801 PARADISE LN RESO24-0022 application •
Jf;, BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
City of Atlantic Beach Building Department PERMIT# I �U Z4-OOZE
r fl
, 800 Seminole Road, Atlantic Beach, FL 32233 **Ail information required to process
----f21.0-%// Phone: (904) 247-5826 Email: Building-Dept@coab.us }}----��
Job Address �$vl 'aol.i l�'`G i ettA4-'c- 1 �1 JR, ,22iliRE# 172 3-../6:2•010,45'
Legal Description I7• t S g` 25 vie. • t3 1-f 2.4t.
Valuation of Work(Replacement Cost) g i 134 Heated/Cooled SF ________ Non-Heated/Cooled SF
- Class of Work. ® New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
- Use of existing/proposed structure(s): ❑Commercial rieResidential
- If an existing structure, is a fire sprinkler system installed? ❑Yes ❑No NIA.
• Will tree(s)be removed in association with proposed project? Elves(Must submit separate Tree Removal Permit) /5/No
Describe in detail the type of work to be p rformed: _
�.evWpslL aWrr 0,44-e No+ t tna1 1 a t e'i w�.q�d r
c77-ev'_tr, r' i i�G‘• A-1470 t I na:l r erg s • (� . �`�'' .p T ��
' moo # ' �K.
Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner Information Name iStr`I. A k.4.42.11-1-14-et, I Phone
Address f,O I d je e City aM GSe..cvt State Ft, Zip - 1,,,2Q-A,
Email Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information Name of Company gpaC404,�/'► (w C. Phone 'lei-1. $51,• (as'72
Address 5 l•2• 43l-tafeu�TL�1'E'L"Gf _ City 'L444 t State Zip �?,.2,77i
Qualifying Agent Kern% _1?-4,1 9 sviT state Certification/Registration# LA ( 325
Email i 1ti•Cc.i erDL 11pL 4'KCr,G6-*y1 Job Site Contact Number
Worker's Compensation Insurer WDld.'JsalA t �V- . OR Exempt ❑ Expiration Date 1 ' ( • 2492q
'wc `s 2
II • Io
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 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. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RE DIN YOUR NOTICE OF COMMENCEMENT.
i n f wn�r or Agent)
Si nature of Contractor)
(S g atu (Signature
Si ned and sworn to(or affirmed)before me this ' day of
Signedland sworn tojor affirmed)before
me this �� `
2day of
't1�1� l� 2 `� _by COOV1 LtAA) , aq by O f;Gc4 (3✓Tc G+-►'eir%
n rof Notary -\(...L. �/�v Si nature of Nota V�
Slg atu e 1�1W��____ � g Notary <`�)V �� au'•,
I I Personally Known OR r4Broduced Identification I I Personally Known OR 4-Produced Identification
OA,of Identification � _ _ _ _ _ _ _ Type of Identification `{�' "
��1 oo NotaryPublic State of Florida Sheena Daim er `�•`o Notary Public State of Florida
• My Commission Hi 007296 aQ Sheena Daim er
+i��r 0.0� Expires 06/07/2024 ,� ; My commission H t 007296 t:
,,,�r a� Expires 06/07!2024 •.
•
sv