404 WHITING LN RERF22-0240 f'','!.' Building Permit Application Updated 10/9/18
J ,
J,l-. ,. -, I City of Atlantic Beach Building Department **ALL INFORMATION
,v�, �/ 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
"-toss» IS REQUIRED.
Phone: (904) 247-5826 Email:: Building-Dept@coab.us
Job Address: 1/09C>•Jl►-%h``lt- Iet/'t-e (.�•- / 1 C bei Permit Number: RE[F ZZ - (Dv
Legal Description '3/-O/( ' / '02S-a9E //P OF P/ Oke_ a-,04-4VflE# /4/` q4/-0004
Cl ut d-4 LOf / gIK/02._
Valuation of Work(Replacement Cost)$ (:=6)oci Heated/Cooled SF Non-Heated/Cooled
2l /2-iwt
• Class of Work: ❑New ❑Addition ❑Alteration Cepair ❑Move EDemo EPool ❑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 project? EYes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed: S44),14 . -/?(.
Florida Product Approval# 6p,'c R 'i o.74-c- PG5/s'k,ii,044,,t12for multiple products use product approval form
Property Owner Information
Name )`31.if tiO1C Address r V ��2-/ ea' J
City it� C..C.iC- 6L14 State I- Zip 32Z 3 Phone WV. $14, 6 Y-3-
E-Mail
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required)
Contractor Informationyyff-
Name of Company /GCS Uwe C C9flJq .. Qualifying�/ Agent /et/Li- l{. vcr X----
Address
Address a`�d//�.�c�7J k d City t/GX ,/ 5fate F- Zip 3 Z 7 Y6
Office Phone 7 e 4• �J�o_ C7/e/?-- Job Site Contact Number Tel` c 09 • Se.-7 b .Y
State Certification/Registration# CCC CS-61063 E-Mail rtS-Uea IV CM a et-/L . Cc)77
Architect Name& Phone#
Engineer's Name&Phone#
Workers Compensation Insurer 5u112- Tn1 OR Exempt❑ Expiration Date ////d 7t1
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
RECORDINGYOLO1 NQT OF COMMENCEMENT.
f. Y. 0-i',z i
(Signature of Owner or Agent) (/ (Signature of Contractor)
Signe sworn (o>affirmed)b7for m3 this d Signed_nd sworn to(or affirmed) efore me i C�� a of
A/ 7- , by C ,LIJs'' /tf V a-r- , by '?"----
amt _/ ,, �
7�i.�+:i�iiil"�c n Si nature of Notaryl
.�"%� ANNA NIKOLAEVNADICHEV • s�.e•'' ANNA NIKOLAEVNA DICHEV
. .•. . . MY COMMISSION#HH 182457 '• ,•. • - MY COMMISSION#HH 182457
[ ersonally Known OR `Po EXPIRES:January 29,2026 [ Personally Known OR : o.,%4.,:o EXPIRES:January 29,2026
[ ]Produced Identification ""•f°`,"°' Bonded 1hru Notary Public Underwriters [ ] Produced Identification "-FgF,f�°"0 Bonded Thru Notary Pubflc UndenvrIters 1
4 'V a�
Type of Identification: Type of Identification: A
•
Permit Number Tax Folio Number /7 'y"en-v
NOTICE OF COMMENCEMENT
STATE OF FLORIDA
COUNTY OF DUVAL
THE UNDERSIGNED hereby gives notice that improvement will be made to certain real property,and in
accordance with Chapter 713,Florida Statutes,the following information is provided in this Notice of
COmmencement. f_� '
j, N LC�f'L�i
1. Description of property(Street address):
Legal Description: /�, r
2. General description of improvement: 6� •� e-
31-C14a l 3 —9-$--d r y eP PT�trF / * Pt�in4—
. Owner formation:
C
►�n �/� /' P wLf?- � L {6k(
Name and Address: (� — - �/ (3.Z) D_S
b. Interest in property:
c. Name and address of fee simple titleholder(other than owner):
4. a. Contactor's namedd ss: S Cl G2 /� e �TYI S�Y'[C C 1 �✓
b. Phone number: y�Z 66-7979? ax number:
5. Surety Information:
a. Name and address:
b. Phone Number: Fax Number:
c. Amount of Bond:
6. a. Lender's name and address:
b. Phone Number:
7. Person within the State of Florida designated by Owner upon whom notices or other documents may
be served as provided by 713.12(1)(a)7.Florida Statutes.
a. Name and address:
b. Phone numbers of designated persons:
8. a. In addition to himself/herself,Owner designates of
to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b).Florida Statutes.
ai
o b. Phone number of person or entity designated by owner:
a-
r-
cn 9. Expiration date of notice of commencement(the expiration date is one(1)year from the date of recording
Q. 00 unless a different date is specified)
o
Li) WARNING TO OWNER:ANY PAYMENTS MADE BY THE OWNERAFTER THE EXPIRATION
a a OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER
m o U CHAPTER 713,PART I,SECTION 713.13,FLORIDA STATUTES.AND CAN RESULT IN YOUR
a: PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY.A NOTICE OF
c' o COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB 911'1,BEFORE THE FIRST
INSPECTION.IF YOU INTEND TO OBTAIN FINANCING.CONSULT WITH YOUR LENDER OR
C.1 o AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YO '
_i z_ COMMENCEMENT. •
34 CL
a o o Z O Signature of Owner(Owner's Authorized Officer/Director/Partner/Manager: CI de-
0 E0 vOOw
C) Za' - Ua'
(Signatory's Title/Office)
The foregoing instrument was acknowledged before me this day of 20 �
by LV comas for ANNA NIKOLAEVNA DICHEV
••. ;; MY COMMISSION#HH 182457
11, / :?,-`.' EXPIRES:January 29,2026
Notary: Jl'a/L. ",r,;;!'7:Y:"°P` Bonded Thru Notary Public Underwriters
Personally Known or Produced Identification Type of identification Produced:
My commission expires: !
Under penalties of perjury,I declare that I have read the foregoing and that the facts stated in it are true
to the best of my knowledge and belief.