71 19th St RES24-0062 BUILDING PERMIT APPLICATION FORINTE AL OFFICE USE ONLY
City of Atlantic Beach Building Department
•�� � PERMIT# �Z4 Ob�
' C�
' . 800 Seminole Road, Atlantic Beach, FL 32233
**ALL information required to process
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address 71 19th Street Atlantic Beach,FL 32233 RE# 169723-1035
Legal Description 47-91 09-25-29E.13 NORTH ATLANTIC BEACH UNIT 3 R/P E 7FT LOT 2,W 50FT LOT 3
Valuation of Work(Replacement Cost) 7,900.00 Heated/Cooled SF Non-Heated/Cooled SF
• Class of Work: ❑ New ❑Addition DAlteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Residential •If existing structure, is a fire sprinkler system installed?:❑Yes❑X No
•Will tree(s)be removed in association with proposed project? ❑Yes (Must submit separate Tree Removal Permit) ❑X No
Describe in detail the type of work to be performed:
Remove and replace the existing vinyl soffit at the 3rd floor roof with Mastic Vinyl Soffit Product-Ventura Vent. Also,install James Hardie
trim surrounding recently installed windows by OTHER Contractor.
Florida Product Approval# FL#32502.1 (For multiple products use Product Approval Information Sheet)
Property Owner Information Name SEAN CLANCY Phone 678-488-0625
Address 71 19TH ST City ATLANTIC BEACH State FL Zip 32233
Email sdclancy@yahoo.com Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) OWNER
Contractor Information Name of Company KMS SYSTEMS, INC. Phone 904-568-4211
Address 13602 MT PLEASANT RD City JACKSONVILLE State FL Zip 32225
Qualifying Agent KEVIN P FITZGERALD State Certification/Registration# CBC1258387
Email kevin@kmssystemsinc.com Job Site Contact Number 904-568-4211
Worker's Compensation Insurer OR Exempt ❑X Expiration Date 1/24/2025
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 NOT E OF CE NT.
AP
Signature o owner or Agent) (Signature . •.7 actor)
Signed and sworn to(or affirmed)before me this 12, day of Signed and sworn to(or affirme ID/before me this 1 a- day of
by ��., �i��„� , G� i by _Alai/ gra
Signature of Notary Signature of Notary dirr
[ ] Personally Kno n OR f/] Produced Identification [ ] Personally Known OR [ Produced Identification
Type of Identification: fir,vet' Type of Identification: Q( V-er ( ,P{/1S `e-
JANMAURICIO WALKER ROBERTSON •
REBECCASIMMONS
: MY COMMISSION#HH 009325
; Commission#11
HH 131192
EXPIRES:June 11,2024
; t� r Expires May 19,2025
•°F,Fk,•• Bonded Thru Notary Public Underwriters P 7019
�.. j 'f of cs°,,0 Bonded Thru Troy Fain Insurance 600.385