393 4th ST RESO24-0015 �3 : i-,; BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
City of Atlantic Beach Building Department PERMIT# F e oZ2( OCU
800 Seminole Road, Atlantic Beach, FL 32233 information required to process
,� f It 9 Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address Z,613 1?It St RE# / I Q`-j - 000 0
Legal Description IZ' S 3-1 U1vfl ?Flt Ac S- b9- 16 -2S _ ag E
Valuation of Work(Replacement Cost) a U f 0iO Heated/Cooled SF Non-Heated/Cooled SF
•Class of Work: 51 New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
•Use of existing/proposed structure(s): ❑Commercial ❑Residential • If 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) RI No
Describe in detail the type of work to be performed:
Tn3+tall coo i f iclk( -104 jritciAti S1ri p3 ( soul On j -1,413h0 S itpS •
n).. y v Sy -F-f f f esti cut pk o
Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner Information Name r WLY (jr rq, 1401d LL-C Phone
Address L1tr I ut;k ,}tat. City Socbc,i ,Iji 111, State r(, Zip 3)R,5-1.)
Email Owner or Agent(If Agent, Power of Attorney1or Agency Letter Required)
Contractor Information Name of Company I�,i d a ?Uv f" Coal)4/iii Phone `�,� j Th tgcn
Address IA f Ot: jet IU City 44 f 6n� ( • `GGt; State jet_ Zip 3 o 3)
Qualifying Agent A(‘ r,'-1-e1 State Certification/Registration#
Email a lc x Ff o►'1 d k A r c o i'✓lp4,V ,L c,,t, Job Site Contact Number /—
Worker's
Compensation Insurer 13 CLIC-' Mew/r �n S OR Exempt ❑ Expiration Date
Architect's Name Email Phone
Engineer's Name Email Phone
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 city/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 YOU PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT
MUST BE RECORDED AND POSTED ON THE SITE OF THE IMPROVEMENT BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF CO MENCEMEENNT.
a04/n
(Signature of Owner or Agent) S' nature of Contractor)
Signed and sworn to(or affirmed)before me this I day of lSigned •and sworn to(or affirmed)bef'or'e me this ,�11� day of
RJB LAOS YL1 ,8 LI by ( D r(\ C�YC�•L 1b(VAC 1 f d,L `�by QA_Ci n cL x x-
Signature of Notary C (-tic,` t 0 '[S? J1 Signature of Notary• SCt-Q
[> ersonally Known OR [ ] Produced Identification [ ] Personally Known OR Produced Identification
Type of Identification: Type of Identification: 1)C t.Co 3 q 01-] '2 03-2 (
�-**\ SUE ARENS-- --- -
BRANDYt mak-•;• BRANDY SUE ARENS
1 Notary Public-State of Florida Notary Public•State of Florida I
4, Commission I NN 233471 Commission I NN 233471
MY Comm.Expires Feb 27,2026
f ti. ay Comm.Expires Feb 27,2026
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