1823 SELVA GRANDE DR DEMO23-0001 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
i`';a°�� IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: I 2--i S�Gt//q ,{ �/tr1/1/o e- P/c Permit Number: 1Z.Ia-SA I, •.L7
Legal Description 33 1a.zi' - Sfi/l/ -7/,6' 4 RE# /G I $ '3
Valuation of Work(Replacement Cost)$ a' /4 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move xi 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) ❑No
Describe in detail the type of work to be performed: 2E74/ l3_4 c KC /°O&-C6,
i°ee-c/se.-- 4 — oric y (rezjV 6 f x,02 r fes,
Florida Product Approval# _ for multiple products use product approval form
Property Owner Information
Name /1, C f-/)t-4- Ge: Address i 7-: .54-'4 /9 el•-1igs,/DG
City / TL-4W is t ��N State y'` Zip -'3 - )-33 Phone ,1- ?f -7UY-
E-Mail /'7iR97�7: �/1,a,�
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) -77s 1)
Contractor Information
Name of Company t3Q)CC 1.3t-V1' Qualifying Agent )9ibf/ BJLo
Address 2-/s. y/90I;'l / ) City ^tc.,JeSU.n' 1/,)1-to State /"-'' Zip 1-7. 3-
Office Phone Ci( .4--—•1/- v i 2-C Job Site Contact Number ,e 4.- X37 -t'Seo '-
State Certification/Registration# C 0-5.'c -/?-- E-Mail `t" /�����C10E (i:'c Cc,.1
Architect Name&Phone#
Engineer's Name&Phone# -
Workers Compensation Insurer MA,,21 y I _S.4 4r7ce OR Exempt❑ Expiration Date III ' 7-1-
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 FIN , CIN e, CONSULT WITH YOUR LENDER OR AN ,TTS ' N . BEFORE
RECORDING F MENCEMENT.
111111111P-
- Lam'
(Signature of Owner or Agent) (Signature of Contractor)
P ,i
Signed and sworn to(or affirmed)before me this f=4kday of Signed and sworn to(or affirmed)before me this /54 day of
3/-1-/✓od-i;/ ad)3 ,by j 17n ,i r'lc c --1/44 ,Jl'f , .tea ,by 7 U'Op /i Ai:
(Signature of Ndtary) (Signature of Notary)
,��.arc tt WILW W L.POPE
pf Personally Known OR •. ' ;. MYCOMMISSION#G(i348645 j Personally Known OR �wee:., WILLIAM L.POPE
� o: EXPIRESmix, :October 19,2023
( )Produced Identificatio : of�o:,, public unds I Produced Identification :4i As s MY COMMISSION#GG 348645
Type of Identification: - . Type of Identification: .•-w�: EXPIRES:October 19,2023
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Bonded Tlw Nobly Pubrec Undelw'Es