605 Plaza POOL24-0004 application_1BUILDING PERMIT APPLICATION
City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233
FOR INTERNAL OFFICE USE ONLY
PERMIT# ---------
Job Address
Phone: (904) 247-5826 Email: Building-Dept@coab.us
f o5 f' I C\Z-c1t D1r l~4-lcx,1,t1 c (3 C FL
**ALL information required to process
RE#
Legal Description
Valuation of Work (Replacement Cost) ________ Heated/Cooled SF _____ Non-Heated/Cooled SF
• Class of Work: 0 New D Addition □Alteration □Repai r 0Move □Demo D Pool D Window/Door
• Use of existing/proposed structure(s): D Commercial □Residential • If existing structure, is a fire sprinkler system installed?:0Yes D No
• Will tree(s) be removed in association with proposed project? D Yes (Must submit separate Tree Removal Permit) D No
Describe in detail the type of work to be performed:
Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner lnform-a-ti_o_n_N_a_m_e_:r:>_1_ .. _e_J ...... "_i _s_k~,-, 0-1.,u-f''" Phone '1 oJ./ o/ 91-/ -2. ?? g
Address bo5 elc-2-c.~ O r I City A ➔l(,\pf ,J~c 8 -e.,.-i(}V, State ~ Zip 32.2..3-3
Email Owner or Agent (If Agent, Power of Attorney or Agency Letter Required) ---------
.Contractor Information Name of Company f>DNA.:f'roe --:foo1.--S Phone qo ±--:'Z':k. -) 312
Address ~q IJIIKWOti7> Kl>. City JJJx-J!;~11ctl State __fL__ Zip 32,.,z~o
Qualifying Age_nt 'f<t26 eg, lr;,t64 ave State Certification/Registration# {{-Po O '7tt> 6j
Email b b 4 .U t:b&nq fr de-P<¾J/~ e t2of / t>Dk. CbM.Job Site Contact Number 7,z_y, -trb CJ-51'5' 'l
Worker's Comp~nsation Insurer
I
OR Exempt [M Expiration Date ----------
Architect's Name --------~------
Engineer's Name ½,J lezJ1' 6e: I 0 c!>k1> •
Application is hereby made to obtain a permit to do the work and installations as indicated. Ice 1fy 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 an d that all work will be done in compliance with a.II applicable
laws regu lating construction and zoning.
**WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT
IN YOU PAVING 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
~ .ORNEY , EFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
'.'t:vJf ~ I n i . -
-_·-:--r __ I ~_0v{:;_~-~-~-----
tsignature of Owner or Agent) ~ (Signature of Contractor)
Signed and sworn to (or affirmed) before me this /'3 1, day of Signed and sworn to (or affirmed) before me this /'51# day of
J/),./V/JJ!~I '--Ht---by 'De't>e .. 21<t2Wyfl/l ,_.)AJ.ivll&il , ___ by~ leV65iR(.)&
Signatureof~otary ~ Fed~ Signatureof~otary :lf0 K~
[ ) Personally Known OR [ ~duced Identification [..,{Personally Known OR [ ) Produced Identification
Type of Identification: 1>l 5 It,;; t)-'78 .., ., '2. Z iJ
.. -~-;i_, •u~··. GEORGE GARY ROBINSON. ff~":··. Notary Public -State of Flonda
\-a·:,~-:;f Commission# HH 173420
··,.'-;t'1i{(o~-· My Comm. EJ<.p1res Dec 29, 2025
•• aoncec through National Notary Assn.
POOL24-0004