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BUILDING PERMTT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach,FL 32233
Office(904)247-5826 Fax(904)247-5845
Job Address: M lbeac� Me/ Permit Number. /A,—
Legal Description 1(0—2-5—-49 E O(R P 1(03 Parcel# %j O" 3 r " 10 O�-
2Z. (�y® or ea o q. t. q—F't
Valuation of Work 1 Proposed Work heated/cooled_ non-heated/cooled�
Class of Work(circle one): New Addition Alteration epair Move Demolition pool/spa window/door
Use of esisting/proposed structures))(circle one): Commercial es
If an existing structure,is a fire sprinkler system installed?(Circle one)- es o N/A
Florida Product Approval# N
For multiple products use pro uct approval form
De�fibe in detail toe type of work to be performed:Re,p lac 2ck �Oa rA 5 a rJ to t l I n% on
2P—" and 3'= f 100rs cif blda # A ,
Property Owner Information:
Name:shocecrd coido kssoc. Address: Iq'3 Gett`t;i, Ave,
City a State Zip Phone q
E-Maif or Fax#(Optional)
Contractor Information:
Company Name: r Q vk% Quali mg Agent; �,a m��rf d&I
Address: -1 City TLiX G State Zip �O
Office Phone Job Site/Contact Number L. `P71 Fax# L o
State Certification/Registration# G C—
Architect Name&Phone# E iQ Q hr P.S 7--
Engineer's Name&Phone# �—
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and 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 pe�omed to meet the standarrb•of all laws regulating construction in this jurisdiction. This permit becomes null
and vdd tf work is rent commenced within six(6 months,or if construction or work is nded ar aba»clorted fara_ppeenod ofsix((6)»mNths at any time er
work is commenced. I understand that separate permits must be secured fo E1e�R'ar1S ►IS Stigtes,W l sell Pods Furnaces,Boilers,Hea&rs,
Tanks and Air ConMoners,ete-
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 RECORDING YOM NOTICE OF
COMMENCEMENT.
I has y certi6 t re examined this a"icatior the same to be true and correct.All provisions cf laws and ardintonces gwarnnis�g this
type of work will complied w r specs ed hes ein ar The granting a permft does oat presume to give authority to vitiate ar cancel the
provisions of arty her fe enol,st e, 1 al Iwo re a rig co ruction o the performance reconstruction.
Signature of Owner Signature of Contractor
-
Print Name t " `n.afol-e
Q/17(S1t t ;int Name !Jl
Sworn to and subscri�i ed me ,, Sworn to and subscn ed before me
this Day of tJc�Feat�' y20�_ this Day of C�d CGrc� 20 to
N lin Notary Pu
Revised 01.26.10
pHNq/ 4'NrP
" P"e�%. JASON DRACH JASON ORACN
Notaryfublic-State of Florida ., NotaryPubltC•Stilh Ol PIONdi
My Comm. Expires Aug 9,2014 My Comm. Expires Aug g 1014
��.','s o?•• Commission # EE 14543 '•/„now":•' Commission#EE 14643
nn.
REVIEWED FOR CODE COMPLIANCE
CITY OF ATLANTIC BEACH
SEE PERMITS FOR ADDITIONAL COPY REQUIREMENTS AND CONDITIONS.
REVIEWED BY: DATE: . ,,—
City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road /GI _ 2
j } Atlantic Beach, Florida 32233-5445
� Phone(904)247-5826 • Fax(904)247-5845
E-mail: building-dept@coab.us Date routed: `� ✓
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: // � a - n " -Department review required Ye No
/ Buildi
Applicant: Planning &Zoning
Tree Administrator
Project: (ti & f9 -5 G; el Public Works
Public Utilities
Public Safety
Fire Services
�r �i r s a&^yap°r ta
�
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified B
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: [Approved. ❑Denied.
(Circle one.) Comments:
qLDING)
PLANNING &ZONING
Reviewed by: Date: lo-$'o
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09