1025 Seminole Rd. RERF24-0043 ROOFJ r� ■ ■
City of Atlantic Beach Building Department
' 800 Seminole Road, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email:
Job Address: 5jGM,e1e 1 G �li J "o nkt c .Y!2.ti c4� Permit Number:
"ALL INFORMATION
HIGHLIGHTED IN GRAY
IS REQUIRED.
Legal Description T-401 (6:-Z5-7-46 441„"r- Eech 5'!& t_aF5 My f{rYSrI� RE# [700 S - OWO
Valuation of Work (Replacement Cost) $_144 , q `b - X5 Heated/Cooled 5F Non- Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Poo[ ❑Window/boor
• Use of existing/proposed structure(s): ❑Commercial ❑Residential
• If an existing structure, is afire sprinkler system installed?: ❑Yes ❑No
Describe in detail the type of work to be performed:
(-j! CW F IAS t r1q 5-pvr Sh i n9Lcs
Florida Product Approval # for multiple products use product approval form
Property Owner l0ftwma%m
Name WiW%&y.. '016c Address rr7 ale- A
City h State I_L—Zip 3'LZ'S xi _Phone 9,511 Z�(g 0&0—
E -Mail &4LE-MaiI
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required)
Contractor lnfQmtlon
Name of Company k D g,.d r %na _._ Qualifying Agent 0.c2)L7-
Address K fe g. city )Q)( Ben,i, State R up 512&
Office Phone R b �j 5 �11 I j Gd Job Site Contact Number
State Certification/Registration # !CL t 41-�S 52 E -Mail . KDQlaa F IVT o►_go-_%,rkM r.1 I. C' p �,
Architect Name & Phone #
Engineer's Name & Phone #
Workers Compensation Insurer Q,r % . y0r[ OR Exempt ❑ Expiration Date
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 YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER O ATOR BEFORE
RE RING YOUR NMC OF COMMENCEMENT.
t1Wnat&e of owner o ent) ISIgnature of Contractor)
Signed and sworn to (or affirmed) before me this n day of Signed and sworn to (or affirmed) before me this Z day of
U2I by wtIittem Q1a% �2 by �ioyxxk ” Ie
ignature of Notary) gnature of Notary)
f] Personally Known OR
I 1 Produced ldenti icali rte'" ANGELA RILE
Notary Public - State of Florida
Commission!: Hit 423900
of fl My Comm. Expires Jul 20, 2027
Bonded through National Notary Assn.
[ ] Produced identification Ih�6Nc -State
[4 Personalty Known OR A TF` ANGELA WIL]2027
Canmkslon / WW
w n
My Comm. Expires Jued through National N