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568 TIMBERBRIDGE LN RESO24-0032 Ss�l,Ai BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY s,, •City of Atlantic Beach Building Department - PERMIT# E-�02 ( vd.DG 800 Seminole Road, Atlantic Beach, FL 32233 **ALL information required to process '&ors" V Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address S6' (2 T/ Prl Gam/ AT/adiric. 2.6644/A 1 32233RE# iy <—vs-2( 3e.--- Legal Description 1 1(ivt7- iC /3,c,ck &_,, ,,f-sry L I c,y o1`T 2 L gr ( 2 S G 7 — / 32 —Oz-2 $ -2 i 6 Valuation of Work(Replacement Cost) 14;13/00 D Heated/Cooled SF Non-Heated/Cooled SF • Class of Work: ❑ New ❑Addition [Alteration ERepair ❑Move ['Demo ❑Pool ❑Window/Door • Use of existing/proposed structure(s): ❑Commercial residential • If existing structure, is a fire sprinkler system installed?:❑YesENo • Will tree(s)be removed in association with proposed project? E Yes (Must submit separate Tree Removal Permit) �No Describe in detail the type of work to be performed: /1C ACL o (I SK- .SS (�Cc.ce- y,/ 7-1- Rr7�/-(c/c ( Tv/,4 SO p e_c-- kcx_.,.-1- _. EL') © I— X L_ /0C)0 s —C Florida Product Approval# (For multiple products use Product Approval Information Sheet) Property Owner Information Name E, lr 2 0 C TQ. L (, ( y Phone d ( — ‘ 2q.. 32(5-- Address 5-6 g T ✓ B r/d9 (c City /4 I iii c. [3-Cac- State 0. Zip 3 2- 2- 3 3 Email e 6 , C P( (2 �S/Q Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) 0 iv V1---V- <911 CG‘7146,r---" Contractor Information Name of Company 3-6- Y O dr poor 0 (vT( °lif Phone p Address 1 7 ( �,C (1/.1ij Q p City ST-a UG State FL Zip 3 LO 4t 5---- Qualifying Agent V_I/ (� 5 4 i t,.t/f State Certification/Registration# L.41,ocle yiL (�t( 6 Email �,/ GL ,C)} TTc o g s�1 —q 6 `( C �-" �,.�� ppm ���,J' �j. �-a v�Job S to C�ntaWct Number o - Worker's Compensation Insurer eY"1 Roy.4.3e. �SI//'GyzLe- R Exempt ❑ Expiration Date 3/ 1 / 202—_C---- Architect's �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. (Signature of Owner or Agent i , (Signature of Contractor) Signed and sworn to (or affirmed) before me this `/ day of Signed and sworn to(or affirmed) before me this V day of i 4 XTC 1,1 , )2L1 by el i/14,n% d;sSell-L-itl�‘' I� otic I/ , ,7 L by L______ It/e-t , Signature of Notary (.l�J� u� 00 ,L 001, Signature of Notary i ' &' '& : /GuD�' � [ ] Personally Known OR [ ] Produced Identification Personally Known OR [ ] Produced Identification Type of Identification: Ty e of Identification: LAURA HAZELWOOD LAURA HAZILWOOD Notary PublicNotary Public State of Florida ,: State of Florida . ....... . Comm#HH380528 ..1.. Gomm#HH380528 Expires 3/29/2027 .14° Expire*3/29/2027 ..... 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