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Permits 615 Aquatic Drive 41 CITY OF ATLANTIC BEACH 00 APPLICATION FOR PLUMBING PERMIT JOB LOCATION D, Ftj-j' C- I)r i' ,) PLUMBING CONTRACTOR LICENSE NUMBERS OWNER BUILDING CONTRACTOR TYPE OF BUILDING SINKS SHOWERS 4�) LAVATORY WATER HEATERS __L_BATH TUBS DISHWASHERS URINALS DISPOSALS CLOSETS WASHING MACHINE FLOOR DRAINS OTHER �4)66 blii,5 --V-TOTAL FIXTURE COUNT cli�) INSTALLATION OF PLUMBING AND FIXTURES MUST BE IN ACCORDANCE WITH THE MOST RECENT EDITION OF THE SOUTHERN STANDARD PLUMBING CODE. CITY OF ATLANTIC BEACH, FLORIDA 7-p—ple,ved by 1,7' APPLICATION FOR EV!CTRICAL PERMIT 19 TO THE Cw,�,F ELECTRICAL INSPECTOR: DATE:___� IMPORTANT NOTICE: IN CONSIDERATION OF PERMIT GIVEN FOR DOING THE WORK AS DESCRIBED IN THE FOLLOWING, WE HEREBY AGREE TO PERFORM SAID WORK IN ACCORDANCE WITH THE ATTACHED PLANS AND SPECIFICATIONS, W141CH t.RE A PART HEREOF,-AND IN ACCORDANCE WITH THE ELECTRICAL REGULATIONS, CODES AND CITY OF ATLANTIC BEACH ORDINANCES. ELECTRICAL FIRM: MASTEii ELECTRICIA� NA!,',E- zso2z zdtm -ADDRESS: RFD-BOX-,----- BLDG.SIZE BETWEEN: RES. APT. COMM. PUBLIC INDUS. I NEW( OLD ( REW. ADDITION TRAILER ( TEMP. SIGNS ( SO. FT. SERVICE: NEW kl' INCREME REPAIR FEE CONDUCTOR SIZE AMPS -" Z-5'_ COPPER ALUM. SWITCH OR BREAKER AMPS PH -3 w APVOLT RACEWAY EXIST.SERV.SIZE AMPS PH W VOLT RACEWAY 0 FEEDERS NO. SIZE SIZE NO. SIZE LIGHTING OUTLETS CONCEALED OPEN TOTAL RECEPTACLES CONCEALED OPEN TOTAL 0.30 AMPS.d 1 :31-100 AMPS. SWITCHES INCANDESCENT FLUORESCENT&M.V. FIXED 0.10 ov APPLIANCES BELLTRANS_ AIR H.P.RATING H.P. RATING CONDITIONING COMP.MOTOR OTHER MOTORS AMPS ICEIL HEAT] KW-HEAT OVER MOTORS' H.P.:,� VOLTAGE PHS NO. I M.P. VOLTAGE PHS Ml'�CELLANEOUS 3 Sal co 'rn A t lhtm�ft �mn lk I CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5826 Application Number . . . . . 05-00031859 Date 12/27/05 Property Address . . . . . . 615 AQUATIC DR Tenant nbr, name . . . . . . REROOF Application description . . . ROOF Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 2400 Owner Contractor - - -- ---- -- -- ---- --- - - --- ------------------------ RUSSELL, BURT SHORE ROOFING COMPANY 615 AQUATIC DRIVE 914 7TH AVENUE SOUTH ATLANTIC BEACH FL 32233 JAX BEACH FL 32250 (904) 241-8842 -- -- -- -- ---- -------- -- - ---- --------- ---- ------------------------------------ Permit . . . . . . ROOF PERMIT Additional desc . . Permit Fee . . . . 68 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 2400 Fee summary Charged Paid Credited Due - - - -------------- ------- --- ---------- ---------- ---------- Permit Fee Total 68 . 00 68 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 Grand Total 68 . 00 68 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. BUILDING OFFICIAL CITY OF ATLANTIC BEACH PERNUT CALCULATION SHEET Address Date Heated Square Footage @ S per sq ft Garage Shed @$ ,,n per sq ft= $ Carport Porch per sq ft= S Deck @$ per sq ft Patio per sq ft S TOTAL VALUATION: Total Valuation 10 t-CC Remaining Value 3. per thous or portion thereof CONSTRUCTION TYPE: TOTAL BUILDING FEE ZONING:* + V2 Filing Fee FLOOD ZONE: )Fireplaces@ $35-00 IMPERVIOUS SURFACE: BUILDING PERMIT FEE S WATER IMPACT FEE S SEWER IMPACT FEE* WATER METER/TAP S CAPITAL IMPROVEMENT$ SEWER TAP C RADON .0050 S SECTION H PAVING HYDRAULIC SHARES S CROSS CONNECTION S ST( ) SURCHARGE S OTBER 00 GRAND TOTAL DUE: CITY OF ATLANTIC BEACH Cc: BUILDING / ZONING DEPARTMENT D. Ford 800 Seminole Road -3-Boerr— Atlantic Beach,Florida 32233 (904)247-5800 (904)247-5845 Fax www.coab.us PLAN REVIEW COMMENTS Permit Application # ,U15 — 5185 9 Property Address: Ly 1 �5 d hali - Applicant: re, �Db-� Project: V This permit application has been: Ell/ Approved -, Reviewed and the following items need attention: Please re-submit your application when these items have been completed. k I I Reviewed By: Date: k�' Date Contractor Notified: CITY OF ATLANTIC BEACH ROOFING PERMIT APPLICATION Date: Job Address: tA Owner of Property: t L', f cc Address:----616: Telephone: 3. Contractor. State License Number: o!r� 1577 F/ L) tA W 6��L, t- 71 IJX L L Contractor's Address: Telephone: 2 WLj-L Fax: 1 S,113 Scope of Work: r-t?a Deck Slope: —Greater than 2:12 Less than 2:12 Valuation of work: 100 Product Name(Example: Timberline): A!�F 1) 6111� Manufacturer(Example: GAF): ASTM Designation(s): 7 3 5-Fto) Requied Inspections: I eathing and Final W -7// Signature of Owner: Date: / V AS TO OWNER: Sworn to and subscribed before me this day of .20 State of Florida, County of Duval Notary's Signature. Personally known son lemons Produced identification ft"WIMSOON32-4254.: Type of identification produced,�� - U "C— is 2.Wft..ftftAm. Signature of Contractor: Date: cz AS TO CONTRACTOR: Sworn to and subscribed before me this day of jLtmb-e 2005 State of Florida,County of Duval ............. Notaxy's Signature. �v � - VARVft KADAMS~RUP CWAW ODDOWn eli,"I,% Personally known Produced identification AML.kv ... sea Type of identification produced 800 Seminole Road Atlantic Beach,Florida 32233-5445 Telephone: (904)247-5800 Fax: (904)247-5845 -http://www.ci.atiantic-beach.1l.us Page I Revised 2/21103 CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH,FL 32233 INSPECTION PHONE LINE 247-5826 Dill, Application Number . . . . . 09-00000333 Date 3/16/09 Property Address . . . . . . 615 AQUATIC DR Application type description RESIDENTIAL ADDITION/ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 5000 ---------------------------------------------------------------------------- Application desc window replacement and siding -------------------- -------------------------------------------------------- Owner Contractor ------------------------ ------------------------ KIRTLEY OWNER 615 AQUATIC DRIVE ATLANTIC BEACH FL 32233 --------------------- Structure Information 000 000 ---------------------- Construction Type . . . . . TYPE 5-A Occupancy Type . . . . . . RESIDENTIAL Flood Zone . . . . . . . . ZONE X ---------------------------------------------------------------------------- Permit BUILDING PERMIT Additional desc . . Permit Fee . . . . 55 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 5000 Expiration Date . . 9/12/09 ---------------------------------------------------------------------------- Special Notes and Comments *2004 FLROIDA BUILDING CODE W/ 105- 106 SUPPLEMENTS . 2004 FLORIDA BUILDING CODE - RESIDENTIAL. 2005 NATIONAL ELECTRICAL CODE. *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. WINDOW AND DOOR INSPECTION: *INSTALLATION INSTUCTIONS REQUIRED *ALL STICKERS ARE TO REMAIN ON THE WINDOWS *PROVIDE ACCESS TO ALL WINDOWS TO INSPECT FASTENERS ---------------------------------------------------------------------------- Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 55 . 00 55 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 Grand Total 55 . 00 55 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233 09 OFFICE:(904)247-5826 0 FAX NO.:(904)247-5845 BUILDING-DEPTCCOAB.US 4*\ BUILDING PERMIT APPLICATION Oda 00 DUVAL COUNTY 1.JOB ADDRESS: 2.VALUATION OF WORK 13.SO.Fr.UNDER ROOF 10 1 gc A-17 e- I 774-LE(P1 DESCRIPTION: 5.CLAS 6.USEPF STRUCTURE: a.QMORK, 13-19-WBUILDING 0 DEMOLITION 04ESIDENTLAL LOT_BLOCK_SUB DIVISION 0 ADDITION 11 CONVERTING USE 0 COMMERCIAL 7.DESCRIPTION OF WORK EALTERATION 0 ACCESSORY BLDG. 8.FILRE SPRINKLER: ErREPAIR 0 POOL/SPA 0�y NIA jJj-717)0 0 5 El MOVE QOTHER fTNO PROPERTY OWNI'R: CONTRACTOR: ARCHITECT/ENGINEER: 9.NAME: 15.COMPANY NAME: 23.COMPANY NAME: AI I y K 16.NAME: 24.LICENSEE NAME: 10.ADDRESS: 17.STATE OF FLORIDA LICENSE NO.: 25-STATE OF FLORIDA LICENSE NO.: A18.ADDRESS: 26.ADDRESS: 11.OFFICE PHONE: 12.FAX NO.: 19.OFFICE PHONE: 20.FAX NO.: 27.OFFICE PHONE: 28.FAX NO.: v.113. E:- 21.CELL PHONE: 29.CELL PHONE: -r CW- 6/-34 14.EMAIL ADDRESS: 22.EMAIL ADDRESS: 30.EMAIL ADDRESS: FEE SIMPLE TITLE HOLDER". BONDING COMPANY' MORTGAGE LENDER: (IF OTHER THAN 011MM); 31.NAME: 33.NAME: 35.NAME: 32.ADDRESS: 34.ADDRESS: 36.ADDRESS: 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 laws regulating construction in this jurisdiction. This permit becomes null and void if work is not commenced within six(6) months, or if construction or work is suspended or abandoned for a period of six(6) months at any time after work is commenced. I understand that separate permits must be secured for Elecitrical Work,Plumbing,Signs,Wells,Pools,Furnaces,Boilers,Heaters,Tanks, Air Conditioners,etc. OWNEWS 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. I will not occupy or use the referenced building or any part therof,until all inspections are finaled and prior to obtaining a certificate of occupancy or completion issued by the building official,as required by law. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. OWNER ArT CONTRACTOR )A omittoln-1 cy (Qualifier Only) g@nt,Power Ag cy etter Required) ate: Signed: Date: Before me this day, 2009 in the county of Before me this day of 2009 in the county Of p r�t Duval,State of Florida,has personally appeared a P.�o Duval,State of Flori Eha a nally appeare herin by himself/herself and affirms that all statements and declarations are herin by himself/herself and affirms that all statements and declarations are true and accurate. true and accurate. N ta P blic at a e,State of County of�Vj 0- Notary Public at Large,State of County of "u 7Pe.nally 0 Personally Known 13 Produced Ida ice 11 Produced Identification- Notary Signatu Notary Signatu L -01 I-Mon tvires Feb 14,,2010 COMMisslon 9 518533T REVZMD FOR CODE COMPLIANCE ssr T IN T� A ' 'Assn. CIW OF ATLANTIC BEACH T BLDG01 Permit Application Bldg:REVISED:12/1812000 d SEE PERMITS FOR ADDITIONAL REQUIREMENTS AND CONDITIONS. T FILE C01 I I LREVIEWED BY: . 3 DATE: CITY OF ATLANTIC BEACH OWNER / BUILDER AFFIDAVIT 1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART I "CONSTRUCTION CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW: DISCLOSURE STATEMENT FOR SECTION 489.103(7),FLORIDA STATUTES: STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPTION TO THAT LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY,TO ACT AS YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST SUPERVISE THE CONSTRUCTION YOURSELF. YOU MAY BUILD OR RVIPROVE A ONE—OR TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS. THE BUILDING MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE. IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR AFTER THE CONSTRUCTION IS COMPLETE, THE LAW WILL PRESUME THAT YOU BUILT IT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF TIES EXEMPTION. YOU MAY NOT HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE LICENSES REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING ORDINANCES. 11. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE, THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED UNDER THE HOMEOWNERS INSURANCE POLICY TO CLEARLY PROTECT THE OWNER. III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY EMPLOY ON THEIR IMPROVEMENT TRADES. IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE NO. 455-228(l). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE BUILDING DEPARTMENT(247-5826)IF IN DOUBT. V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT. It a- Aa a#*i c.—Dri-VA- U 134 ADDRESS I PHONE NUMBER kllv J.All'W 7_A .v _-41P&T NAMV #1 (�kK_o 0 IQ \1 1 —SIGM'FlUkE 2007inthecou yof DATE Before me this 'u Duval,State of FS-6da,kespersonally appeared herin�y himself herseill afl irms that all statements and declarations are true and accurate. Notary Public at Large,State of County of ............ 1H GGfRRiAARAM 11 Personally Known 'RLEY L I PU at 11 Produced Identification- f� _tM Notary i Puiblic-State of Flonda s. z E r 0�i s Co ton Expires Feb 14,2010 omm s S 01 Commission#DD 518533 B, B Notary Signature: LV .101 Bonded By National Notary Assn. U COAB FORM BLDG07:REVISED, 8/14/2007 R W R W Building Consultants, Inc. BConsulting and Engineering Services for the Building Industry C P.O.Box 230 Valrico,FL 33595 Phone 813.659.9197 Facsimile 813.754.9989 Florida Board of Professional Engineers Certificate of Authorization No.9813 Product Evaluation Report Report No.: FL 6136.1 R2 i d �re P rC.) 0 Y1 Date: August 1, 2007 Product Category: Windows Product sub-category: Horizontal Slider Product Name: Series 2800 Model 2802 Horizontal Slider Window Extruded Vinyl w/Nailing Fin Manufacturer: Silverline Building Products Corporation One Silverline Drive North Brunswick,NJ 08902 Phone—732.435.1000 Facsimile—732.247.6820 Scope: This is a Product Evaluation report issued by R W Building Consultants, Inc. and Wendell W. Haney,P.E. (System ID# 1993)for Silverline Building Products based on Rule Chapter No. 913- 72.070,Method I d of the State of Florida Product Approval,Department of Community Affairs- Florida Building Commission. RW Building Consultants and Wendell W. Haney,P.E. do not have nor will acquire financial interest in the company manufacturing or distributing the product or in any other entity involved in the approval process of the product named herein. This product has been evaluated for use in locations adhering to the Florida Building Code(2004 Edition)and where pressure requirements,as determined by Chapter 16 of The Florida Building Code,do not exceed the following design pressures: Design Pressure Rating: Maximum Design Pressure Rating Positive 50.0 PSF Negative 50.0 PSF (See Limitations for size restrictions) See Drawing No.: FL 839 prepared by R W Building Consultants, Inc. and signed and sealed by Wendell W. Haney,P.E. (FL#54158) for specific use parameters. Wendell ey,P.E. FL o. August 1, 2007 PF 1013 Sheet I of 3 Supporting Documents A Drawing 1. Drawing No.FL 839 titled The Series 2800 Model 2802 Horizontal Slider Window Extruded Vinyl w/Fin prepared by R W Building Consultants, Inc. (Florida Board of Professional Engineers Certificate of Authorization No. 9813) signed and sealed by Wendell W. Haney,P.E. B Tests Performed Testing per 10 1/1.S. 2-97 as performed by Architectural Testing, Inc. and reported in test report number 0 1-05480.03,dated June 28, 2004, signed and sealed by Steven M. Urich, P.E. 2. Testing per 10 1/1.S. 2//A440-05 as performed by Architectural Testing,Inc. and reported in test report number 64765.04-10947,dated July 31,2006, signed and sealed by John H. Waskow,P.E. 3. Plastics testing in accordance with the"High Velocity Hurricane Zone"substantiated by Issuance of Miami-Dade Notice of Acceptance 03-1110.03,expiring August 15,2007 C Calculations I. Product anchoring is in accordance with manufacturer's published recommendations as substantiated by tested specimens reported in test report nurnbers 01-05480.03 and 64765.04-109- 47. 2. Buck anchor analysis for loading conditions,prepared,signed and sealed by Wendell W. Haney, P.E. 3. Glass Load Resistance Report ASTM E 1300-02 prepared by Wendell W.Haney,P.E. D Other Certificate of Participation issued by National Accreditation&Management Institute,Inc., certifying that Silverline Building Products Corporation is manufacturing products within a quality assurance program. Wendell ey, E. 'A F o. 541 Au-gust 1, 2007 PF 1013 Sheet 3 of 3 Limitations I- The 2800 Series Horizontal Slider Window Extruded Vinyl w/Fin has been evaluated and meets the requirements for use within the State of Florida excluding the"High Velocity Hurricane Zone", 2. When used in areas requiring wind-borne debris protection this product is required to be protected with an impact resistant covering that complies with section 1609.1.4 of the Florida Building Code. 3. Size Limitations: ConflMrAtions MAX Width MAX. Height Double X0, Ox 82.84" 63.84" 4. See Drawing#FL 839 for Design Pressure ratings. Wendell W fL,, o. 5 8 August 1, 2007 PF 1013 Sheet 2 of 3 i-0 Vi City of Atlantic Beach APPLICATION NUMBER Building Department (To be assigned by the Building Department.) 800 Seminole Road Atlantic Beach, Florida 32233-5445 d333 Phone(904)247-5826 - Fax(904)247-5845 E-mail: building-dept@coab.us Date routed: &2- City web-site: hftp:/Atvww.coab.us APPLICATION REVIEW AND TRACKING FORM Qapaftment review required Yes 7Wo— Property Address: Buildino A 9%irflng &Zoning Tree Administrator Applicant: Public Works Public Utilities Project: 1A)iA_hA1.0_-& Public Safety Fire Services Other Agency Review or Permit Required Review or Receipt Date of Permit Verified By Florida Dept.of Environmental Protection Florida Dept.of Transportation St.Johns River Water Management Distdct Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLIPATION STATUS Reviewing Department First Review: [!aA/pproved. F]Denied. (Circle one.) Comments: (��DN G PLANNING &ZONING Reviewed by: Date:311lub TREE ADMIN. 4 If V PUBLIC WORKS Second Review: ElApproved as revised. RDenied. Comments: PUBLIC UTILITIES PUBLIC SAFETY FIRE SERVICES Reviewed by: Date: Third Review: F]Approved as revised. FIDenied. Comments: Reviewed by: Date: Doc # 2009063645, OR BK 14813 Page 309, Number Pages: 1, Recorded 03/17/2009 at 03:58 PM, JIM FULLER CLERK CIRCUIT COURT DUVAL COUNTY RECORDING $10.00 NOTICE OF CONMIENCENIENT State of Tax Folio No. County of To Whom It May Concern: The undersWed hereby mf—you that improvements will be me&to certain MW property,and in MCCOrdwee with Section 713 of the Florida Statutes,the following inkrmation L's sr ipn�hu;XOTICE OF(COMMEN—CEMEKT. Legal Description of property being improved-it j021, au Ll fl, 1>�o VAP-1 AhaxAl-r— Address of property being improved: CCUTY—%I?--, (kneral description of improvements:— w- O=--ka ddre-�- � Wner- Wt.st�e improve A en Owner's interest in i of the improvemen Fee Sunple Titleholder(if other than owner): Name: contractor. eAd2dress: lol� 1 %15 Telephone No.. ' Fax No::.�� Surety(if any) Address: Amount of Bond$ Telephone No: Fax No: Name and address of any person making a loan for the construction of the improvements Name: Address: Phone No: Fax No: Name of person within the State of Florida,other than himselt designated by owner upon whom notices or other documents may be served:- Nam: Address: Telephone No: Fax No: In addition to himself,owner designates the fbllowing person to receive a copy of the Lienor's Notice as provided in Section 713.06(2)(bl Florida Stames. (Fill in at Owner's option) Name: Address: Telephone No: Fax No: Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a different date is speciiied): THIS SPACE FOR RECORDER'S USE ONLY OWNER Z Date: Before me&is day of ry)�Mdh�qDIM M the County of DuvaL State Of Florids,has appeared V Pz=of Florida,County of Duval. Notary Pubfict Large. My cornntission expires: k PersonaRy Known:__. .\,,- —or CIUSAXIN'TIULLIVAN Produced Identification: .0 co_�