1738 SELVA MARINA DR RES23-0022 Building Permit Application Updated 10/9/18
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City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
J';�rIS REQUIRED.
Phone: (904) 247-5826 Email: Buillddiiy `e r \n�g-Dept@coab.us
Job Address: 1�7via X" `A 4 / t 1 V► �1/ Permit Number: ES Z O 3` 0 ZZ_
Legal Description l -05 Gv(f 3-i/A'C Ats•--t_ RE# l 1 7 -. -06
Valuation of Work(Replacement Cost)$'Z- 21 600 /Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition PlAlteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial l'Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ®flo
• Will tree(s) be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Permit) lit
Describe in detail the tXpe of work to be performed: YV/ 1 a�,
r
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name t(f\- Ct ��A Ir.� Address \5(D6 7c:54-Tert
City N State FL- Zip S-22 3 J Phone sari 23 5• ---(,$21
E-Mail \ICACGC\\tr-�ri1-s•Ci 1 . co,Y-,
Owner or Agent(If Agent, Poiver of Attorney or Agency Letter Required)
Contractor Information
Name of Company / I 111' ( ua ifying �gent AMAA �
Address U7:41
Ir- City A j, State 3 _'22 �--ZipOffice Phone 3. --ci 1'7 ?7 Job Site Contact Number
C/�
State Certification/Registration# C ( 2 21 E-Mail I7YL 14_114A4'21 ' ( O vt, .L
Architect Name&Phone# _
Engineer's Name&Phone# � �
Workers Compensation Insurer OR Exempt'tyExpiration Date 'I�)'2,,-r
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 FINA,,N, NG •CONSULT WITH YOUR L ER OR AN ATTO'' EY BEFORE
RECORDING Y. 11' t/ICE OF COMMENCEMENT
— / p" 4 III . 4_AL... / l
(Sig .ture of Owner or Agent) (Signature of Contractor)
Si:ned and sworn to(or affi• -ed) aefore me his 314,day of t.•ed and sworn to(or a rm:• •efor- me this t0 day of
1 ?913 ,b ' SG./ c...k- AAb / i'AA IAA
'avTONI GINDLE _ •a - / 0- 5---d
�4,.w). ' n: ur = N. a (Signature of Notary)
r•' I. ,:: MY COMMISSION#GG 353 >
.iyC. EXPIRES:October 6,2023
."f: Thru No i Fcbiic Underwriters
•-i.1°` • . • [ 1 Personally Known OR --s
Produced IdentificationL. [ 1 Produced Identification'' 4,!;4'.*„. TONI GINDLESPERGER
Type of Identification: Type of Identification: ?«; MY COMMISSION#GG 353178
:;; , —EXPIRES:October 6,2023
I. �'r-u �:!.... Bonded Thru Notary Public Underwriters