1545 MAIN ST COMM24-0007 Vii'-A,T;-,�, BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE�UISEONLY --7
t) ' �\.S' City of Atlantic Beach Building Department PERMIT#CC�IY�,ri �`t `�d�
'' -47.,.��- 800 Seminole Road, Atlantic Beach, FL 32233
**ALL information required to process
< o,ti'%- Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address 1545 MAIN STREET ATLANTIC BEACH,FL,32233 RE# 17Z3ZS—O01 0
Legal Description ASPHALT OVERLAY
Valuation of Work(Replacement Cost) 70,000 Heated/Cooled SF Non-Heated/Cooled SF
•Class of Work: ❑X New n 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) ❑ No
Describe in detail the type of work to be performed:
ASPHALT OVERLAY OVER EXISTING PARKING LOT
Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner Information Name r Pro L To Phone
Address City State Zip
Email Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information Name of Company ATLANTIC ASPHALT Phone 3025624709
Address 12574 FLAGLER CENTER BLVD City JACKSONVILLE State FL Zip 32258
Qualifying Agent EDWARD BURDEN State Certification/Registration#
Email nedburden77@gmail.com Job Site Contact Number 3025624709
Worker's Compensation Insurer NEXT INSURENCE OR Exempt ❑ Expiration Date 05/10/2024
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 COMMENCEMENT.
t/c r 7ouriyez 64/,,,,,f;&,‘,..._
(Signature of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this 8 day of Signed and sworn to(or . firmed) before 4 e this day of
Pia
March 2024 by Victor Rodriquez 01CQ-(\. , ±.449.1 by 1142,cf,„ ur A 0
Signature of Notary WSignature of Notary 0�_ IR_.
[ ] Personally Known OR [Produced Identification [ ] Personally Known OR [ ] Produced Ide aication
Type of Identification: Florida Driver License Type of Ide : c�,`a .: --
-
.. .'' . ; •' �1
MY COMMISSION#HH 407122
KELLEY MAwcA waunMs `•; z ''''./ October 6,2027
Electronic Notary Public Completed via Remote Online Notarization using 'vv .ioNidt Pte��5rio o
Commonwealth of Virginia I
N it r ; i aA8 e-c39b-4bb7-9698-73fd3fd4e6a8
Certificate of Acknowledgement
Commonwealth ofh25ielr�tleld
City/County of
On 3/8/2024 , before me, Kelley M Williams personally appeared, Victor RocIricpue7 ,
proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s) or the
entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal
KELLEY MARICA WILLIAMS
Electronic Notary Public
Commonwealth of Virginia
Signature (Seal) Registration No. 7961837
Commission Exp.
8/31/2025 , My Commission Expires Aug 31, 2025
Completed via Remote Online Notarization using 2way Audio/Video technology
NotaryCam Doc ID: 4897888e-c39b-4bb7-9698-73fd3fd4e6a8
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COMPLEIE LEG.DESCRIPTION
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LENER.SAVO'NOTES
BOATWRIGHT LAND SURVEYOR! INC. X ..,j..or $
VONIDI MAP.AND KEY MAP
: -:.:,..,, 1500 RODER/S 0.9.JACKSON...13E004 FL0.0.4 32250 (.)904-2..50
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