439 20th ST POOL24-0006 Meringolo app_1Building Permit Application
City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address:439 20 Ø ec. 32233 Permit Nub
Updated 10/9/18
*'ALL INFORMATION
HIGHLIGHTED IN GRAY
IS REQUIRED.
RE llåWp-Legal Description
Valuation of Work (Replacement Cost) $ Heated/Cooled SF Non- Heated/Cooled
• Class of Work: ONew OAddition OAlteration ORepair OMove ODemo Pool OWindow/Door
• Use of existing/proposed structure(s): OCommercial Residential
• If an existing structure, is a fire sprinkler system installed?: ayes ONO
• Will tree s be removed in association with ro osed ro•ect? OYes must submit se arate Tree Removal Permit ONO
Describe in detail the type of work to be performed:
rd 2æ3F s)ß5deee b9jq
Florida Product Approval #
Pro e Owner nfor tion olØName Address
for multiple products use product approval form
State Zip
E-Mail rino au.
Owner or Agent (If Agent, P er of Attorney or Agency Letter Required)
Phone
Contractor Inform ion
Name of Comp ny aDb
Address
Office Phone
State Certification/Registration #
Architect Name & Phone #
Engineer's Name & Phone #
Workers Compensation Insurer
Quali •n Agent
Ci State Zip
Job Site Co tact Number
E-Mail
OR Exempt O Expiration Date
5
App!ication 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
this iurisdict;on. understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
W€uS, BOiLERS, HEATERS, TANKS, and AIR CONDITIONERS, etc. NOTICE: In addition to the requirements of this
additionai 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 OR AN ATTORNEY BEFORE
RECORDI G YOUR OTICE OFC MENCEMENT.
(Signature of Owne o Agent)
Si ed and sworn to (or affirm ) before me this day of
( gnature of Contractor)
ed and sworn to (or affir d) before e this day of
by
[ J Personally Known OR
DEBORAH WERLING
MY COMMISSION # HH 422502
EXPIRES: 17, 2027 Personally Known OR
of Nota
DEBORÆ WERLING
W COMMISSION # HH 422502
Produced Identificati
Type of Identification:
[ ] Produced Identification
Type of Identification:
EXPIRES: November 17, 2027
POOL24-0006
TREE & VEGETATION AFFIDAVIT FOR WTERNAL OFFICE USE ONLY
City of Atlantic Beach PERMIT #
Community Development Department
800 Seminole Road Atlantic Beach, FL 32233
000b by(P) 904-247-5800
SITE INFORMATION
is NOT ary
ADDRESS
SUBDIVISION Norfe
IIDZ&
APPLICANT INFORMATION
NAME 5essica
ADDRESS 1439
CITY
EMAIL
BLOCK LOT 69
RESIDENTIAL COMMERCIAL C] OTHER
PHONE#
CELL #
STATE ZIP CODE
OWNER LEGAL AUTHORIZED AGENT
I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation", of
the Municipal Code of Ordinances for the City of Atlantic Beach Florida and/or I have participated in a pre-
application meeting with the Administrator of those regulations. Subsequently, I affirm that no regulated
trees and no regulated vegetation will be damaged, destroyed and/or removed from the above-described
?nd/or adjacent properties including right-of-way.
FORMATION P IDED IS CORRECT: Signature of Property Owner(s) or Authorized Agent
YPLiCAN
SiGNATURE OF APPLICANT (2)
Signed and sworn before me on this
Identification verified:
oath sworn:
( x:ssücæ Merca
PRINT OR TYPE NAME
PRINT OR TYPE NAME
day
DEBORAH WERLING
?ßØq by
Qbou,h
MY COMMISSION # HH 422502
EXPIRES: November 17, 2027
Notary Signature
My Commission expires
DATE
State of p
County of
04 TREEAND VEGETATION AFFIDAVIT03.012018
POOL24-0006
Form 9B-3.053-2002-01
Notice to Building Official ofUse of Private Provider
Effective January 20, 2003
Project Name:
Parcel Tax ID:Jleæ
Services to be provided:Plans Review Inspections
Note: If the notice applies to either private plan review or private inspection services the BuildingOfficial may require, at his or her discretion, the private provider be used for both services pursuant toSection 553.791 (2) Florida Statute.
1 5eg-3)ca the feeowner, affirm I have entered into a contract with the Private Provider indicated below to conduct the servicesindicated above.
Private Provider Firm. Leqacv Enqineerinq. Inc.
John E. Ellis Ill PEPrivate Provider
Address:6415 Greenland Road, Jacksonville, FL 32258
Telephone: 904-320-0408 Fax:
Email Address (Optional): ppidept@legacyengineering.com
Florida License, Registration or Certificate #:81349
I have elected to use one or more private providers to provide building code plans review and/or inspectionservices on Statutes. 'L ding
building that is the subject of the enclosed permit application, as authorized by s. 553.791, Floridathat the local building official may not review the plans submitted or perform the requiredto determine compliance with the applicable codes, except to the extent specified in said law.uv.l/or required building inspections will be performed by licensed or certified personnelDipp%caiion. The law requires minimum insurance requirements for such personnel, but I! require more insurance to protect my interests. By executing this form, .1 acknowledge that Ifiltr.;e i. ta:air:,• regarding the competence of the licensed or certified personnel and the level of their insuranceand arn sati?åicd that my interests are adequately protected. I agree to indemnify, defend, and hold harmless thelocal goven-jrj:ent, the local building official! and their building code enforcement personnel from any and allclaims arising from my use of these licensed or certified personnel to perform building code inspection serviceswith respect to the building that is the subject of the gnclosed permit application.
I understand the Building Official retains authority to review plans, make required inspections, and enforce theapplicable codes within his or her charge pursuant to the standards established by s. 553.791, Florida Statutes. If Imake any changes to the listed private providers or the services to be provided by those private providers, I shall,within I business day after any change, update this notice to reflect such changes. The building plans reviewand/or inspection services provided by the private provider is limited to building code compliance and does notinclude review for fire code, land use, environmental or other codes.
Page I of 2
POOL24-0006
lhe following attachments are provided as required:
I. Qualification statements and/or resumes of the private provider and all duly authorized representatives.
2. Proof of insurance for professional and comprehensive liability in the amount of $1 million per
occurrence relating to all services performed as a private provider, including tail coverage for a minimum
of 5 years subsequent to the performance of building code inspection services.
Individual
(signature)Print
Name:
TelephoneNo.:
Please use appropriate notary block.
STATE OF bia
COUNTY OF
IndividualBefo e me, this day of20personally
appearedwho executed the foregoing instru ent,
and acknowledged before me that same
was executed for the purposes therein
expressed.
Corporation
Print Corporation Name
By:(signature)
PrintName:Its:Address:
Telephone
No.
CorporationBefore me, this
personally appeared
day of
20
of acorporation, onbehalf of the state corporation, who
executed the foregoing instrument andacknowledged before me that same was
executed for the purposes thereinexpressed.
known ; or Produced identification Type of identification produced
Sigrgalire of Nc!ary Print Name
Notary Public: NOTARY STAMP BELOW
DEBORAH WERLING
MY COMMISSION # HH 422502
My commission expires:EXPIRES: November 17, 2027
Partnership
Print Partnership Name
By:(signature)
PrintName:Its:
Address:
TelephoneNo.:
PartnershipBefore me, this dayofpersonally appeared
partner/agent on behalf of
a partnership, who executed theforegoing instrument andacknowledged before me that samewas executed for the purposes thereinexpressed.
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