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Permit Int. Alt 304 1st St 2011 P` LA r A Jet CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD '" =" ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247 -5814 JJi19' Application Number 11- 00002091 Date 5/19/11 Property Address 304 1ST ST Application type description RESIDENTIAL ALTERATION Property Zoning TO BE UPDATED Application valuation . . . 8250 Application desc add kitchenette etc see app Owner Contractor O'BANNON, PAULA R. SOLID BUILT CONSTRUCTION AND 3319 APPLESHAW CT ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32225 (904) 241 -4505 (904) 998 -7124 Permit RESIDENTIAL ALT /OTHER Additional desc . Permit Fee . . . 95.00 Plan Check Fee . . 47.50 Issue Date . . . Valuation . . . . 8250 Expiration Date . 11/15/11 Special Notes and Comments *2007 FLORIDA BUILDING CODE W/2009 REVISIONS NATIONALELECTRIC CODE *SUBMIT "CERTIFICATE OF COMPLIANCE" BY A LICENSED PEST CONTROL COMPANY PRIOR TO C.O. *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. Other Fees STATE DCA SURCHARGE 2.00 STATE DBPR SURCHARGE 2.00 Fee summary Charged Paid Credited Due Permit Fee Total 95.00 95.00 .00 .00 Plan Check Total 47.50 47.50 .00 .00 Other Fee Total 4.00 4.00 .00 .00 Grand Total 146.50 146.50 .00 .00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. BUILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Road, Atlantic Beach, FL 32233 f U n Egti IN . . - . V .r , - - . - ill , , r 2011 ili Job Address: 304 1 Street. Atlantic Beach, FL 32223 Permit Number: / " ae 1 By �� Legal Description 5 - 21 - 2S - 29E Parcel # oor a ea o q. t. q. Valuation of Work $ `6 -5 ON Proposed Work heated/cooled non - heated/cooled Class of Work (circle one): New Addition Alteration Repair Move Demolition pool /spa window /door Use of existing/proposed structure(s) (circle one): Commercial Residential installed? an existing structure, is a fire sprinkler system nstalled? (Circle one): Yes No N /A Florida Product Approval # For multiple products use product approval form Describe in detail the type of work to be performed: 1 move washer and ! er to utili close • the , - -. - • ' - _t.,. laundry area to a kitchenette: move water heater from utility closet to garage: demo 557,,Apc ' n..of �p bearing w ; • in downstairs storage area to make a 2' deep closet that bumps out into garage. Kitcl ettL y egshall j6nX ' sink, microwave and 9.55 cubic feet refridgerator. CB.., a � o 1 . o i wf: r Property Owner Information: i i Q AQ E Q Q i Name: Paula Marmon Address: 304 1 Street 0 W o Q City Atlantic Beach State FLZip 32233 Phone 904- 241 -4505 ; Lassi < A '' Z E -Mail or Fax # (Optional) H .J Contractor Information: 4 i Lamm t w Company Name :Solid Built Construction and Dev., Inc._ Qualifying Agent Alexander Allen ,. _,. I # , W o w Address: 3319 Appleshaw Ct City Jacksonville . State FL Zip 32225 A w j-: Office Phone 904 -998 -7124 Job Site/ Contact Number _904 - 686- 4019_Fax # 904 -998 -712,1 w State Certification/Registration # CBC 1255618 V v' Architect Name & Phone # none Engineer's Name R- Phon # none Fee Simple Title Holder Name and Address Paula ()'Bannon 304 I ° st, AB .32.2-ii Bonding Company Name and Address_none rx Mortgage Lender Name and Address none Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 ‘work is not commenced within six (6) months, or if construction or work is suspended or abandoned for a_pertod of six _(6) months at any time after work is commenced I understand that separate permits must be secured Electricaaf Work, Plumbing, Signs, Wells, Pools, Furnaces, Boilers, Heaters, Tanks and Air Conditioners, do WARNING TO OWNER: YOUR F'_' T _ . ` T _ _ 7' _- _ - - - - - - COMMENCEMENT MAY RESULT IN YOUR F II. v r i, i 14 ii i i: vi i ii, i -s ... � , TI , - rr n • irxr l have ,w(ii 'rnn e i- n r n ina n rn . yn» a nal i ,h m ina rnr 41l rn in h tr and i roa n r r ty l , :fir 'r "e. ss ,,, a netts. rrsnes. 'w I ._....... f .. .. o .s .,... ...... ., ,,, i�r i/. ca: useia ra l "viii rri raffia- arc �r uraurss i� u 1�eriiiu 4 }ui Yi eSrria2 to Marc i �Cy7r'i�t�' Ai hawsie "AM. GS. urd pruv tsiutuN ul um ()user leuerul, saute, or local law regulating construction or the performance of construction. .. / 4ce, , l (9% _ibs tt:.iei, t . '.. cliff i r t` itdii[ l.tt ililtll ri�i" -. f 1, ' Print Name ` 1,� P. O //Z k tf!v Print Name 44/4 vv / A' it( =. _ Sworn to and subscribed before me this 1 `7may of An a-y , 20 1 1 this I7 ''Day of / , 20 1 ( Notary ' ' 1t v ► N otary Pubiic State of Florida ` ` "''"' , ," ✓` k�.- N P is a �' Debra Ann Simmons y °'`" ` . Notary Public State of Honda . o My Commission DD68072 , Debra Ann Simmons n ----- n a .1z.• 1 n � > c o Expires 08/24/201 , e MY Commission DD680724 °F f� l'o,, Expires 08/24/2011 / NOTICE OF COMMENCEMENT Permit No. I! '',9 0 (7/ Tax Folio No. State of Florida, County of Duval THE UNDERSIGNED hereby give notice that the improvement will be made to certain real property in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 1. Description of property (legal description of property and address if available): 5 - 69 21 2S - 29E 3041st St. Atl Bch. FL 32233 2. General Description of improvements: Turn laundry room into kitchenette: make small closet in downstairs storaae area 3. Owner Information: a) Name and Address: Paula O'bannon: 3041st ST. ATL Bch. 32233 b) Interest in property: Owner c) Name and address of simple titleholder (if other than owner): 4. Contractor Information: a) Name and Address: Solid Built Construction and Dev.: 3319 Aooleshaw Ct. Jax. FL 32225 b) Phone Number: 904 - 686 - 4019 eSA 5. Surety Information: a) Name and Address: none b) Phone Number: c) Amount of Bond: $ 6. Lender Information: a) Name and Address: none b) Phone Number: 7. Person within the State of Florida designated by owner upon whom notices or other documents may be served as provided by 713.13 (1Xa) 7, Florida Statutes: a) Name and Address: b) Phone Numbers of Designated Person: 8. In addition to himself/herself Owner designates of to receive a copy of the Lienor's Notice as provided in Section 713.13 (1) (b), Florida Statutes. a) Name and Address: b) Phone Number of person or entity designated by owner: 9 Expiration date of Notice of Commencement (The expiration date is one (1) year from the date of Recording unless a different date is specified: WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13, FLORIDA STATUTES, AND CAN 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 COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. f ' ,e L+. 0 ,MJ L - 1 3 6-44c4. g . 6' 6i. riti bIi C - N I Signature of Owner or Owner's Authonzed O' tcer/Director/Partner/Manager Signatory's Printed Name & Title/Office The foregoing instrument was acknowledged before me this �, day of i V L , 20 ) 1 , by (6-.1 C, C..0k r,c�,y cr-... as v ?c:v ..`z ( for (Name of Person) (Authority Type, i.e. Officer /Attorney) (Name of Party Instrument was Executed for) S y ... ,_____... s L L,�i(0 I IC f Po'dk Notary Public State of Florida NOTARY PUBLIC, STATE OF FLORIDA - Debra /,nn Simmons Print Name: t A - t n7 4Y� A c` My Commission DD680724_ ' ' ov p �,n* Expires 08/24/'2011 1— L.. � ' tit Ct ^5 ❑ Personally Known h , , / " , . . r ' ' � ' + , . ' � , f , , yldentification/Type: 0 1 5 — L7 (c:s' 5 / "‘*,:: i ' 6 Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true to the best of my knowledge and belief 0 ! Doc 4 2011 '108/29, OR BK I E802 Page "i 625. Signatur= ofNatural Person Signing bove Number Pages: 1 Recordted 05;1 71201 'I. at 08:32 AM, Revised 10/1/2009 JIM FULLER CLERK CIRCUIT COURT DUVAL COUNTY RECORDING $10.00 , 1 1 , ..■ k, o ct •Is,,‘ ,...\0,4ri V ts 71 — — r. 1 _ . \ i , -. ..„.... ; pc).1,40...-( , —____ :/ i -4\ ' ; 1.4.-A-rert 41>M-1a. le• , 1.,1' umrt. 1 1 i ) I f Qfint ( r .,,......---- rt a v ■ a _,_,... , 0,A- t/0-1K- i 1 W m , k ' ILI 1,, i IL-I 41 7, -- -, A 6 I. t __ 41111 1 1 l b u4141 LOVVErt FLOOR •....-.. II 6 la -E66Ee9FRIei*4:161011• .. * A-c-f4t\ 0 - 1 '. neivii kill-- oitui-d2 t For_n\v --- 6.. W � AttftA4CtAi . ._ . • -,- 3 -3 _ istb ;AGSM .13161 a a.•ac. Rams soy .asor -- 4reauTs..valca. t manrimi IMMI,J.' : :--' - - .!-- - , '2 Gar:GANG r - ........„..:_,_: ,- z - 1 . 24 =WOG JoGIPPS 0 Item t. 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V : I [ i_ , re I f -- " -- 4=1 ---------- . ..,... • - ? 2 4€1-e, t • m ,7111.a ( A I D ...., .‘0" BUILDING SECTIONS ,-- •.--- Pe.,,,,, 5 t,,,,,vik- i I ......i.-ez - '', k i ,...„ die/el) Cilo 5 e/ ) 1 i 7 a Lt loi../ i.i 1 'ff "4,1 dl < 0 -f Noli — Iv '€4V 1 InfiNI -, \ st, 1 tv (pirtit amt . ,.. Is. ..._... c ......,, 2 _ ) . , ----k----. , l• . _ _ ,, „..... ---): , ,. 0 ,.....„ „.., .....,_, 0 1 , , ._,/...., 4........ i 1 0 C4.4 'k.4 I 0 1 .1 3 , , I 4 ,„,..•c .-- _ 1 1 , 1 .....„.., ; , to i g 2 3 3 H o ei. ■ ii cr •• 7 CO ig ct, __t _ , 7 U - 1 ' _ :: _.L1 ill ,! ii x fn 041 tn . -. 0 G co ■-• 11' . o.. 6 in: [2:1- CL: i . 1 I C I , 1 . 1 -r-ais-N ....--, , Cs.- - (iN o , ,<,......,., " 11 iiiK) 1 , ____..,, L 0 , L____ I > ....._.) ,--- •• A i 0 , ,..„ . cm @ , -- • • .r."•,) (.........r. * ■ .. . , -... ■-. (....r......„, $...5".", C.-7... n i 1 l..3 04 0 .P. ' ,.... 0 ■L''' (... ",.../.. 4 2... , ^-• 11/4„:79(.1, 42___e.... ,_ I ! ..... i C ,...... '7- • City of Atlantic Beach APPLICATION NUMBER �, � Building Department (To be assigned by the Building Department.) C.,? 800 Seminole Road � 1/ _ Q 9 / v C Atlantic Beach, Florida 32233 -5445 Phone (904) 247 -5826 • Fax (904) 247 -5845 `V.01119'' E-mail: building- dept @coab.us Date routed: 4 City web -site: http: //www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: 3e4 /T ' = = - '.ent review required Y Applicant: ( a i Planning & Zoning Tree • ministratior Project: . d Ai 3 E - ctiA a " Public Works - Public Utilities 6/t / Public Safety i l l ei h Fire Services Review fee' $ Review or Receipt Other Agency Review or Permit Required of Permit Verified By Date 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: proved. ['Denied. (Circle one.) Comments: BUILDIN PLANNING & ZONING Reviewed by: - 11 4 Date: S / 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. EDenied. Comments: Reviewed by: Date: Revised 07/27/10 1,11"44.Jri City of Atlantic Beach APPLICATION NUMBER z, Building Department (To be assigned by the Building Department.) 800 Seminole Road /// _ d 9 / u ° , Atlantic Beach, Florida 32233 -5445 s Phone (904) 247 -5826 • Fax (904) 247 -5845 /, / , . „ 9,. E -mail: building- dept @coab.us Date routed: e/ ® City web -site: http: / /www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: 3e 4 /r er ID - = = • 01 ent review required Yes No Applicant: Sr t b Lr (errinkc a 0 Planning & Zoning Tree ' •minis r- .r Project: 4 , E - I CA 4 ' Public Works � Public Utilities eh Public Safety 6C-6 y-p/J / / tit /7QA Fire Services 60 Review fee $1 +a Dept Signature 4,. . Other Agency Review or Permit Required Review or Receipt Da of Permit Verified By Florida Dept. of Environmental Protection tile Florida Dept. of Transportation St. Johns River Water Management District Army Corps of Engineers 11 Division of Hotels and Restaurants V 47009.1 Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS ai- .< Reviewing Department First Review: ❑Approved. ❑Denied. t4.` (Circle one.) Comments: BUILDING 1 PLANNING & ZONING Reviewed by: Date: TREE ADMIN. Second Review: Approved as revised. ❑Denied. PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: DApproved as revised. ❑Denied. Comments: Reviewed by: Date: Revised 07/27/10 "Or t CITY OF ATLANTIC BEACH A 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 44.4 01119 Application Number . . . . . 11-00002091 Date 5/19/11 Property Address 304 1ST ST Application type description RESIDENTIAL ALTERATION Property Zoning TO BE UPDATED Application valuation . . . 8250 Application desc add kitchenette etc see app Owner Contractor O'BANNON, PAULA R. SOLID BUILT CONSTRUCTION AND 3319 APPLESHAW CT ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32225 (904) 241-4505 (904) 998-7124 Permit ELECTRICAL PERMIT Additional desc . RELOCATE WATER HEATER CIRCUIT Sub Contractor . LIMBAUGH ELECTRICAL CONTRAC Permit Fee . . . 59.20 Plan Check Fee . . .00 Issue Date . . . Valuation . . . . 0 Expiration Date . 11/15/11 Special Notes and Comments *2007 FLORIDA BUILDING CODE W/2009 REVISIONS NATIONALELECTRIC CODE *SUBMIT "CERTIFICATE OF COMPLIANCE" BY A LICENSED PEST CONTROL COMPANY PRIOR TO C.O. *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. Other Fees STATE ELEC DCA SURCHARGE 2.00 STATE ELEC DBPR SURCHARGE 2.00 Fee summary Charged Paid Credited Due Permit Fee Total 59.20 59.20 .00 .00 Plan Check Total .00 .00 .00 .00 Other Fee Total 4.00 4.00 .00 .00 Grand Total 63.20 63.20 .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 2 (904) 247 -5826 Fax (904) 247 -5845 JOB ADDRESS: 30�} S4 fi ��-}- ` 10 I PERMIT # 1 I JEA INFORMATION REQUIRED ON ALL PERMITS i ,,, AMP (2 - " VOLTS , ( PHASE VALUE OF WORK $ /5(* I. NEW SERVICE ❑ Overhead n Underground ED Underground up Pole ❑ Residential (Main) Service 00 -100 amps ❑ 101- 150amps ❑ 151- 200amps ❑ amps # of Meters ❑Commercial (Main) Service 00 -100 amps ❑ 101- 150amps ❑ 151- 200amps ❑ amps OCT Service amps Conductor Type Size :Multi-Family (Main) Service 0 0 -100 amps ❑ 101- 150amps ❑ 151- 200amps ❑ amps # of Unit Meters :Temporary Pole ❑ amps SERVICE UPGRADE ❑ amps ❑ CT Service amps NEW FEEDER (ADDITIONS, ACCESSORY STRUCTURES, ETC.) ❑ * 100 amps ❑ 150amps 0200amps ❑ amps OCT Service am ADDITIONS, REMODELS, REPAIRS, BUILD -OUTS, ACCESSORY STRUCTURES, ETC. Outlets/Switches: l 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: 2 OTHER ELECTRICAL PROJECTS ❑Swimming Pool ❑ Sign 0 Smoke Detectors Qty 0 Transformers KVA 0 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 I �d [ � jOther: . C..(lLt — /'rtd d CAA, /Livid c W C' . 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 _ Phone Number Electrical Company L%I ■ 2O:,i&9 h Elect ri C4 l }rpm; rnKce Phone 2-U et a5 ( Fax Co. Address: 42 L,.JeS# gi-h 9creek City Ai([In•1 ic iC.FState Fl. Zip - 322g3 License Holder (Print): . ( L . ; , A ` r State Certification/Registration # Notarized Sign, r ` s. vim ' o F e : . � EC 13002296 4 ar u+ rc tate o B-- �rbara K iti::nAeNy p• My Commrssiob @$$tand s bscr bed before i. - th ; ay of /d . J _ 20 11 4 oF r. Expires 0 311 1/201 3 .k .. otary Public ..��t » 1 4' CITY OF ATLANTIC BEACH zSy 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 <, , INSPECTION PHONE LINE 247 -5814 \ Application Number 11- 00002091 Date 5/23/11 Property Address 304 1ST ST Application type description RESIDENTIAL ALTERATION Property Zoning TO BE UPDATED Application valuation . . 8250 Application desc add kitchenette etc see app Owner Contractor O'BANNON, PAULA R. SOLID BUILT CONSTRUCTION AND 3319 APPLESHAW CT ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32225 (904) 241 -4505 (904) 998 -7124 Permit PLUMBING PERMIT Additional desc . REPLACE 3 FIXTURES Sub Contractor . B & G PLUMBING .00 Permit Fee . . . 76.00 Plan Check Fee . . Issue Date . . . Valuation . . . . 0 Expiration Date . 11/19/11 Special Notes and Comments *2007 FLORIDA BUILDING CODE W/2009 REVISIONS NATIONALELECTRIC CODE *SUBMIT "CERTIFICATE OF COMPLIANCE" BY A LICENSED PEST CONTROL COMPANY PRIOR TO C.O. *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. Other Fees STATE PLBG DCA SURCHARGE 2.00 STATE PLBG DBPR SURCHARGE 2.00 Fee summary Charged Paid Credited Due Permit Fee Total 76.00 76.00 .00 .00 Plan Check Total .00 .00 .00 .00 Other Fee Total 4.00 4.00 .00 .00 Grand Total 80.00 80.00 .00 .00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. PLUMBING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd Atlantic Beach, FL 32233 Ph (904) 247 -5826 Fax (904) 247 -5845 - co-L. - PERMIT #1 1 1 -- a p 1 ' JOB ADDRESS: . ) j d � 1 s � NEW OR REPLACEMENT INSTALLATION: Project Value $ TYPE OF FIXTURE QTY TYPE OF FIXTURE QTR' Bathtub Septic Tank & Pit Clothes Washer Shower Dishwasher Shower Pan Drinking Fountain Slop Sink Floor Drain Three Compartment Sink Floor Sink Toilet Hose Bibs Urinal Kitchen Sink Vacuum Breakers Laundry Tray Water Connected Appliances Lavatory Water Heater Other Fixtures Water Treating System RE -PIPE: TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY Bathtub Septic Tank & Pit Clothes Washer ) Shower Dishwasher Shower Pan Drinking Fountain Slop Sink Floor Drain Three Compartment Sink Floor Sink Toilet Hose Bibs Urinal Kitchen Sink Vacuum Breakers Laundry Tray Water Connected Appliances Lavatory 1 Water Heater Other Fixtures i Water Treating System MISCELLANEOUS: ❑ Sewer Replacement ❑ Back Flow Preventer ❑ Grease Interceptor (Trap) gallons (Requires 3 sets of plans) ❑ Lawn Sprinkler System - Number of Heads ❑ Well * * ** SJRWD Well Completion Form. Completed form to be submitted to the Building Department for final inspection. ** ❑ 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 Phone Number Plumbing Company '17'C- L) Office Phone =t3- S8 S Fax D9 3 - � Co. Address: Q3 Lov ° VIA1 - _ S q � WA. City -I. w3,_so...,u',, <<c State CL Zip 3 2-7 --<<- License Holder (Print): G-c...'c: C. i'Z a e' //A / A S Pfk - Certification/Registration # CE G Ga3s� Notarized Signature of License Holder ARE 1 _¢,, ,_ t r Notary Sworn and subscribed before ii: this oZ3 = , day of o 20 /1 lav °ue Public State of Florida Lon S Nordgren f I ILItAA y ac My Commission 00766611 Signature of Notary Public /A ` .� t or �o Expires 03/10/2012 o