Permit Fence 571 Seaspray 2012 CITY OF ATLANTIC BEACH
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800 SEMINOLE ROAD
' J .. . � ATLANTIC BEACH, FL 32233
" =° = INSPECTION PHONE LINE 247 -5814
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Application Number 12- 00000437 Date 4/23/12
Property Address 571 SEASPRAY AVE
Application type description FENCE PERMIT
Property Zoning TO BE UPDATED
Application valuation . . . 0
Application desc
6ft Oft fence
Owner Contractor
TUSCANA, DAMIJAN KELLY OWNER
571 SEASPRAY AVENUE
ATLANTIC BEACH FL 322334166
Permit FENCE PERMIT
Additional desc . .00
Permit Fee . . . • 35.00 Plan Check Fee .
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 10/20/12
Special Notes and Comments
Avoid damage to underground water /sewer utilities. Verify
vertical and horizontal location of utilities. Hand dig if
necessary. If field coordination is needed, call 247 -5834.
Roll off container company must be on City approved list
and container cannot be placed on City right -of -way.
Fee summary Charged Paid Credited Due
Permit Fee Total 35.00 35.00 .00 .00
Plan Check Total .00 .00 .00 .00
Grand Total 35.00 35.00 .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
Tc 0 t `� Permit Number:
Job Address: `-� � \
Legal Description Parcel # •
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work $ 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 structures) (circle one): Commercial Residential
i
If an existing structure, is a fire sprinkler system installed? (Circle one): Yes No N /A
Florida Product Approval #
For multiple products use product approval form j - '
Describe in detail the type of work to be performed: 0 C--- 1
Property Owner Information:
Name - \ _ - ti `'--n '`^ Addre s:
City P, _�j.M. fr c State y Zip 572 Phone c 10'4. (..0 55 5 S c i
E - Mail or Fax # (Optional) i
Contractor Information:
Company Name: Qualifying Age
Address: City State Zip
Office Phone Job Site/ Contact Number Fax #
State Certification/Registration #
Architect Name & Phone #
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 /nstallationsasindicatedlcert 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 if work is not commenced within six (6) months, or if construction or work is suspended or abandoned for a_ period of six (6) months at any time after
work is conznzenced. 1 understand that separate permits must be secured for Electrical Work, Plumbing, Signs, Wells, Pools, Furnaces, Boilers, Healers,
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.
1 hereby certify that I have read and examined this application 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 co truction or the performance of construction.
Signature of Owner toy\ k • � st4n al Signature of Contractor
Print Name - t,.ymk s C.,. If= (a Print Name
Swor o and subscrib ; d bef• e Sworn to and subscribed before me
this A , de of that, i'� / , 200— this Day of , 20
� / I A .' SHIRLEY L. GRAHAM
■Adai Ail i ! q h . s • -: .. - - - , 00 957760�,, TT
Notary ' ub is = ., y .,, ri . , EXPIRES: February 14, 2014" 'orrY Public
14;: Bonded Thru Notary Public Underwriters
Revised 01.26.10
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with Florida Building Code and all other applicable •
• local, State and Federal permitting lequirements
must be verified by pigpatUre of the City of Atlantic •
,Beach Building Official prior to (b Issuancq of a •
Building Permit. • t ' .
=it— ED
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CITY OF ATLANTIC BEACH
_ 41 WNER / BUILDER AFFIDAVI
I. FLORIDA STATUTES; CHAPTER 489, TO ACKNOWLEDGE THE LAW: 1 "CONSTRUCTION
CONTRACTING" REQUIRES OWNER / BUILDER
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 COMMERCIL 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 N 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 BY TO MAKE LAW SURE
AND BY COUNTY OR BY YOU HAVE ; LICENSING
ORDINANCES. i
,
II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED. 1
O IRS V E I RS WITHHOLDING E TAX AND /OR FORM 1099 99 REQU EMPLOYERS AND SHOULD ALSO
S ON THE WORKERS THEY
OBSERVE
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 I
BUILDING DEPARTMENT (247 -5826) IF IN DOUBT. 1
V. STATEM I ( COMPLY WITH ALL THEER THAT I HAVE EQUIREMENTS READ OR THE ISSUANCE DISCLOSURE
IISSUANCE OFAN
OWNER- BUILDER PERMIT.
ADDRESS PHONE NUMBER
. - IN) P
P 14 N. 0 \, vS �-
PRINT NAME ^ ` -7--C9 Z
Cx /VV��_, 1. s 7 ( �? 2 NA DATE
SIG NATCfR2
/ t L. 20�in the county of
Before me this �_ day of r
Duval, State of Florida, has personally - ppeared herin by himself / herself and affirms that
all statements and declarations are true apd accurate. �
r.` ‘fa (-- Notary Public at Large, State of / I-- L ' , County ,
of
❑ Personally Known �- 'I
P duced Identification - Jib: V i ' �
l «TM° SHIRLEY L. G RAHAM
. r ice. � � :.= MY COMM;SSIGN DD 9577E0
Notary Signature: - it IL � " W,., ' EXPIRES: February 14, 2014
',1;i,;;,0' r B onded Thru Notary Public Underwriters
FtBLDG /Owner - Builder Affadavit; REVISED: 4/ 6/2009 "
i, City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Byilding Department.)
800 Seminole Road
r Atlantic Beach, Florida 32233 -5445
7fair Phone (904) 247 -5826 Fax (904) 247 -5845 Date routed: /6f//
E -mail: building- dept @coab.us
City web -site: http: /lwww.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 7/ Si
AVE. Department review required Yes No
�1 Bui /
Applicant: (/ 7) �� Planning & Zonin ✓
PP T ree Administra or
Project: r ublic Wo
ublic Utility
Public Safety
Fire Services
3117 _
.fi ,a.:p • if ? 8 �:y: p ` ._ �.,�_� _ .��...
Review or Receipt Date
Other Agency Review or Permit Required 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:
APPLICATION STATUS
Reviewing Department First Review: 12 pproved. ['Denied.
(Circle one.) Comments:
BUILDING /C..LL " ANNO Reviewed by: . 4 L t� Date: 0(7 624/2
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 07127/10
S � , !f , City of Atlantic Bea
APPLICATION NUMBER
Building Department (To be assigned by the B4ild ng Department.)
r .- 800 Seminole Road ! `' 4 . _ /2? Y Atlantic B Florida 32233 - 5445 -*/
Phone (904) 247 -5826 • Fax (904) 247- 58451P ?d Date routed:
�J,i �, E -mail: building- dept @coab.us 12 lc .
City web -site: http: /lwww.coab.usY':� AN
APPLICATION REVIEW T ` CKING FORM
7/ .,
Property Address: ' C� lei y / 1" Department review re•uired Yes No
Applicant: 9 C` h•- i Planning & Zonin'
Tree ' *minis r
(1
Project: _ T `� T i Ct rblic Wo -
riiblic Utilitie
Public Safety ==
Fire Services
RI
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... `�a.� �4 .4F,i.. �'�. er !s��3"fs.�^�'.. ... r �u7� :.t'.R. r u_ ._. ris „Y- -. $�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:
APPLICATION STATUS
Reviewing Department First Review: [ ['Denied.
(Circle one.) Comments: (”
BUILDING
PLANNING & ZONING Reviewed by: Date: / /7 / 2_
TREE ADMIN. Second Review: []Approved as revised. ❑Denied.
P O' KS ,,Comments:
P BLIC TILITI
PUBLIC SAFE Y Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ['Denied.
Comments:
Reviewed by: Date:
Revised 07127/10
BUILDING PERMIT APPLICATION
•
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247 -5826 Fax (904) 247 -5845
Job Address: - .7.c21. i � 0 i--- Permit Number:
Legal Description
Parcel # •
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work $ 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)s) (circle one): Commercial Residential
If an existing structure, is a fire sprinkler system installed? (Circle one): Yes No N /A
Florida Product Approval #
For multiple products use product approval orm 1 '
Describe in detail the type of work to be performed: � - C---
Property Owner Information:
Name. .` v ` ' \.O-ti `'.sov\� Address:
City a •� v-=� � State Zip 32 2 3 Phone el 0 u Co S5 j `"l 3
E -Mail or Fax # (Optional) i
Contractor Information:
Company Name: Qualifying Age •
Address: City State Zip
Office Phone Job Site/ Contact Number Fax #
State Certification/Registration #
Architect Name & Phone #
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 ork 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 if work is not commenced within six (6) months, or if construction or work is suspended or abandoned for a period of six 6) months at any time after
work is commenced. 1 understand that separate permits must be secured for Electrical Work, Plumbing, Signs, Wells, Pools, F urnaces, Boilers, 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.
1 hereby certify that 1 have read and examined this application 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.
Signature of Owner .. _ .. : ('',7)1'v-ac. Signature of Contractor
r. '
Print Name Lk-S Stk..) A Print Name
Sworp,t_o_and subscrib - bef.i e Sworn to and subscribed before me
this � a` of
tie t C 1 -- 2011 this Day of 20
e �� ' ,.o ....I ..... SHIRLEY L GRAHAM
Nota1�• tc : *: , , :* - -: DD957760, • Public
Y 1 ,k,.•;a, EXPIRES: February 14, 201
".'f 04s Bonde Thru Notary Public Underwriters •
»f„ - Revised 01.26.10
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APPROVED
, .1 • : �` ' CITY OF ATLANTIC BEACH
' !v` {! l:{ 'fir •!'' 4,� ; B U!'LDINCC+�rOFFICE •
•
•
' EB 10199
I
. n
•
CITY OF ATLANTIC BEACH
l 1E / BUILDER AFFIDAVIT
I. FLORI REQ 1 "CONSTRUCTION
CONTRACNTRAC UIRES OWNER BUILDER TO ACKNOWLEDGE THE LAW: TING
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.
il. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED.
III. 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 i
BUILDING DEPARTMENT (247 -5826) IF IN DOUBT.
V. STATEMENT AND I ( COMPLY WITH ALL THE ER THAT I HAVE EQUIREMENTS READ OR THE ISSUANCE DISCLOSURE AN
OWNER- BUILDER PERMIT.
ADDRESS PHONE NUMBER
PRINT NAME .. _ p
\ ci V� ` DATE
r SIGMA
• Before me this ` W day of I 1 L- 20a-in the county of
Duval, State of Florida, has personally ppeared herin by himself / herself and affirms that
all statements and declarations are true pd accurate.
L �< \f�
' ,
Notary Public at Large, State of ,County of 1
0 Personally Known -'•~
P ced Identification - . _,
du -
` � t r �i�!"..".�h SHIRLEY 1. GRAHAM
Notary ignature: ,,t . 4 ` I rimer iwH ,, ,,° MY COMMISSION DD 957760
ry + ..► • Nur ';rl1 EXPIRES: February 14, 2014
fi df o Bonded Thru Notary Public Underwriters
F: B ff
LDG /Owner -Builder r Aadavit; REVISED: 4/ 6/2009 r ^ '
City of Atlantic Beach APPLICATION NUMBER
y Building Department (To be assigned by the Building Department.)
) 800 Seminole Road ..,;.
/ r Atlantic Beach, Florida 32233 -544
.
Phone (904) 247 -5826 Fax (90 247 -5114 /,'"' r E -mail: building- dept @coab.us � 7 s , • Date routed: ` � -
City web -site: http: / /www.coab.us • p ail
APPLICATION REVIEW ‘•• TACKING FORM
/ J
Property Address: `� f Ra/ fiVL Department review required Yes No
p Buil _
Applicant: e a) L`/� ( & Zoning
- // Tree Administrator
Project: CO r �, C ublic Wo
blic Utilit
Public Safety
Fire Services
a..,.ae.;�.ra- -4-?.._ t�" ez..1" ...dut ,. .v+�. •.A..e.. __ n .n..- - E._' .�, j:2'_
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:
APPLICATION STATUS
Reviewing Department First Review: [ Approved. ['Denied.
(Circle one.) Comments: ' 1 /(
BUILDING
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 i-.eview: Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247 -5826 Fax (904) 247 -5845
Job Address: ...7 ( \ 0E-- Permit Number:
Legal Description Parcel # .
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work 5 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
If an existing structure, is a fire sprinkler system installed? (Circle one): Yes No N /A
Florida Product Approval #
For multiple products use produ app rove orm •
Describe in detail the type of work to be performed: C c l� 1 .L ,
Property Owner Information:
Named a v '� _r- s•x—Dc . k i∎, Addre s: _
City ( c State ' Zip 223 -'Phone e l 0'4. (, S S J L-( 3
E -Mail or Fax # (Optional) I
Contractor Information:
Company Name: Qualifying Age •
Address: City State Zip
Office Phone Job Site/ Contact Number Fax #
State Certification/Registration #
Architect Name & Phone #
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 ork 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 if work is not commenced within six (6) months, or if construction or work is suspended or abandoned for a� period of six (6) months at any time after
work is commenced. 1 understand that separate permits must be secured for Electrical Work, Plumbing, Signs, Wells, Pools, Furnaces, Boilers, 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 certify that I have read and examined this a plication 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 cot truction or the performance of construction.
Signature of Owner t` - , A to -a Signature of Contractor
Print Name c ---" ^ .t - Print Name
Swor to_and subscribed bef e Sworn to and subscribed before me this , !i . ` of , • ge ,r 1, , 20I this Day of , 20
Obalmfillislilailbiled
, SHIRLEY L. GRAHAM
Notai ub �c �I J o i�!F' ."f n�;. ,j : ,,_ . -:. , Doss77s0 -'
y `., EXPIRES: February 14, 2014` `� 3 Public
{ '' : d:• Bonded Thru Notary Public Underwriters •
�........�.. -.t Revised 01.26.10