335 4TH ST RERF23-0020 v ■ ■
City of Atlantic Beach Building Department
**ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (901).247-5826 Email: Building-Dept@coab.us IS REQUIRED.
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Job Address: Ll J� Permit Number: ��--t* I"- 3 0 Z 0
Legal Description -&i 1/ �~0?6 /1ilo_n//1- 6,eldi t - /V/ RE# k)9031/-050°
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Valuation of Work(Replacement Cost)$ rbr7JS ' Heated/Cooled SF - Non-Heated/Cooled_� �'
-----W.-
• Class of Work: ❑New ❑Addition ❑Alteration ERepair ❑Move ❑Demo :Wool ❑Window/Door 9`1—ro
• Use of existing/proposed structure(s): ❑Commercial ' esidential tt
• If an existing structure, is a fire sprinkler system installed?: ❑Yes ❑No tl!?Iclat-t)
• Will tree(s)be removed in association with Proposed Prot ct? 1:1Y9 ust sub it geparate Tree Removal Permit) 11No
Describe indetail the type of work to be performed: tire-1 1 -r0 n "ll
r� i pL /o/vy r�r ', ,,//z- iI( 0 9 l-tyfix T /Fa%
Florida Product Approval# /`' /-1'79 for multiple products use product approval form
Property Owner Infor ation
Name r- 1IRh/ Address LieV >/
City fi-1 C ji,;IN l-1 State r/ Zip ,3��33 Phone 9e4— co/- 3(16 _
_
E-Mail Ofi/4' )Gjr) /�
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) !-P a ;t� 'Zv ji-(
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Contractor Infor ti �N" g,--7,--0
Name of Company L) f 7 Qualifying Ment
Address I N (, Sr r"-700 5)1t-P PI City /'/(6'11 Ur fte F- Zip 3 PS O
Office Phone qm-541- 11(Y) Job Site Coritac!`'Nu ber "^ / e!�! -/3"'
State Certification/Registration# l =/31,6gJ5 , E-Mail /4�(r mofl 1'{1'I46-I 'CO i
Architect Name&Phone#
Engineer's Name&Phone# Qp f-I ',/ -,
Workers Compensation Insurer idr k (ty-fi(.9 i L- OR Exempt❑ Expiration Date L7 CC,'o
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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 FINCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BE E
RE DINGY U N pF COMMENCEMENT. i ,
f Sig iture of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed),before m, his / day of Signed and swornto(or affirmed)before a this .. day of
VY---- , rib'i . b - D1 1-(41 . FI1 ' ,by r ,1 F,_
AA. f, 7 MUM'. (\ �IrYlai''„I,ra->-1
/ (Signature o:Notary) (Sign re of Notary)
[ 1 Personally Known OR Personally Known OR
p4 Produced Identification ft,p1— [ 1 Produced Identification "' . S�ERRI_vNN EMAHISER
• `�;: Notary Public State of Florida
B S' RR, YNti a s HISER Commission#HH 476
1 I"--.., sf- Notary Public-State o a i SHERRI LYNN EMA ";oF'�d'' My Comm.Expires May 31.202-
Tr. `: Commission tt N i i�c -'''°
\�: Notary Public State of Florida ;,ended through National Notary Assn.
4 're F.. ` My Comm.Expires May '. "� "a; Commission ri HH:3:16,
8 Y 3, My Comm.Expires May 7024
3orcec throw h Nations`. nom ,: Assn.
JV- 3onded through National Nory
_._ DTICE OF COMMENCEME___'
(PREPARE IN DUPLICATE) 11,9 e 3z//P� ^
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Permit No. Tax Folio No. ��--k/yy �v
State of FLORIDA County of VAL
To whom it may concern:
The undersigned hereby informs you that improvements will be made to certain real property,and in
accordance with Section 713 of the Florida Statutes,the following Information is stated in this NOTICE OF
COMMENCEMENT.
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Legal descriptio b prop bein impro ed: (a / / Z / •
Do r "loch
i >L 19 el--K- (n
Address of property being improved:
General description of improvements: RE ROOF/50 YR SI tINal.lis
Owner biril,y qr /, IJ �/Address , 3 `7 f"I 51, L?/�/Z/C, ,4 L
�/ mac � 3oa�j�
Owner's interest in site of the improvement OWNER
Fee Simple Titleholder(if other than owner)
Name
Address
Contractor K&D ROOFING&CONSTRUCTION COMPANY,INC.
Address 74 6111 STREET SO11TI I,SUITE 104 JACKSONVILLE REACT 1,FL 32250
Phone No.904-541-1700)904-223-6069 Fax No. 904-309-3244)E-FAX
Surety(if any)
Address Amount of bond$
Phone No. Fax No.
Name and address of any person making a loan for the construction of the improvements.
Name
Address
Phone No. Fax No.
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other
documents may be served:
Name
Address
Phone No. Fax No.
In addition to himself,owner designates the following person to receive a copy of the Lienor's Notice as provided in
Section 713.06(2)(b),Florida Statutes.(Fill in at Owner's option).
Name
Address
Phone No. Fax No.
Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a
different date is specified):
THIS SPACE FOR RECORDER'S USE ONLY 1 11;- .� OW ER l I
Y /a/ /
signed:� l � .. 1 i:D.
Before me thi II day . .,��1L2 : in the
C/�Jgnnty of D ;Jrriog,has personally appeared
Doc gym' "1g0 OR RK 20572 P 1RR3 L {-J r79/1'{ ♦ ftUl by Page himse; r_n a at6rms that all statements and declarati>lls � SHERRI_ LYNN MAHISER
Number Pages: 1 v are t n.accurate 4 . .�; Notary Public•State of Florida
Recorded 02/03/2023 02:50 PM, , ''" My Comm.ExpiresMay 31.2024
JODY PHILLIPS CLERK CIRCUIT COURT DUVAL , 3orcec through Natiorai Notary Assn.
•COUNTY t l 1_-.Mr'MN, ----�
RECORDING $10.00 N Ty Public rge.`3r�° LORD. Ire DUVAL
My commi ' xpires:/OP_
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Personally Known N__ 1,72.. or
Produced Identification