2135 SEMINOLE RD FNC23-0001 („ -('-'-'2,,, Building Permit Application Updated 10/9/18
a 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.us
Job Address: .2-)3.5-5-4,021-40 le kid, Permit Number: FU CZ3 —000)
Legal Description pr 1p- 1 ()he /6 y06/15$1, SEL 9-2S -29E RE# /69515 05-20
Valuation of Work(Replacement Cost)$ Al.:.,2t 7000.2 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 Mer�sidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes i io
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Re oval Permit) QNo 1
Describe hi doiI the type of work to be performed:ter lace Q,�r,�4' '6-'ood 74+8)'4.`7 (-41), , 4y Ae`,t-4Q/ 't.5".'').-1. f t6.1e../0 40e/'.1-. /
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name 'Y44.i y 6 Aa'fc s Address .2135 S.;io le /ed.
City /0/..,4-•C icw State FL Zip 3.2233 Phone 701/-8X-0/27
E-Mail ,iar icharfeje.o t/ooI(.cd+,
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
• •tractor Information
Name o _.mpany Qualifying Agent
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Registr. '• # E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt a Expiration Date
Application is hereby made to obtain a permit to do the , • k and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all wor • ” be performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a separate permit • be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONE• - c. NOTICE:In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be •.•• in the public records of this county,and
there may be additional permits required from other governmental entities such as water m.•.:ement 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 co • - •ce 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
_ -,.......„
ORDI/NG YOUI ,NOTICE OF COMMENCEMENT
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(Signature of Owner or Agent) (Signature of Contractor)
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The undersigned ac nowledges that this
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PONT OF PERRET AND ASSOCIATES INC'
COMMENCEMENT
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