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55 Forrestal Cir 2013 roof CITY OF ATLANTIC BEACH j 800 SEMINOLE ROAD J ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 �J1119'� Application Number . . . . . 13-00002072 Date 2/05/13 Property Address . . . . . . 55 FORRESTAL CIR Application type description RESIDENTIAL ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 7500 ---------------------------------------------------------------------------- Application desc reframe and sheath ---------------------------------------------------------------------------- Owner Contractor ------------------------ ------------------------ ECHEVARRIA LINDA A & RICHARD OWNER 55 FORRESTAL CIR S ATLANTIC BEACH FL 322333323 --- Structure Information 000 000 REFRAME AND SHEATH NEW ROOF Occupancy Type . . . . . . RESIDENTIAL ---------------------------------------------------------------------------- Permit RESIDENTIAL ALT/OTHER Additional desc . . Permit Fee . . . . 90 . 00 Plan Check Fee 45 . 00 Issue Date . . . . Valuation . . . . 7500 Expiration Date . . 8/04/13 ---------------------------------------------------------------------------- Special Notes and Comments 2010 FLORIDA BUILDING CODE, 2008 NATIONAL ELECTRIC CODE *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 90 . 00 90 . 00 . 00 . 00 Plan Check Total 45 . 00 45 . 00 . 00 . 00 Other Fee Total 4 . 00 4 . 00 . 00 . 00 Grand Total 139 . 00 139 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. fILE COPY PRODUCT APPROVAL INFORMATION SHEET PAIS FOR THE CITIOF J/Y► YN VILL .,,y `( (Revised-July 8,2008) ^ ► ��rt t l'��A 60 I� Permit#: L Project Name: Project Address As required by Florida Statute 553.842 and Florida Administrative Code 913-72, please provide the information and product approval number(s)for the building components listed below asapplicable not know thbuilding ing conproducapproval ructionroject or he pyer the nmit umber listed above. You should contact your product supplierif y applicable listed products. Information regarding statewide product approval may be obtained at: http://www.floridabuilding.org. See Bulletins G-25-04 and G-03-05 for more information. Product escrip ion or �Kuo ucCategory/Subcategory Manufacturer Model No. Limits of Use Apoval# Local# A. EXTERIOR DOORS 1. Swinging 2. Sliding 3. Sectional 4. Roll up 5.Automatic 6. Other: B.WINDOWS 1. Single hung 2. Horizontal slider 3. Casement 4. Double hung 5. Fixed 6. Awning 7. Pass-through 8. Projected 9. Mullion 10. Wind breaker 11. Dual action 12. Other: C. PANEL WALL 1. Siding 2. Soffits 3. EIFS 4. Storefronts 5. Curtain walls 6. Wall louvers 7. Glass block 8. Membrane 9. Greenhouse 10. Synthetic stucco 11. Other. Page 1 of 3 Printed Date: 7/10/2008 Category/Subcategory Manufacturer Product Description Limitation of Use State# Local# D. ROOFING PRODUCTS Q M z� 1.Asphalt shingles ,. 2. Underlayments r l>1 ` ��i 14 3. Roofing fasteners 4. Nonstructural metal roof 5. Built-up roofing 6. Modified bitumen 7. Single ply roofing 8. Roofing tiles 9. Roofing insulation 10. Waterproofing 11. Wood shingles/shakes 12. Roofing slate 13. Liquid applied roofing 14. Cement-adhesive coats 15. Roof tile adhesive 16. Spray applied polyurethane roof 17. Other: E. SHUTTERS gColoniall els 5. Roll-up 6. Equipment 7. Other: F. STRUCTURAL COMPONENTS 1.Wood connectorlanchor �/?f, 2.y��s- ` 1p� ;vv�IG- 3..Engineered-lumber 4:-Raisin - --` _ 5. Coolers-freezers 6. Concrete admixtures 7. Material 8. Insulation forms 9. Plastics 10. Deck-roof 11. Wall 12. Sheds 13. Other: Page 2 of 3 Printed Date: 7/10/2008 Category/Subcategory Manufacturer Product Description Limitation of Use State# Local# G. SKYLIGHTS 1. Skylight 2. Other: H. NEW EXTERIOR ENVELOPE PRODUCTS 1 2 In addition to completing the above list of manufacturers, product descriptions and State approval numbers for the products used on this project, it is the Contractor's or Authorized Agent's responsibility to have a legible copy of each manufacturer's printed instructions, along with the list above, on the job site available to the inspector. The products listed below did not demonstrate product approval at time of plan review. I understand that before these products can be inspected, they must be submitted for review for code compliance and approved by a Plans Examiner. This form will be revised to include each new product in the categories listed above and will be highlighted to indicate the new products and required information. Contractor/Authorized Agent: +C�`lUfG'� � �ev'(t(� +o'i ' (Print) (Signature) Company Name: Mailing Address: j� City: J�}�0.1`� �C �� � State: Zip Code: J3 j Telephone Number. L5& Fax Number: Cell Phone Number: CIC U a��� E-mail Address: � �'�t� CIC, Printed Date: 7/10/2008 Page 3 of 3 . ....w. ."!!'w2/vs. fr¢.-MM,CYC-•..�v«._ .� ....fw0*7 CITY OF ATLANTIC BEACH MWER BUILDER AFFIDAV[ bib I. 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 WITm 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. i 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 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. ADDRESS �— PHONE NUMBER 7 / r r PRIN AME V1111URE 22,,,, � DATE 30 Before me this day of A Q-tt L_QSES6 1 20 1 2 J in the county of Duval,State of Florida,has personally appeared herin by himself/herself and affirms that all statements and declarations are true and accurate. Notary Public at Large,State of�\r�"r. .County of V 0��- '>"••., COWISIA JACKSON 2 MY COMMISSION#EE 06434 _ EXPIRES:June 14,2015 Personally Known BW ThN Notary Public Underwriters ❑Produced Identi5�cabon- Notary Signatu2: F:BLDG/Owner-Builder Affadavit REVISED: 4/16/2009 I rs' +Yr,_a City of Atlantic Beach APPLICATION(NUMBER 800 Seminole Road t Buildingeir Department (To be assigned by the BW*V DqM mt) `K Atlantic Beach.Florida 32233-5445 Phone(,%4)247-5826 - Fax(904)247-5345 r,Jiiygr E-mail: building-deptacoab_us Date routec / City web site: http:l/www_coab.us APPLICATION REVIEW AND TRACKING FORMA Property Address: -Dll-;g;��/�� I,e De rtment review uked Y No Building Applicant: SGV-72�-,e /�pr��j�L'�� Planning&Zoning J�, Tree Administrator Project: /gym � �,CaPublic Works Public Utilities o Public Safety Fire Services Review fee $ Dept Signature Other Agency Review or Permit Required Review or Receipt Date Ve Florida Dept.of Environmental on of Permit rified By 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: roved. ❑Denied. (Circle one.) Comments: i B�Ut!_�DiNG� L C ` PLANNING&ZONING Reviewed by:—> Date: 31-13.J1–/ 3 ' TREE ADMIN. Second Review. QApproved as revised. E]Derfed. PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FERE SERVICES Third Review: ❑Approved as revised. ❑Denied. Comments: Reviewed by: Date: €?evfs;-d 07rZ7/10 BUILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Road, Atlantic Beach, FL 32233 Office (904) 247-5826 Fax (904) 247-5845 Job Address: cc)s /U(fe64oIA G cc ` - Permit Number: Legal Description VO-So 3�-as '0),01 Parcel# Floor Area o q. t. Sq.Ft Valuation of Work$ OCA Proposed Work heated/cooled non-heated/cooled Class of Work(circle one): New Addition GteratiDRepair Move Demolition pool/spa window/door Use of existing/proposed structure(s)(circle one): Commercial If an existing structure,is a fire sprinkler system installed? (Circle one): Yes No N/A Florida Product Approval# For multiple products use product approva orm _ Describe in detail the type of work to be performed: 12e CCS- (ArJ .04 (b t)<�tx Property Owner Information: _ Name: L Ada 0?1Clnccj cckww i C, Address: S t�{�"5-�t ( CPr City u,Jl i C State_CZip 3.03 Phone 5611-0`1G, - 3 E-Mail or Fax#(Optional) Q_Ii V 03 uO LK(A Contractor Information: Company Name: Ov�c���u���e� Qualifying Agent: Address: City State Zip Office Phone Job Site/Contact Number Fax# State Certification/Registration# Architect Name&Phone# Engineer's Name&Phone# TbS i b tD4V>eC,6"t 09- 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 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 thisjurisdiction. This permit becomes null and work er void o wmenced I understand that separate permits muor st be secuconstruction or work is suspended or red for Electrical-Work,Plumbing, Signs,aWellsoPo Pools, Ftirnacesmontls at,Boilers,Heaime ters, 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 here b 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.)Vwork will be complied with whe speci:ed herein or not. The granting of a permit does not presume to gave as to violate or cancel the provisions of any other federal,stat law re ating construction or the performance of construction. Signature of Owner Signature of Contract r Print Name / �r1r►'�.� Print Name ......... �ll/1...... f!!/C.( !. ..................................... ?...!(..................................................................................... Before me Before me 20 3 this 3 Day of?O-Ts" �., 20 \3 this Day of Not �c N �,�� liC PATROA PA JACKSON .L W COMMISSION ti EE 064342 �.; W COMMISSION/EE 064342 •. EXPIRES:June 14,2015 is ed 10.24.12 EXPIRES:June 14,2015 i ;fir• WWed Tom+Nam Public Uader olWs Balled Thru Notary Pubk UmWwrftm Fo o� S...TOP WORK CITY OF ATLANTIC BEACH BUILDING AND ZONING DEPARTMENT NOTICE Loivd V This building has been inspected and: ®' General Construction ❑ Mechanical ❑ Concrete and Masonry ❑ Electrical ❑ Plumbing ❑ Gas Piping IS NOT ACCEPTED CORRECT AS NOTED BELOW, BEFORE ANY FURTHER WORK P vyl Gt t�ZoP v .�fl d u✓ �� ty ' '1 DO NOT REMOVE THIS NOTICE Inspector: Date: l 2 Failure to respond to this Notice within 10 days will result in this violation being forward to the CODE ENFORCEMENT BOARD. The posting of this Placard by its contents shall serve as due noticse,X- '' SENDER: COMPLETE THIS SECTION �; COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restrlcted Delivery is desired. ■ Print your name and address on the reverse X ❑Agent so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, B Received Printed Name) C. Date of Delivery or on the front if space permits. 1. Article Addressed to: D. I > ' rent from item 1? ❑Yes ,enter deli dress below: ❑No 'Q JV 5NJ �� 3. Se 13 Certified Mail ❑Express Mail ❑Registered O Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Feel 2. Article Number E3 Yes (Transfer from service 7011 2000 0002 0346 6671 PS Form 3811,Feb Domestic Return Receipt 102595-02-M-1540 11-S. Postal CERTIFIED MAILW RECEIPT f` (Domestic Mail Oinsurance nly,No Coverage ..0 M Postage $ 0 ru Certified Fee M Return Receipt Fee Postmark C3 (Endorsement Required) Here O Restricted Delivery Fee Q (Endorsement Required) O M Total Postage&Fee RJ r-1 Sent To ' r-R O •-- Apt.No.------•-----------•---•Street, ; •--•"------------•----- r� or PO Box No. --------------- -------------------- - City,State,ZIP+4-�--•---------""-"" :r0 August 2006 —See Reverse for in-structin— CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 PHONE (904) 247-5855 January 4, 2013 CERTIFIED MAIL RETURN RECEIPT REQUESTED Linda A. Echevarria 55 Forrestal Circle S Atlantic Beach, Florida 32233-3323 RE: Notice of Violation— International Property Maintenance Code, Roofs 55 Forrestal Circle S, Lot 1, Block 1, Atlantic Beach Villa Unit NO 1, Atlantic Beach RE#17737-0000 CASE NO. 90212 ` Vy Dear Ms. Echevarria: J 1CM/0 Please be advised, Atlantic Beach Code Enforcement has found the BuilCiug11"i-t-s-- city be in violation of the International Property Maintenance Code, Ct D� City of Atlantic Beach, Code of Ordinances to wit: Section 304.7—Roofs and Drainage. The roof and flashing shall �� l defects that admit rain. Roof drainage shall be adequate to prevent (/ the walls or interior portion of the structure. Roof drains, gutters a ppt/ maintained in good repair and free from obstructions. Roof water v/ manner that creates a public nuisance. (inadequate, substandard www.icmarc.org 1-800-669-7400 This letter requests you comply by replacing your roof within 1 _ this notice and call to schedule an inspection when repairs are completed. If the violation is corrected and then recurs or if the violation is not corrected by the time specified in this notice this case may be presented to the Atlantic Beach Code Enforcement Board even if the violation has been corrected prior to the board meeting. The Code Enforcement Board may impose fines up to two hundred fifty ($250.00) dollars per day for each day the violation is not corrected. Upon completing the corrective action required, it is your responsibility to contact Atlantic Beach Code Enforcement and arrange for an inspection to verify compliance. It Page 2 55 Forrestal Circle South January 4, 2013 It is our goal to enforce the codes and ordinances of the City of Atlantic Beach and protect the health, safety and welfare of the City, and accordingly, your cooperation in this matter is greatly appreciated. Please contact Atlantic Beach Code Enforcement at 904 247-5855 if you have any questions or need additional information. Sincerely, Deborah White CODE ENFORCEMENT OFFICER J r Olt ' Compliance Investigation Form r � v Investigation# I Date of Request: , Time of Request: Name of Person Making Request: Address: Phone # Investigation Type Location (Address) of Violation: Property Owner: i P7C� VIOLATIONS: X-b 2 S Action Take J Legal Description: RE#: Compliance: F:\Code Enforcement\Compliance Investigation Form.doc Oct 9 2009 .Property Appraiser- Property Details Page 1 of 2 ECHEVARRIA LINDA A Primary Site Address Official Record Book/Page Tile# 55 FORRESTAL CIR S 55 S FORRESTAL CIR 08406-02351 9417 ATLANTIC BEACH, FL 32233-3323 Atlantic Beach FL 32233 ECHEVARRIA RICHARD 55 S FORRESTAL CIR Property Detail Value Summary ._ ...... RE# 171737-0000 2017 reMed ? 13 In Piss Tax District USD3 Value Method CAMA CAMA _ ..- - Total Building Value $79,663.00 ;$79,046.00 Prop .Use 0100 SINGLE FAMILY __ ...... . _ .... _......... #of Buildings 1 Extra Feature Value $5,793.00 $5,723.00 ........... _ _. ._. .___ ._ _.._... _. ....__..... ............. Legal Desc. 30-56 38-2S-29E Land Value(Market) :$39,150.00 $39,150.00 ATLANTIC BEACH VILLA UNIT NO 1 . and MalUe .. (Agricl $0.00 $0.00 Sltbdiveslop 03124 ATLANTIC BEACH VILLA#01 Just(Market)Value j$124,606.00 $123,919.00 Total Area 8581 Assessed Value $81,532.00 $81,532.00 _.... ___ . ._._ .......................................... _ ... _ _ 9 property g _ . .. Amt i$43,074.00/$0.00 $42,387.00/$0.00 The sale of this property may result in highertaxes.For more information oto Cap Diff/Portability _ Save Our Homes and our Prnppity Tax Fstamp or.Property values,exemptions and other Exemptions i$50,000.00 See below information listed as'In Progress'are subject to change.These numbers are part of the 2013 _ working tax roll and will not be certified until October.Learn how the Property Appraiser's Taxable Value $31,532.00 See below Office values property. Taxable Values and Exemptions—In Progress If there are no exemptions applicable to a taxing authority,the Taxable Value is the same as the Assessed Value listed above in the Value Summary box. County/Municipal Taxable Value SIRWMD/FIND Taxable Value School Taxable Value Assessed Value $81,532.00 Assessed Value $81,532.00Assessed Value $81,532.00 .............................................................................................................. ................................................................................................................. .............................................................................................................. Homestead Exemption(HX) -$25,000.00 Homestead Exemption(HX) -$25,000.00 Homestead Exemption(HX) -$25,000.00 ................................................................................................................. ................................................................................................................. .............................................................................................................. Amend 1 Homestead(HB) -$25,000.00 Amend 1 Homestead(HB) -$25,000.00 Taxable Value $56,532.00 Taxable Value $31,532.00 Taxable Value $31,532.00 Sales History Book/Page I Sale Date Sale Price Deed Instrument Tvce Code ;oualifled/Unqualified Vacant/Improved 08406-02351 7/30/1996 $55 000.00 WD-Warranty Deed Qualified Improved 06179-01960 8/13/1986 1$34,000.00 WD-Warranty Deed Unqualified Improved Extra Features LN Feature Code Feature Description Bldg. Length Width j Total Units Value 1 DKWR2 1 Deck Wooden 1 40 40 1,600.00 $5,360.00 2 GZSR2 Gazebo Standard 1 8 :8 .64.00 $363.00 Land&Legal Land Legal LN j Code Use Description �Zoning _Front Depth Category ,Land Units �LandType I Land Value LN�Legal Description 1 0100 RES LD 3-7 UNITS PER AC ARG-3 '87.00 103.00 ;Common 87.00 Front Footage�$39,150.00 1 30-5638-2S-29E 2 ATLANTIC BEACH VILLA UNIT NO 1 3 LOT 9 BLOCK 1 Buildings Building 1 _ Building 1 Site Address Element Code Detail 55 S FORRESTAL CIR Atlantic Beach FL 32233 Exterior Wall 17 ; 17 C.B.Stucco F '� Exterior Wall 6 6 Vert Sheet Siding ( �AoJ Building Type 0101-SFR 1 STORY SOH Roofing Structure 3 3 Gable or Hip �_p I Year Built1961 Roofing Cover 2 2 Rolled Comp I TDI, -- _-- Building Value 1$79,046.00 Interior Wall E 5 j 5 Drywall I eas Int Flooring 11 11Ceramic Clay Tile As 1 Gross Area Heated Area Effective Area Int Flooring 14 14 Carpet Addition 240 240 216 Heating Fuel- 4 4 Electric Addition 120 120 108 I Heating Type 4 4 Forced-Ducted Addition 100 100 90 I Air Conditioning 3 j 3 Central Addition 48 48 43 Base Area 925 925 925 i Element�— Cod http://apps.coj.net/pao_propertySearchBasic/Detail.aspx?RE=l 717370000 12/17/2012 NOTICE OF COMMENCEMENT (PREPARE IN DUPLICATE) Permit No. Tax Folio No. /7'� ✓� 7 State of 61 County of rbc_ To whom it may concern: The undersigned hereby informs you that improvements will be made to certain real property,and in accordance with Section 713 of the Florida Statutes,the following information is stated in this NOTICE OF COMMENCEMENT. Legal description of property being improved: Address ofppropertyeing improved: 3a�� General description of improvements: Owner c IC�C��CtrC, �C41C1tG�C`i Address Owner's interest in site of the improvement ��YY,bhGl rtC Fee Simple Titleholder(if other than owner) Name Address Contractor `�b` 'Address C ' Phone No. FaNo. 76 rety - of any} Amount of bond Address S Phone No. Fax No. Name and address of any person making a loan for the construction of the improvements. Name Address i Phone No. Fax No. Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other I documents may be served: Name Address Phone No. Fax No. In addition to himself,owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 713.06(2)(b),Florida Statutes.(Fill in at Owner's option). Name Address Phone No. Fax No. Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a different date Is specified): OWNER THIS SPACE FOR RECORDER'S USE ONLY .�� Signed: T�--DATE /~ Before sig_ of in the _ oun f Duval.State of odds,t as personalty app ared Doc#2013031930,OR 6K 16242 Page 481. hi se/herself and affirms that all statements and dec arab s pATRK;IA JACKSON Number Pages:1 are true and accurate :t = I MY COMMISSION t EE 064342 Recorded 02'05.-12013 at 09:56 AM. EXPIRES:June 14,2015 ' Bonded Thru Ndar)'Public Underwmers Ronnie Fussell CLERK CIRCUIT COURT DUVAL ,Rf„"�' COUNTY RECORDING$10.00 NotaryPublic a,Large,SlateofFr�+. � County of My commission expires: or Personally Known Produced Identification