770 SAILFISH DR ROOF24-0010 LAN: BUILDING PERMIT APPLICATION
FOR INTERNAL OFFICE USE ONLY
City of Atlantic Beach Building DepartmentPERMIT# ,�Oo(= 2'4—O0I D
800 Seminole Road, Atlantic Beach, FL 32233
**ALL information required to process
D' Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address '17O (Li') 411,-,411,-, A
i1 ! S
. T11ard C iSea&A, F• \RE# /7Iab3-a
Legal Description Rc- /'JI020:3-woo $I P I6' i 'T- Q IZSg 30/ p 17-3z�•�!9 C 4,,,,r1/ 1-'2kc )Lr
Valuation of Work(Replacement Cost) 7 ow, Heated/Cooled SF Non-Heated/Cooled SF �t
•Class of Work: New Addition `
❑ ❑ ❑Alteration El EMove ❑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) E 'No
Describe in detail the type of work to be performed:
1-7,rc 11 6 rade eois '�'n1 ro j aC /1aVe 2
Florida Product Approval# FL -. 3 %—�_ 5-‘44-1 14, I (For multiple products use Product Approval Information Sheet)
Property Owner Information` Name Nn�aea 6r7 t�// Phone qpy) (�a( -s( 7y.
Address '1g Q 5a.., )4')..5 n j)✓. i City (*lam-,c.:— 6eI/ State L. Zip .a /
Email gd jr; /'olrt' Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
,J
Contractor Information Name o Company fir. � �1'-�Ir� ��Of;,5 ITirtPhone (1 oq 1 L/ C qIS'
Address S1-4Q/9g (2Orne/I x CT City (2Q//,i4 State F . Zip �3aa3-j
Qualifying Agent 6-1 en ars '�,�.-% '1
State Certification/Registration# ��_13.36 )(p
Email U 3r i-1�:rc�1�.�-�r'`M i ti5C puna Job Site Contact Number ()i f 1 L� _Gr 1���
Worker's Compensation Insurer J 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 maybe 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 COMMENCEMENT.
''L
4
ign ure of Owner or Agent) (Si ature of Contractor)
Signed and sworn to(or affirmed)before me this a(AA day of Signed and sworn to(or affirmed)before me this 2(4t day of
F e t,k ( , ?O Z'f by 1(OW FE l3RU fl-Ry , Po 24{ by 61->%A1 GR I FFi-ril
Signature of Notary-7// ( .- i/'OU/ Signature of Notary 4,/,,, (/ 4 A,C __
Q
[x] Personally Known OR [ ] Produced Identification [Y] Personally Knclwn OR [ ] Produced Identification
Type of Identification: (V/A Type of Identification: A' M*RJ1HKOI E
4' t' MNtVI1 V.0UPREE * = * COnM11MfI ..a a MVO*
* Comml 11on#IIH240040 op,47
art.
art.a� EA1neAuuust4,2024