2209 ALICIA LN RES23-0017 Building Permit Application
Updated 10/9/18
' ; fS 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-Deept@coab.us
33
Job Address + t./
��r�f �� �'L ti h/1�! rmit Number: I \ESZ3- DCA 7
Legal Description qt,,,-9(1 F4?ty 1-5,7-7f/f 5 E REa (_24 1-(-144
Valuation of Work(Replacement Cost)$ q /(2o Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑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 project? EYes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed:
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Florida Product Approval# '7'> I for multiple products use product approval form
Property Owner Information
Name 54a 4 Ra,,C 1114:-y Address 7 1(.7) 1 A t,Oct •^f!u<
City i e).02C[4 _State Zip ? '' 3 r' Phone y>f {(Y; -
E-Mail
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
Contractor Informion
Name of Company "lk 54 4 (bn'A4 C 44 yr s Qualifying Agent (.1‘44 w'5 Ce-1 Address: l2g ?2 i f=r s v. ,4 12,. City State 't( Zip:?2 L e
Office Phone Job Site-VntactNumber
State Certification/Registration# (y04: E-Mail ' $i11ret
coLij c. I c 1
Architect Name&Phone# C-(3 '\ n C
Engineer's Name& Phone#
Workers Compensation Insurer r ¢t u" OR Exempt CI Expiration Date"-
Application
ate 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
RECORDING YOUR NOJICE OF COMMENCEMENT.,--1
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'fSignature of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this day of Signed and sworn to(or affirmed)before me this 1' day of
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(Signature of' otary) at + ' of
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,rR' NotaryPublic State of Fioncla Expres 02/17/2025
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[ ]Personally Known OR • " My Commission HH 084270 [ ] P sonally Known OR
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