Permit 87 Forrestal Circle South (2) Aug 10? 04 02:43p City of Atlantic Beach Bu 904 -247 - 5845 p•2
Signature of Contractor: Date:
Address and contact information of person to receive all correspondence regarding this application (please print).
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Name: �. p 4'l V'l � �� . LL {
Mailing Address: (p M a \i (24 i ["", L11 "i ;1-1 i 4-e- 1 441/0 lie_ C ( 8 ' 0 6,6 32.24 '2?
Telephone: 1-11-3 Fax: a (F - Lt E -Mail: _
AS TO OWNER: klkrbt Sworn to and subscribed before me this Q� day of , 20
State of Florida, County of Duval
Lisa Harmon Notary's Signature: I - v-�
' • MY COMMISSION # DD294572 EXPIRES
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�.,.� February 26, 2008 0 Personally known
•, c° F .dS' BONDED THRU TROY FAIN INSURANCE, INC
„Et. Produced identification -
Type of identification produced
AS TO CONTRACTOR:
Sworn to and subscribed before me this day of , 20 .
SW.e of Florida, Coun of Duval
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