1961 W SEVILLA BLVD RES24-0063 Permit AppBUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
City of Atlantic Beach Building Department PERMIT # I RES24-0063
r�
r 800 Seminole Road, Atlantic Beach, FL 32233 -*ALL information required to process
�p Phone: (904) 247-5826 Email: Building-DeptCMcoab.us
Jab Address 1 (� RE# &9 ��—
Legal Description - d i IGacAeus.
Valuation of Work (Replacement Cost) Heated/Cooled SF ] LCP Non-Heated/Cooled SF
• Class of Work: ❑ New T7 Addition- []Alteration []Repair []Move ❑Demo ❑ Pool 9INindow/Door
• Use of existinglproposed structure(s): ❑ Commerc!a1 ❑Residential ■ If existing structure, is a fire sprinkler system instaIIed7:❑yes ❑ No
e Will treejs) 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:
17 repfacem-end �J,n aws -0- S,"r s+z-e.
Florida Product Approval # S ee a )For multiple products use Product Aporoval Information Sheetl
Property Owner Information Name �ULL�A Yl iA]iL _ Phone c[N- S4 3- 35x2 A
Address ce l Si 1 [ l I City - C, state -E 4 zip ,X) 33
Email owner or Agent (If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company fl ; n' Phone
Address �P � City State �ir Zip
� State CertificativnJRegistration#
Qualifying Agent
Email Job Site Contact Number -
Worker's Compensation Insurer } y�-� ��C L, r-iC-� DR Exempt Expiration Date
❑
Architect's Name
EmailPhone
Phone
Engineer's Name
Email
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. 1 understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, and AIR CONDITIONERS, etc. applicable to this property that may be found in
NOVICE: In addition to the requirements of this permit there may be additional restrictions app
the public records of this city/caunty, 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 al 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 YOUR NOTICONSULT E OF COMMTH YOUR ENCEMENT.
(Signature
OR AN
ATTORNEY BEFORE RECORDING
.. (Signature of Contractor)
(Signature of Owner or Agent) ��da of
Signed and sworn to (or affirmed) before me this day of Signed and sworn to (or affirmed) before me this Y
by
by
Signature of Notary
Signature of Notar 1zr
ersona cation
Personally nIdentification [ `$ JAMES orrltoe
,� ham,,. JAAIE$ OASLpR
Type of Identification: N Type of Identificat
Commission A HH 434778
Carmm40M N 44 434770 �« s�� My Comm. Esplres AuQ 17, 2{127
` •., !?r rL,,: '' ASV Comm- Expires Aug 17, 7027 Horded through National Notary Assn.
Banded through Natioeal Notary Assn.