392 7th ST RESO23-0008 Building Permit Application w as FI Loi 5 Updated 10/9/18 110
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.0
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Job Address: — 0 w
�� / c Permit tuber:
Legal Description /Uk'rys- B/P Pr 8iI ' man//f talc` /Ory RE# /697/4-0000
Valuation of Work(Replacement Cost) $ t9/500 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move EDemo ❑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? ❑Yes(must submit separate Tree Removal Permit) ENo
Describe in detail the type of ork to be performed:
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name /7- � Address 79-2 7/A S/re e-A
\, City / (/(f/Jff 'l C/ State FL Zip 3aa 3 3 Phone 904 - 3C 7 - 700?
E-Mail Fr 1 JOB'S _/),-4 S / co/1'7
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company j71')Qt7dl pec ( t} fly '/( Qualifying Agent key 67atc-.//cA
/ Address /9(.2 ,wa//o ) un CityOfQi79( A/•% State PZ Zip j 9.67 T
Office Phone QOL(- 77K-51,25 Job Site Contact Number ' , - - 3
State Certification/Registration# E-Mail !Vex iilltC�./ C CrIrnal/, (crv)
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt❑ Expiration Date
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
ffECORDII)YO1 O ICE OF COMMENCEMENT.
(S:nature of Owner
gent) (Signature of Contractor)
d^and sworn to(or a' irm•d)b-fore mi thi day of Sird nd sworn to or aff' ••.) efore me his day of (^
to V J Zr b rC'ML• • - - b >� �! (e,v-\
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TONI GINDLESPE'•-' . atur- of No ary - ure 1747;11.:,
A-k MY COMMISSION#GG 353178 ,
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4l•.f);$er fy'kroyt%blic Underwriters [ ]Personally Known OR TO MDLES•' R
MY COMMISMISSION#G GG 353178
ro uce entification [ ]Produced IdentificationI =
•:,. ' EXPIRES.October 6,2023
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