Permit Remodel Bath/kitchen 191 12th St 2011 1 " h, ` s CITY OF ATLANTIC BEACH
.� " 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247 -5814
Application Number 11- 00002584 Date 9/09/11
Property Address 191 12TH ST
Application type description RESIDENTIAL ALTERATION
Property Zoning TO BE UPDATED
Application valuation . . . 50000
Application desc
RENOVATE BATH AND KITCHEN
Owner Contractor
ENNIS GENESIS BUILDING CORP
2158 MAYPORT RD.
ATLANTIC BEACH FL 32233 ATLANTIC BEACH FL 32233
(904) 241 -0320
Permit RESIDENTIAL ALT /OTHER
Additional desc .
Permit Fee . . . 300.00 Plan Check Fee . . 150.00
Issue Date . . . Valuation . . . . 50000
Expiration Date . 3/07/12
Special Notes and Comments
*2007 FLORIDA BUILDING CODE W/2009 REVISIONS
NATIONA1 ELECTRIC 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
Other Fees STATE DCA SURCHARGE 4.50
STATE DBPR SURCHARGE 4.50
Fee summary Charged Paid Credited Due
Permit Fee Total 300.00 300.00 .00 .00
Plan Check Total 150.00 150.00 .00 .00
Other Fee Total 9.00 9.00 .00 .00
Grand Total 459.00 459.00 .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
Office (904) 247 -5826 Fax (904) 247 -5845
Job Address: f ?i 42--- f re e; -/ ,,, k c t cx` F Permit Number: //= d .5 - 8 4
Legal Description /0.1 1 / (a 5 -- '9' / l C,t .1 c (c ct Parcel #
Floor Area of Sq.Ft Sq.Ft
Valuation of Work $ J _d b ( :.0 Proposed Work heated /cool 19 5/Y
non - heated /co : ' d 3
Class of Work (circle one): New Addition Repair Move Demolition pool /spa ) do
Use of existing/proposed structure(s) (circle one): Commercial I S4-7, 0 '74 If an existing strucure, is a fire sprinkler system installed? (Circle one): Yes N /A OS
Florida Product Approval # e 208
For multiple products use product approval form
Describe in detail the type of work to be performed: r'Qft v. dr4. 4.x ^c- &-
v
Property Owner Information: / _ n / / p _
Name: 46\24- DQ1 L ivi ( S Address: OAT /"r � Occ L� "i .� L �-�f2c(QIN
City t Cri" -hc- d6 r-t_ac Stater6 — Zip . 33 Phone `70‘7 ( n)3.2
E -Mail or Fax # (Optional)
Contractor Information: / e..----16A ` , Q
Company Name: G - ;,... L5 S c� )M �?05 co J ¢ �� Qual i' i g Agent: )305
Address: iyiely [J City LA. -f a6e.ct.c, "- State FL Zip .3
Office Phone `()q 2'// D 3j Job Sit - .1 .ct Number 0 02 r 0 Fax # `"c '-/ yi .0
State Certification/Registration # C/► o� J --- -°-'•` ----- _
Architect Name & Phone # �� F R CODF. _ ° _
C mpuANC :06 —,. ,.,. ,,
Engineer's Name & Phone # 1 y II _ u i � _ :.,,• y .
Fee Simple Title Holder Name and Address 1 • ;
Bonding Company Name and Address RE1UI a �� • ,,� �
Mortgage Lender Name and Address 1 X11 L i.sioas. :: 43. j
' ' I " D BY: AND DATE: r -' . 1 x
Application is hereby made to obtain a permit to do the w: °"- • .......... :...,:_•, _ , ' • ' •_,! • '. , , o wor o • . � n d coinmi'nced' ei to-the
issuance ofa permit and that all work will be performed to meet the standar o a aw regu . . ---' -. .. i!.�ion 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 aperiod o .17x L6) months at any time after
work is commenced. I understand that separate permits must be secured for Electrical Work, Plumbing, Signs, Wells, Pools, Furnaces, Bo Heaters,
Tanks 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.
I hereby certj that I have read and examined this a placation and know the same to be true and correct. All provisions of laws and ordinances governing this
type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of any other federal, state, or local law regulating construction or the performance of construction.
t eig----- -----------
Signature of Owner Signature of Contracto
Print Name to S C. As.. .$J t11 S Print Name 7Zi') /Q ,"f cc)
Sworri,taand subscribed fore e Sworp tp and subscribed for me
this b 5Day of , 20 / ( this rft Day of , 20 1/
4J - ° .' 4)2" /
Notary Public Notary Public
WILLIAM L POPE WILLIAM L POPE Revised 01.26.10
Notary Public, State of Florida Notary Public, State of Florida
My comm. exp. Oct 19, 2011 My exp. Oct 19, 2011
Comm. No. 00 714216 Comm. comm. No. 00 714216
NOTICE OF COMMENCEMENT
Permit No. / / _,) S $1 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 wi
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):
/ mi l/ /,) 5 7 ` Aft: A t, 6 .C1• /0 — // ) 6 -� S -. %. / 4,,
2. General Description of improvements: 1
( 2-4. o VCAQ 6-2 J ti- &'.1- C
3. Owner Information:
a) Name and Address: >4 LCc<1 6 ,i59 C/1/l ( 5 0165 L —e.. Dq.k L ,L (r '. hr L /5.2F
b) Interest in property: 0 ("of. +2.-r
c) Name and address of simple titleholder (if other than owner):
4. Contractor Information:
45)
a) Name and Address: 4)2.5-/ S D 6 5c3 0 ,.. ,- )7),--, Q_5- / 54' Aa ,edi 1-20( ., - e ci.
�u b) Phone Number: 0 <� 2 y/ a � jc) /
5. Surety Information:
a) Name and Address:
b) Phone Number:
c) Amount of Bond: $
6. Lender Information:
a) Name and Address:
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 (1)(a) 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 $ection 713.13 (I) (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
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
1. 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.
- -- ■ Arr.• De4.11� e k• E tSt115 ow R
A e of Owner or Owner's Authorized Officer /Director /Partner /Manager Signatory's Printed Nanie & Title /Office
The foregoing instrument was acknowledged before me this (1 day of 54y-10,k'
4 a.‘,_ , 20(( , by
as for
(Name of Person) (Authority Type, i.e. Officer /Attorney) (Name of Party Instrument was Executed for)
WILLIAM L POPE NOTARY PUBLIC, STATE OF FLORIDA
Notary Public, State of Florida Print Name:
My comm. exp. Oct 19, 2011
Comm, No. DD 714216 "Personally Known C
❑ Identification/Type:
• Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, I declare that I have read the
fnres'nins' and that the facts stated in it are true to the best of my knowledge and belief.
Docg 2 u11193307,ORBK - i5703 Page 232'1,
Number Pages: 1
Recorded 0910612011 at 11:45 AM,
JIM FULLER, CLERK CIRCUIT COURT DUVAL Signature of Natural Person Signing Above
COUNTY
RECORDING $10.00
Revised l 0/1/2009
111111) A. Settlement Statement (HUD-1)
OMB Approval No 2502 -0265
L. ' ililli�
B. Type of Loan
1 FHA 2 RHS a X CONY. UNINS. 6. File Number: , 7. Loan Number: ' 8. Mortgage Insurance Case Number:
a VA 5. CoNV.iNS . 11A246 5001852286
C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown_ Items marked "(p.c.c.)" were paid
outside the dosing; they are shown here for informalionat purposes and are not included In the totals
D. Name & Address of Borrower: E. Nan* & Address of Seller: "' i F. Name & Address of Lender.
Alan Thomas Ennis and Denise Ennis , Jonathan C. Currier, Teresa A. Currier, Irene TO Bank, N.A.
1865 Live Oak Lane i C. Titherington, individually and as Trustee and 11 Portland Square
Atlantic Beach, Florida 32233 The Irene C. Titherington Living Trust dated i Portland, Maine 04101
November 2, 1982 as to 50%
G. Property Location: N. Settlement Agent. !I. Settlement Date:
191 12th Street Keith Watson Title Services, Inc. September 2, 2011
Atlantic Beach, Florida 32233 208 Ponte Vedra Park Drive, Suite 101
Lot 1 and West 25 feet of Lot 2, Block 50, Ponte Vedra Beach, Florida 32082
MANDALAY PB 10 PG 11 Duval County, (904) 273 -7009 fax'. (904) 273 -6370
Florida.
Place of Settlement:
Keith Watson Title Services, Inc.
'208 Ponle Vedra Park Drive, Suite 101
:Ponte Vedra Beach, Florida 32082 �
I Phone: (904) 273 -7009
J. Summary of Borrower's Transaction K. Summary of Seller's Transaction
100. Gross Amount Due From Borrower 400. Gross Amount Due To Seller:
101. Contract Sales Price 595,000.001 401. Contract Sales Price 595,000.00
102 Personal Property 402 Personal Property
103. Settlement Charges to Borrower (line 1400) 21,646 32 i 403.
Adjustments for Items Paid by Seller in Advance: Adjustments for Items Paid by Seller in Advance:
City 106. City / Town Taxes 1 406. Cit / Town Taxes ".... ___..
107. County /Parish Taxes 407. County/Parish T a xes
108. Assessments 408. Assessments
120. Gross Amount Due from Borrower: 616,646.32 420. Gross Amount Due to Seller : 595,000.00
200. Amounts Paid by or in Behalf o f Borrower: 500. Reductions in Amount Due to Seller:
201 Deposit or Earnest Money 50,000.00 501, Excess Deposit (see instructions)
202. Principal Amount of New Loan 446,250.00 i 502. Settlement Charges to Seller (Line 1400) 40,797.00
203. Existing Loan(s) taken subject to 503. Existing Loan(s) taken subject to
204. Daily interest credit 504. Payoff of First Mortgage Loan 48426101484 to
Chase 12,430.27
205. LENDER PAID CREDITS 2,239.70 505. Payoff of Second Mortgage Loan
206. EMPLOYEE DISCOUNT 1,000.00 • 506. Purchase Money Mortgage
207 SELLER PAID OWNERS TITLE INSURANCE 3,050 00 507 50% Proceeds to Jonathan C. & Teresa A. 266,141.62
PREMIUM Currier
50% Proceeds to Irene C. Titherington as
208. ! 508. Trustee of the Irene Titherington Living Trust 266,141.62
Dated No
209. r 509. Seller paid Owners Title Insurance Premium 3,050.00
Adjustments for Items Unpaid b y Seller: 1 Adjustments for Items Unpaid by Seller:
210 City /Town Taxes 510. City / Town Taxes
211 County / Parish Taxes Jan 1, 2011 thru Sep 1, 6,439.49 511 County / Parish Taxes Jan 1, 2011 thru Sep 1, 6,439.49
2011 2011
212. Assessments 512. Assessments
220, Total Paid by / for Borrower: 508,979.19 520. Total Reductions in Amount Due Seller: 595,000.00
300. Cash at Settlement from/to Borrower: 600. Cash at Settlement to / from Seller:
301 Gross Amount due from Borrower (line 120) 616 646.32 601 Gross Amount due to Seiler (line 420) 595,000.00
302. Less Amount Paid by /for Borrower (line 220) 508,979.19 602. Less Reductions Amount due Seller (line 520) 595,000.00
303. Cash From Borrower: $107,667.13 ; 603. Cash From Seller: $0.00
The Public Reporting Burden for this collection of information is estimated at 35 minutes per response for collecting, reviewing, and reporting the
data. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control
number. No confidentiality is assured; this disclosure is mandatory. This is designed to provide the parties to a RESPA covered transaction with
information during the settlement process.
Previous editions are obsolete Page 1 of 4 HUD -1
"See supplemental page for additional information September 2. 2011 11 AM
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RIGHT LAWS.
City of Atlantic Beach
s APPLICATION NUMBER
i1 Building Department (To be assigned by the Building Department.)
800 Seminole Road
0 Atlantic Beach, Florida 32233 -5445 // 6
a
Phone (904) 247 -5826 • Fax (904) 247 -5845 /rf o
j » E -mail: building- dept @coab.us Date routed: 9 7 /1
City web -site: http: / /www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: /9/ Jr
O nt review required Yes No
Building
Applicant: 9 - 71 X15 Jc/ ( �� �� nning & Zoning
_ Tree Administrator
Project: 2 � so lid f e 4rehi 72 /977 17 i Public Works
Public Utilities
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 District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPL ATION STATUS
Reviewing Department First Review: IrApproved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING & ZONING
Reviewed by: /? r Date: ? 7
TREE ADMIN. Second Review:
DApproved 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
i rt ,
ry Jr— gu n a CITY OF ATLANTIC BEACH
J �
800 SEMINOLE ROAD
Z ATLANTIC BEACH, FL 32233
c Ii INSPECTION PHONE LINE 247 -5814
Application Number
Property Address 11- 00002584 Date 9/29/11
Application type description 191 12TH ST
Property Zoning RESIDENTIAL ALTERATION
Application valuation . TO BE UPDATED
• . 50000
Application desc
RENOVATE BATH AND KITCHEN
Owner
Contractor
ENNIS
GENESIS BUILDING CORP
2158 MAYPORT RD.
ATLANTIC BEACH
FL 32233 ATLANTIC BEACH
(904) 241 -0320 FL 32233
Permit ELECTRICAL PERMIT
Additional desc .
Sub Contractor . MUNSON & BRYAN ELECTRICAL CO.
Permit Fee . . . 69.60 Plan Check Fee
Issue Date .00
Valuation . . • . 0
Expiration Date
• 3/27/12
Special Notes and Comments
*2007 FLORIDA BUILDING CODE W/2009 REVISIONS
NATIONA1 ELECTRIC 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
Other Fees STATE ELEC DCA SURCHARGE
STATE ELEC DBPR SURCHARGE 2.00
2.00
Fee summary Charged Paid
Credited Due
Permit Fee Total 69.60 69.60
Plan Check Total .00 . .00
.00 . .00
Other Fee Total
4.00 4.00 .00 .00
Grand Total 73.60 73.60
.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: /5 / i,z 7" 1 . i q,--z= PERMIT # 6 -11- o o c''� •@
JEA INFORMATION REQUIRED ON ALL PERMITS 2.6 o AMPS (2* VOLTS / PHASE
VALUE OF WORK $ Ji 9 So ' c; o
NEW SERVICE n Overhead n Underground E Underground up Pole
Residential (Main) Service
0 -100 amps 1 ;101- 150amps 151- 200amps 1 amps # of Meters
Commercial (Main) Service
0 -100 amps 101- 150amps 151- 200amps 1 ! amps 'CT Service amps
Conductor Type Size
Multi Family (Main) Service
0 - 100 amps ;101 150amps 1 151 200amps II amps # of Unit Meters
Temporary Pole amps
SERVICE UPGRADE 1 amps 11 CT Service amps
NEW FEEDER
(ADDITIONS, ACCESSORY STRUCTURES, ETC.)
100 amps 1150amps ]200amps X So amps !CT Service amps
ADDITIONS 1: ► ODE ,EPAIRS, BUILD -OUTS, ACCESSORY STRUCTURES, ETC.
Outlets/Switc - 0- 30amps 3I- 100amps 101- 200amps
Appliances: a. 0- 30amps 31- 100amps 101- 200amps
A/C Circuits: 0- 60amps 61- 100amps
Heat Circuits: i # circuits @ kw
Number of Lighting Outlets, Including Fixtures: 17
OTHER ELECTRICAL PROJECTS
Swimming Pool [ Sign I 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 1 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 1 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 k/)" t S Phone Number (qa "0 2'//1a 3 2 O
Electrical Company M ; ,G„ c_,„1 44 BR-NJ . icio - Office Phone(. q' /) 3q4 . c Fax 3 ?C /(3 rG
Co. Address: 3134( SA;,yr R u trusriAt. Q,<;.4o City jrj `,(s,c;,fo, kg, State FL Zip 3 .201o7
License Holder (Print): JOIN) $(; v/v:z,J t) • = State Certification/Registration # �G 6 b o 171,...5
Notarized Signature of License Holder ' i'W —
:ma KIRK L. HEDRICK
"`"�"'7Sworn and subscribed before me this ' day of fern 4" 20 11
.: Commission # EE 07765 Si nature of Notary Public @'(� -(— / ( b4
Expires July 7, 2015 g y
r r� L ''
Banded Thu Troy Fain Insurance 8(a- 85•''r
. .' to CITY OF ATLANTIC BEACH
r i , s) 800 SEMINOLE ROAD
t ATLANTIC BEACH, FL 32233
}
' �' "'� INSPECTION PHONE LINE 247 -5814
Application Number 11- 00002584 Date 10/03/11
Property Address 191 12TH ST
Application type description RESIDENTIAL ALTERATION
Property Zoning TO BE UPDATED
Application valuation . . . 50000
Application desc
RENOVATE BATH AND KITCHEN
Owner Contractor
ENNIS GENESIS BUILDING CORP
2158 MAYPORT RD.
ATLANTIC BEACH FL 32233 ATLANTIC BEACH FL 32233
(904) 241 -0320
Permit . . . . . . MECHANICAL HVAC PERMIT
Additional desc . . INSTALL NEW 4 TON SYSTEMS
Sub Contractor . . HAMMOND AIR CONDITIONING INC
Permit Fee . . . . 113.00 Plan Check Fee . . .00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 3/31/12
Special Notes and Comments
*2007 FLORIDA BUILDING CODE W/2009 REVISIONS
NATIONA1 ELECTRIC 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
Other Fees STATE MECH DCA SURCHARGE 2.00
STATE MECH DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 113.00 113.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 117.00 117.00 .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: 19 ■ \ 1 fie.-c PERMIT # / � — 2 �� 7 /
PROJECT VALUE $ S 000 .'"' ARI # 3 - 1 01 i 2
REQUIRED
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
Air Conditioning: Unit Quantity i Tons Per Unit Li
Heat: Unit Quantity I BTU's Per Unit i-I$ oov Seer Rating i t
Duct Systems: Total CFM 1 Loo i 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:
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 is 1 q u N : s Phone Number spy -' nFc. -(
Mechanical Company N pmtr.,. m 11 r ,> �� • ,u,- . *.r=\ Office Phone ( -104- 4$8'ax ci o -t - :3`os . Go ' 5
Co. Address: ?,'iii.- l:>ee 1 . City J ae3C ,. >v� State Zips' Z
License Holder (Print): -- , State Certification/Registration # CAA ,.,,ve I (9' -160
Notarized Signature of License Holder
o AMA ' k 4 y � o and subscribed befor: t is d y of `' `'' 20
s a s, MY COMMISSION # EE ri /
EXPIRES: May 21, 20 5 /
-I, - — .11 - Ba Notary Public Unc 1 e of Notary Publi
fq- (17 L H cs-30-7,--2v3a,
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