Permit Remode 2102 Beach 2011 . ✓
`` CITY OF ATLANTIC BEACH ,
" �' ` ) 800 SEMINOLE ROAD
J ' ' -z" ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5826
Application Number 11- 00001922 Date 4/27/11
Property Address 2102 BEACH AVE
Application type description RESIDENTIAL ALTERATION
Property Zoning TO BE UPDATED
Application valuation . . . 60000
Application desc
RENOVATE HALLWAY AND 2 BATHS
Owner Contractor
ROCHOW OWNER
Permit RESIDENTIAL ALT /OTHER
Additional desc .
Permit Fee . . . 320.00 Plan Check Fee . . 160.00
Issue Date . . . Valuation . . . . 60000
Expiration Date . 10/24/11
Other Fees STATE DCA SURCHARGE 4.80
STATE DBPR SURCHARGE 4.80
Fee summary Charged Paid Credited Due
Permit Fee Total 320.00 320.00 .00 .00
Plan Check Total 160.00 160.00 .00 .00
Other Fee Total 9.60 9.60 .00 .00
Grand Total 489.60 489.60 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
.s� -L City of Atlantic Beach APPLICATION; NUMBER
\ jt - Building Department (To be assigned by the Building Department )
.� yi v 800 Seminole Road F T
Atlantic Beach, Florida 32233 -5445 t
` ""` ° Phone (904) 247 -5826 • Fax (904) 247 -5845 x,
..oi3 S P ' E - mail: building- dept @coab.us Date routed w r 4 . {
City web -site: http: / /www.coab.us -`
APPLICATION REVIEW AND TRACKING FORM
Property Address: ,-2'- /d ■ot €ed Zvi _ Depart review required Yes No
CC /1/6,-- �ildji) V
Applicant: 0 /I/c ` Planning & Zoning
Tree Administrator
Project: A i/V.0 VQ' /1 / , „d Public Works
Public Utilities
c2 Public Safety
Fire Services
Re /IeVI/rfee ' ' xn� i - . "-^, ' .. , emu vtt�s a p , �r AN
, �DeP.!9a #lire , MAO, 5 �� }
Other Agency Review or Permit Required Review or Receipt Date �° D
of Permit Verified By A Florida Dept. of Environmental Protection b Florida Dept. of Transportation A
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: proved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING & ZONING
Reviewed by: Date: ( 1 - / 3- 1/
TREE ADMIN. Second Review:
Approved as revised. ❑De ied.
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
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247 -5826 Fax (904) 247 - 5845
rob Address: 20Z- 130ett- AU__
Ay, -3.3a-3 Permit Number: 1l — i 9 o?).-
Jegal Description Parcel #
Taluation of Work $ / !�
Floor Area of Sq.k t. 5 Ft
Proposed Work heated/cooled ,f 7O on- heated/cooled /<-/A
:Ias of Work (circle one): New Addition (te Repair Move Demolition pool/spa window /door
Tse of existing /proposed structures) (circle one) : Commercial • - . - , .
f an existing structure, is a fire sprinkler system installed? (Circle one): 4 Le No N /A
lorida Product Approval #
'or multiple products use product approva form
)escribe in detail the type of work to be performed: ? J9 (4IV /J7lit - 47 AzA a 4M I-S
roperty Owner Information:
came: k) g6V)1 ) Address: 1 02- PC` 4- /"c. 3x-3 3
ity 4 . State Zi Phone 40c f •--� Sj7- z -(
-Mail or Fax # (Optional) 1,4) QC• f0 w ) , k/G T
' ontractor Information:
ompany Name n!, Qualifying Agent:
ddress: S4 f f} x Xk _ City State PL Zip32-
ffice Phone Job Site/ Contact Number Fax #
`.ate Certification/R.egistration #
rchitect Name & Phone #
agineer's Name & Phone # C114 5 t !.) j �v • p - - 7 - r+
:e Simple Title Holder Name and Addr ss etaneie. ,54 ,t--> ' /VC._
onding Company Name and Address /4
[ortgage Lender Name and Address �, L. ' G. r � / 4, ' f `fir
)placation is hereby made to obtain a permit to do the work and installations as indicated I certify that no work or installation has commencer prior tto tt
.uance 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
: d void (work is not commenced within six (6) months, or if construction or work is suspended or abandoned for a_pereod of six 6) months at any time after
)rk is commenced. I understand that separate permits must be secured for Electricar Work, Plumbing, Signs, Wells, Pools, F urnaces, Bo t ers, Heaters,
rnks and Air Conditioners, etc.
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 YOUR NOTICE OF
COMMENCEMENT.
ereb certify that I have r- ad and examined this a plication and know the same to be true and correct. All provisions of laws and ordinances governing this
re of work will be compl. -d , th whether specified herein or not. The granting of a permit does not presume to z'q authority, to jzplgt_� he
visions of any other fede .1 s ate, or local law regulating construction or the performance of construction. "��``
gnature of Ownek Signature of Contractor
int Name / Xt)C F �//
Print Name , . k . . , y....,. »
vo to and subsori')ed befo e me t � t�
is 0 - . *L... ww ■�■r �w � , 20 /) R U *1'1 c 6O E eOM PLIANCE 20
_ :, CITY OF ATLANTIC BEACH
I M
$ RMITS FOR ADDITIONAL '
)tart' "us lie ?*: : "? MY COMMISSION # DD 957160 NOt
' ` �` ; � „ ?? CONDITIONS. -',
2 ENTS AND
'Mu u Notary Public Underwriters
,u REVIEWED BY: _Z4_,___ � 2��. 1:
DA TE: R
1
,t» CITY OF ATLANTIC BEACH
� ,tl � OWNER / BUILDER AFFIDAVIT
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "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 IMPROVE 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 THIS 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.
II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED.
111. 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(1). 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.
1 62- BEA-C/{ AvE- �� 4.307 -3er/ 3
A RESS
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PHO NE NUMBER
PRIN E " �yC�
vs SIG / U R E _ 4 /16
DAT
Before me this /Z day of / L 20* in the county of
Duval, State of Florida, has personal) appeared herin by hi self / herself and affirms that
all statements and declarations are true and accurate. 1 �c_�
Notary Public at Large, State of / L , County of
❑ Personally Known
O.Pr6duced ldensficati•. _
• 1111 ' 'Y P SHIRLEY L GRAHAM
Notary Signature. _ r / t :+r_ MY COMMISSION # DD 957760
�" - " ' b = -:or EXPIRES: February 14, 2014
4 , i t ` Bonded 'Nu Notary Public Underwriters
F:BLDG /Owner - Builder Affadavit; REVISED: 4/16/2009
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�y , tkik, CI TY OF ATLAN TIC BEACH
. 9 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
Application Number 11- 00001922 Date 5/27/11
Property Address 2102 BEACH AVE
Application type description RESIDENTIAL ALTERATION
Property Zoning TO BE UPDATED
Application valuation . . . 60000
Application desc
RENOVATE HALLWAY AND 2 BATHS
Owner Contractor
ROCHOW DONALD W OWNER
2102 BEACH AVE
ATLANTIC BEACH FL 32233
Permit MECHANICAL HVAC PERMIT
Additional desc .
Sub Contractor . AIR EXCELLANCE INSTALLATION
Permit Fee . . . 75.00 Plan Check Fee . . .00
Issue Date . . . Valuation . . . . 0
Expiration Date . 11/23/11
Other Fees STATE MECH DCA SURCHARGE 2.00
STATE MECH DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 75.00 75.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 79.00 79.00 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
MECHANICAL PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd Atlantic Beach, FL 32233
Ph (904) 247 -5826 Fax (904) 247 -5845
JOB ADDRESS: (/ Oa FyoLciv A \J E PERMIT #
PROJECT VALUE$ 500
NEW AIR CONDITIONING & HEATING SYSTEM INSTALLATION
Air Conditioning: Unit Quantity Tons Per Unit
Heat: Unit Quantity BTU's Per Unit Seer Rating
Duct Systems: Total CFM REQUIRED
REPLACEMENT AIR CONDITIONING & HEATING SYSTEM INSTALLATION
ARI #
Air Conditioning: Unit Quantity Tons Per Unit REQUIRED
Heat: Unit Quantity BTU's Per Unit Seer Rating
Duct Systems: Total CFM REQUIRED
FIRE PREVENTION
Fire Sprinkler System Quantity (Requires 3 sets of plans)
Fire Standpipe Quantity (Requires 3 sets of plans)
Underground Fire Main Value (Requires 3 sets of plans)
Fire Hose Cabinets Quantity (Requires 3 sets of plans)
Commercial Hoods Quantity (Requires 3 sets of plans)
Fire Suppression Systems Quantity (Requires 3 sets of plans)
FIRE PLACES MISCELLANEOUS:
Prefabricated Fireplace Qty Automobile Lifts
Gas Piping Outlets Boilers BTU's
Elevators/Escalators
ALL OTHER GAS PIPING Heat Exchanger
Quantity of Outlets Pumps
# Vented Wall Furnaces Refrigerator Condenser BTU's
# Water Heaters Solar Collection Systems
Tanks (gallons)
Wells
OTHER: ?�nS4..11ln 02 , j nc, lL den- - - 110 &Atkrccyv
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have read
this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified
or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction.
D / 2: 1 \1 Property Owners Name ,,,U+v ROC J Phone Number 5q5-9 )S
Mechanical Company /ail' bcce /fence s-qc, _Th54 Office Phone x.1,3 -V96.? Fax
Co. Address: SF 3 Pv J EAsit L' City :Tax State R- Zip, a57
License Holder (Print): ReAc,(cf G J %�� State Certification/Registration # l'gcig•oa
Notarized Signature of License Holder /.6--_-
Sworn and subscribed befor me this al +‘..` day oof M 20
# DEBRA A. REN ZELL S gnature of Notary P 7 . I� e n �"2 C
Comm DD 804100
1 Expires July 25, 2012
1,;;r w • 8adsdTMu Troy Fr instance l9o-385.7O19
r \Jy_
0 CITY OF ATLANTIC BEACH
..c1 800 SEMINOLE ROAD
!=>," ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
Application Number 11- 00001922 Date 5/24/11
Property Address 2102 BEACH AVE
Application type description RESIDENTIAL ALTERATION
Property Zoning TO BE UPDATED
Application valuation . . . 60000
Application desc
RENOVATE HALLWAY AND 2 BATHS
Owner Contractor
ROCHOW DONALD W OWNER
2102 BEACH AVE
ATLANTIC BEACH FL 32233
Permit ELECTRICAL PERMIT
Additional desc . WIRE ALT JOB
Sub Contractor . KNIGHT ELECTRIC LLC
Permit Fee . . . 68.20 Plan Check Fee . . .00
Issue Date . . . Valuation . . . . 0
Expiration Date . 11/20/11
Other Fees STATE ELEC DCA SURCHARGE 2.00
STATE ELEC DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 68.20 68.20 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 72.20 72.20 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
ELECTRICAL PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd, Atlantic Beach, FL 32233
Ph (904) 247 -5826 Fax (904) 247 -5845
JOB ADDRESS: ;2M,,2 ,,,,G, mi PERMIT # /1" /i
JEA INFORMATION REQUIRED ON ALL PERMITS AMPS VOLTS PHASE
VALUE OF WORK $
NEW SERVICE ❑ Overhead ❑ Underground nT Underground up Pole
Residential (Main) Service
❑0 -100 amps ❑ 101- 150amps ❑ 151- 200amps ❑ amps # of Meters
❑ Commercial (Main) Service
❑ - 100 amps ❑ 101- 150amps ❑ 151- 200amps ❑ amps ❑ CT Service amps
Conductor Type Size
❑ Multi - Family (Main) Service
❑ - 100 amps ❑ 101 150 amp s ❑ 151- 200amps ❑ amps # of Unit Meters
❑ Temporary Pole ❑ amps
SERVICE UPGRADE L7 amps ❑ CT Service amps
NEW FEEDER (ADDITIONS, ACCESSORY STRUCTURES, ETC.)
[7100 amps ❑ 150amps 0200amps ❑ amps ❑ CT Service amps
ADDITIONS, REMODELS, REPAIRS, BUILD -OUTS, ACCESSORY STRUCTURES, ETC.
Outlets /Switches: / 0- 30amps 31- 100amps 101- 200amps
Appliances: 0- 30amps 31- 100amps 101- 200amps
A/C Circuits: 0- 60amps 61- 100amps
Heat Circuits: # circuits @ kw�
Number of Lighting Outlets, Including Fixtures: �
OTHER ELECTRICAL PROJECTS
❑ Swimming Pool ❑ Sign ❑ Smoke Detectors Qty ❑ Transformers KVA ❑ Motors hp
FIRE ALARM SYSTEM (Requires 3 sets of plans & Fire Alarm Checklist)
Qty volts /amps VALUE OF WORK $
REPAIRS/MISCELLANEOUS
❑ Replace Burnt/Damaged Meter Can ❑ Safety Inspection ❑ Panel Change ❑ OH to UG
Other:
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have
read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether
specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of
construction.
Property Owners Name l C Phone Number
Electrical Company Kitt fk r C-- - LC- Office Phone .2 f 3F K Fax 7` f8 `i1
Co. Address: + / 0 1161' /WC ST Ci ty J State R. Zip 7225-1)
1 ' �e K �f
License Hold ' �i * , . , 1 _ State Certification/Registration #
+, ') g,o„f ,r�
Notarized , v ii a r('ier
;: <.S wo and subscribed before , th'. da of 20 '---
Signature of Notary Public �� "l
rt X11
� CITY OF ATLANTIC BEACH
' °� 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
ey, ` INSPECTION PHONE LINE 247 -5814
Alp. - on Number 11- 00002168 Date 6/08/11
Prnrarf y nddrQsc 2102 BEACH AVE
RE number 169722 - 0400 -80 -A
NCR OLD ACCOUNT NUMBERS . .
Application type description MECHANICAL FIRE PERMIT
Subdivision Name
Property Use
Property Zoning TO BE UPDATED
Application valuation . . . 0
Owner Contractor
ROCHOW DONALD W WAYNE AUTOMATIC FIRE SPRINKLER
2102 BEACH AVE HAZARD FIRE PROTECTION ENG
ATLANTIC BEACH FL 32233 222 CAPITOL COURT
OCOEE FL 34761
(904) 268 -3030
Permit MECHANICAL FIRE PERMIT
Additional desc .
Sub Contractor . WAYNE AUTOMATIC FIRE SPRINKLER
Permit Fee . . . 85.00 Plan Check Fee . . .00
Issue Date . . . Valuation . . . . 0
Expiration Date . 6/08/11
Qty Unit Charge Per Extension
BASE FEE 55.00
1.00 30.0000 EA M FIRE SPRKL 1ST 40 HEADS 30.00
Other Fees STATE MECH DCA SURCHARGE 2.00
STATE MECH DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 85.00 85.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 89.00 89.00 .00 .00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
r City of Atlantic Beach APPLICATION NUMBER
.c ,� Building Department (To be assigned by the Building Department.)
t 800 Seminole Road ! /e0600
N- '" ' = s) Atlantic Beach, Florida 32233 -5445 /
Phone (904) 247 -5826 • Fax (904) 247 -5845 /-.V/ _. 0 —119 %' V % / E -mail: building- dept @coab.us Date routed: (7
City web -site: http: / /www.coab.us
/
APPLICATION REVIEW AND TRACKING FORM
Property Address:
/i. �' Q () N /OE Department review required Yes No
f;zi (Building
Applicant: //u„g A � S-
Planning & Zoning
Tree Administrator
Project: 4 I' 12) , e/-r 3/ 6.7 -- Works
Public Utilities
Public Safety
Fire Services
Reyieiit fee` V 4. H ,, r . Qept Sig! tune ; Ig, , _ s .11• F
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 District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APP 'ICATION STATUS
Reviewing Department First Review: DiApproved. ❑Denied.
(Circl ) Comments:
BUILDING
PLANNING & ZONING Reviewed by: r ` Date: 6 - 6 I(
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 07/27/10
MECHANICAL PERMIT APPLICATI
CITY OF ATLANTIC BEACH '' -'- ------
800 Seminole Rd Atlantic Beach, FL 32233
Ph (904) 247 -5826 Fax (904) 247 -5845 J ` "
JOB ADDRESS: C. c,c\ f\vr
v e B y , Tit
PROJECT VALUE $ l 60(} , o0
NEW AIR CONDITIONING & HEATING SYSTEM INSTALLATION
Air Conditioning: Unit Quantity Tons Per Unit
Heat: Unit Quantity BTU's Per Unit Seer Rating
Duct Systems: Total CFM REQUIRED
REPLACEMENT AIR CONDITIONING & HEATING SYSTEM INSTALLATION
ARI #
Air Conditioning: Unit Quantity Tons Per Unit REQUIRED
Heat: Unit Quantity BTU's Per Unit Seer Rating
Duct Systems: Total CFM REQUIRED
FIRE PREVENTION 15 ysVe M
Fire Sprinkler System Quantity 6- Sp (Requires 3 sets of plans)
Fire Standpipe Quantity (Requires 3 sets of plans)
Underground Fire Main Value (Requires 3 sets of plans)
Fire Hose Cabinets Quantity (Requires 3 sets of plans)
Commercial Hoods Quantity (Requires 3 sets of plans)
Fire Suppression Systems Quantity (Requires 3 sets of plans)
FIRE PLACES MISCELLANEOUS:
Prefabricated Fireplace Qty Automobile Lifts
Gas Piping Outlets Boilers BTU's
Elevators/Escalators
ALL OTHER GAS PIPING Heat Exchanger /
Quantity of Outlets Pumps 6 (
# Vented Wall Furnaces ` ' ' - °° , Refrigerator Condenser BTU's
# Water Heaters AY Solar Collection Systems 861
2011 Tanks (gallons) 36/ Wells
OTHER:
Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby c ify that I have read
this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied w' h whether specified
or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the perfori once of construction.
Property Owners Name 1�C,\ -,0vJ Phone Number
(0,4.)
Mechanical Company vA6t 't(S ) a-, - \c.,, Office Phone 6 Fakcl- \)2-07ZIA
Co. Address: \ \? - 'cc�,■.)- 4.c,., Lt \\!..)e City -- 0,.c \2. , \ \t StateVL Zip ,S22-S
License Holder (Print): cy, 0, \-\NA,r,. ate Certification/Registration # ` \ cs:o12,cc a,
Notarized Signature of License Holder .
SAMANTHA GON?ALES Sworn and subscribed before me is c)- a )' f a L' 20 <
NOTARY PUBLIC
4 `; '_ STATE OF FLORIDA
.4 � ; Comm# EE043T64 Signature of Notary Public "�? �i� 1 f
0,01 t 11 /R1/2614 t