions applicable to this property that may be found in the public records of this county,andJ
there may be additional permits required from other governmental entities such as water management districts,state agencies,o'r
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 i NTT*RNEY BEFORE
RECORDI G YO7 NGJ�1 F C ENCEMENT. 4o,
/4) - i---e--e ---
(Signature of Owner or Agent) (Signature of Contractor)
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Signed and sworn to(or affirmed) before me this I` day of Signed and sworn to(or affirmed)before me this I7 day of
(3G-bbe‘ , 2-6a-A . by 128.4-5) p-t;les tv-� C--(-dbes-- , 'D-0- 9-, by_12 r - zl
_ -L'.a 7rIT:T^ri • nlru�
,o,,;,;!;:,8,,� STEFANI SERNA ouuu,, STEFANI SERNA
b c%Nota Public-State of Florida o,1ra °i;
.:`��� n, ry ,r �^Notary Public-State of Florida
3, �e Commission#HH 23832 =*/ Commission#HH 238328
[ ]Personally Known OR % 11I1,FAZ My Commission Expire ersonally Known OR ii,
1,, ,ri;= My Commission Expires
',,,,,,�t`� July 04,2026 [ roduced Identification ,''�Nii,� �
i*roduced Identification July 04,2026
Type of Identification: P- vT'_c s Z., -LsE iype of Identification: 10........
ii 40,
PRODUCT APPROVAL INFORMATION SHEET FOR THE CITY OF ATLANTIC BEACH, FLORIDA (*REQUIRED)
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*Project Address: ISG � P‘C\-( AN/C Permit#:
*Owner/Project Name: ?v\T \( (4 l LAS- ,
As required by Florida Statute 553.842 and Florida Administrative Code Rule 61G20-3, please provide the information and product approval number(s)
for the building components listed below as applicable to the building construction project for the permit number listed above. You should contact
your product supplier if you do not know the product approval number for any of the applicable listed products. Information regarding statewide
product approval may be obtained at:www.floridabuilding.org.
Category/Subcategory Manufacturer Product Description Limitation of Use State# Local#
A. EXTERIOR DOORS
1.Swinging
2.Sliding
3.Sectional
4.Garage Roll-Up
5.Automatic
6. Other
B.WINDOWS
1. Single hung --4Iat &11._ •-is SING:L 9vNCI--)1 RIJyL A4op Si„la- ioc /74''74.2
2. Horizontal slider 1
3. Casement
4. Double hung
5. Fixed
6.Awning
7. Pass-through
8. Projected
9. Mullion
10.Wind breaker
11. Dual action
12. Other
Page 1 of 4 Updated 06/21/21
Category/Subcategory Manufacturer Product Description Limitation of Use State# Local#
C. PANEL WALL
1.Siding -( 0 3i\-0 ) 1"(9�_ D-
2.Soffits
3. EIFS
4.Storefronts
5. Curtain walls
6.Wall louvers
7. Glass block
8. Membrane
9.Greenhouse
10.Synthetic stucco
11. Other
D. ROOFING PRODUCTS
1.Asphalt shingles
2. Underlayments
3. Roofing fasteners
4. Nonstructural metal
roof
5. Built-up roofing
6. Modified bitumen
7.Single ply roofing
8. Roofing tiles
9. Roofing insulation
10.Waterproofing
11.Wood shingles/shakes
12. Roofing slate
13. Liquid applied roofing
14. Cement-adhesive
coats
15. Roof tile adhesive
16.Spray applied
polyurethane roof
17. Other
Page 2 of 4 Updated 06/21/21
Category/Subcategory Manufacturer Product Description Limitation of Use State# Local#
E.SHUTTERS
1.Accordion
2. Bahama
3.Storm panels
4. Colonial
5. Roll-up
6. Equipment
7. Other
F.STRUCTURAL
COMPONENTS
1.Wood
connector/anchor
2.Truss plates
3. Engineered lumber
4. Railing
5. Coolers-freezers
6. Concrete admixtures
7. Material
8. Insulation forms
9. Plastics
10. Deck-roof
11.Wall
12.Sheds
13. Other
G.SKYLIGHTS
1. Skylight
2. Other
H. NEW EXTERIOR
ENVELOPE PRODUCTS
1.
2.
Page 3 of 4 Updated 06/21/21
In addition to completing the above list of manufacturers, product description and State approval number for the products used on this project, the
Contractor shall maintain on the job site and available to the Inspector, a legible copy of each manufacturer's printed specifications and installation
instructions along with this Product Approval Sheet.
I certify that this product approval list is true and correct to the best of my knowledge. I further certify that use of different components other than the
ones listed in this document must be approved by the Building Official.
*Contractor Name (Print Name):_ toirtae L )ntractor Signature:
*Company Name: ? -T2t'k CoN\--C2C\\tc'a
*Mailing Address: 9-14 q(:=' I u A•i?c`
*City: ��\ ,I ._scz) Ji u - *State: FL-- *Zip Code: CD-�r--- S
*Telephone Number: d'4-)L41-11�\ *E-mail Address: '-\caep tz. s-1<.(0 \
Cell Phone Number: l(-1-I_`7b3-`7-7-71E3 Fax Number:
Page 4 of 4 Updated 06/21/21