315 Skate Rd (vault) CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5826
Application Number . . . . . 09-00000341 Date 3/19/09
Property Address . . . . . . 315 SKATE RD
Application type description FENCE PERMIT
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
----------------------------------------------------------------------------
Application desc
replace 6ft fence
----------------------------------------------------------------------------
Owner Contractor
------------------------ ------------------------
HALL OWNER
315 SKATE ROAD
ATLANTIC BEACH FL 32233
----------------------------------------------------------------------------
Permit . . . . . . FENCE PERMIT
Additional desc . . REPLC 6 FT FENCE
Permit Fee . . . . 35 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 9/15/09
----------------------------------------------------------------------------
Special Notes and Comments
*2004 FLROIDA BUILDING CODE W/ 105- 106 SUPPLEMENTS .
2004 FLORIDA BUILDING CODE - RESIDENTIAL.
2005 NATIONAL ELECTRICAL CODE.
*ALL FENCES OR ENCLOSURES OF LAND SHALL BE SUBSTANTIALLY
CONSTRUCTED.
*SCHEDULE FINAL INSPECTION ONCE FENCE HAS BEEN COMPLETED.
PERMIT AND APPROVED SURVEY MUST BE AVAILABLE FOR FINAL
INSPECTION.
*EMAIL INSPECTION REQUESTS TO BUILDING-DEPT@COAB.US
----------------------------------------------------------------------------
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.
MAP SHOWING BOUNDARY SURVEY OF
LOT BLOCK -2 ' - - SHOWN ON MAP OF
F /-".= 4
ZA 60) W.
=4,= 42T !:!5 ONIT 7WO . A .
AS RECORDED /M PLA T BOOK PA GES /69 0 OF THE CL4Tn��yr g
CERTIFIED TO: ��&—Z:54q
-F(/90r AllryP� LT
4c,- WA MCA/
City of Atlantic Beach
Planning and Zoning Deparbymft
This approval verifies Compliance with appffaft
Izoning, subdivision and other local land
development regulations, but does not constitute
approval for the issuance of permits. Compliance
with Florida Building Code and all other applicable
local, State and Federal permitting requirements
must be verified by signature of the City of Atlantic
Beach Building Off' ial prior to the issuance of S
0 r /-,r. Building Permit.
p(rtved By:
omm eve opment
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OX A TE
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233 09-
F7
OFFICE:(904)247-5826 e FAX NO.:(904)247-5845
BUILDING-DEPT@COAB.US
BUILDING PERMIT APPLICATION DUVAL COUNTY
1�JOB ADDRESS: 2-VALUATION OF WORK: 13.SQ-FT-UNDER ROOF
3 1 S S�<J� -�rv"4 1
4.LEGAL DESCRIPTION: 5.CLASS OF WORK:
6�USE OF STRUCTURE:'-:.,�
LOT-a BLOCK Zq SUB DIVISION aj ?6�1 11 NEW BUILDING 13 DEMOLITION El RESIDENTIAL
7.DESCRIPTION OF WORK: 11 ADDITION 11 CONVERTING USE 0 COMMERCIAL
11 ALTERATION 11 ACCESSORY BLDG. 8.FIRE SPRINKLER'
11 REPAIR 11 POOL/SP 10-1 - El YES 0 N'11-
- "
Re-))lo'c'e- 4�-nce IA-1 11 MOVE --A
I PROPERTY OWNER, CONTRACTOR: XOTHER PILZr.10 EINO
(Y ' ARCHITECT I ENGINEER:
9 NAME 15.COMPANY NAME 23 COMPANY NAME
16.NAME 24.LICENSEE NAME
10.ADDRESS: 17,STATE OF FLORIDA LICENSE NO, 25.STATE OF FLORIDA LICENSE NO.
3 (<Cupp-
18.ADDRESS: 26.ADDRESS:
12. 0.FAX NO.: 27.OFFICE PHONE: 28.FAX NO.:
11�OFFICE PHONE: FAX NO.: 21 19.OFFICE PHONE:
13.CELL PHONE: 21.CELL PHONE: 29.CELL PHONE
11.EIA71AD'DRESS: 22.EMAIL ADDRESS: 30.EMAIL ADDRESS:
5 ctlIia rl'�,ko(,)
FEE SIMPLE TITLE
(IF OTHER THAN OMER) BONDING COMPANY: MORTGAGE LENDER:
31 NAME 31 NAME 35 NAME
5-U.S6(JA 04- 117qrKe-VlCC(
32.ADDRESS:
1� 34.ADDRESS 36.ADDRESS:
Application is hereby made to obtain a permit to do the work and installations as indicated. I 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. I understand that separate permits must be secured for
Electrical Work,Plumbing,Signs,Wells,Pools,Furnaces,Boilers,Heaters,Tanks, Air Conditioners,etc.
OWNER'S AFFIDAVIT- I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
laws regulating construction and zoning. I will not occupy or use the referenced building or any part therof,until all inspections are finaled and
prior to obtaining a ceffificate of occupancy or completion issued by the building official,as required by law.
WARNING TO OWNER:
YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY 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 ORAN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
OWNER or AGENT CONTRACTOR
(IfAgent,Power ofAtiomey orAgency,�etter Required) (Qualifier Only)
Date: Signed: Date:
Signed:
Before me this_day of 2009 in the county of Before me this_day of 2009 in the county of
Duval,State of Florida,has personally appeared Duval,State of Florida,has personally appeared
herin by himself/herself and affirms that all statements and declarations are herin by himself/herself and affirms that all statements and declarations are
true and accurate. true and accurate.
Notary Public at Large,State of jr--I- County of Notary Public at Large,State of_,County of
11 Personally Kno El Personally Known
0 Produced Idel.1=- 11 Produced Identification-
Notary Signature: Notary Signature:
I
otary Public State of Florda
Y Commission Expires Feb 14,2010
Commission #DD 518533
BLDG01 Permit Applic.2 Bonded By National Notary Assn.
City of Atlantic Beach APPLICATION NUMBER
Building' Department (To be assigned by the Building Department.)
800 Seminole Road
Atlantic Beach, Florida 32233-5445
Phone (904)247-5826 - Fax(904) 247-5845
E-mail: building-dept@coab.us Date routed: -3112
City web-site: hftp://www.coab.us I
APPLICATION REVIEW AND TRACKING FORM
papartnWrit review re Yes No
Property Address: Akning &Zonind�)
Tree Administrator
Applicant: 0 OJ A/f -15'u—blic Worlk�)
�ITu_blic Utilities)
Project: 7- 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:
APPLICAPON STATUS
Reviewing Department First Review: KrA-Pproved. ODenied.
(Circle one.) Comments:
BUI Q
PLANNING &ZONI 2
Reviewed by: Date:
TREE ADMIN.
PUBLIC WORKS Second Review: FlApproved as revised. DDenied.
Comments:
PUBLIC UTILITIES
PUBLiCSAFFTY
FIRE SERVICES Reviewed by: Date:
Third Review: FlApproved as revised. [_�Deniecl.
Comments:
Reviewed by: Date:
CITY OF ATLANTIC BEACH
F7 800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233 09
OFFICE:(904)247-5826 e FAX NO.:(9G4)247-5845
BUILDING-DEPT@COAB US
BUILDING PERMIT APPLICATION DUVAL COUNTY
—1-JOB ADDRESS: 2.VALUATION OF WORK: 3.SO.FT.-UNDER ROOF
313 SL�� -�rvx�' 1
—4.LEGAL DESCRIPTION: .5.CLASS OF WORK: 6.USE OF STRUCTURE:
El NEW BUILDING El DEMOLITION El RESIDENTIAL
LOT-L BLOCK!N SUB DIVISION 11 ADDITION 11 CONVERTING USE 10 COMMERCIAL
7.DESCRIPTION OF WORK, El ALTERATION 11 ACCESSORY BLDG, 8.FIRE SPRINKLER�
11 REPAIR 11 POOL/SPA S El'�/Al
El MOVE �(OTHER NO
I PROPERTY OWNER: IV CONTRACTOR: ARCHITECT I ENGINEER:
9.NAME 15.COMPANY NAME 23 COMPANY NAME:
+6A\ 16.NAME 24.LICENSEE NAME
10.ADDRESS: P4 17,STATE 01 FLORIDA LICENSE NO,: 25.STATE OF FLORIDA LICENSE NO.:
S18.ADDRESS: 26.ADDRESS:
11.OFFICE PHONE: 12,FAX NO. q S3 19.OFFICE PHONE: 20.FAX NO.: 27,OFFICE��FAX NO.:
13.CELL PHONE: 21.CELL PHONE: 29.CELL PHONE:
!�qy- GS( -7QJZ
14.EMAIL ADDRESS: 22.EMAIL ADDRESS: 30 EMAIL ADDRESS:
5L'��neCtilap
FEE SIMPLE TITLE HOLDER: BONDING COMPANY: MORTGAGE LENDER:
(tF OTHER THAN OWNER)
31.NAME 31 NAME 35.NAME
OoLrie rli� FqMe-VICC(
32.ADDRESS: 34.ADDRESS: 36.ADDRESS:
-315 2S.4-e' 1�oaj - I
Application is hereby made to obtain a permit to do the work and installations as indicated. I 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. I understand that separate permits must be secured for
Electrical Work,Plumbing,Signs,Wells,Pools,Furnaces,Boilers,Heaters,Tanks, Air Conditioners,etc.
OWNER'S AFFIDAVIT- I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
laws regulating construction and zoning. I will not occupy or use the referenced building or any part therof, until all inspections are finaled and
prior to obtaining a certificate of occupancy or completion issued by the building official,as required by law.
WARNING TO OWNER:
YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY 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 RECORDING YOUR NOTICE OF COMMENCEMENT.
OWNER or AGENT CONTRACTOR
(if Agent,Power of Attorney or AgencyI-etter Required) (Qualifier Only)
Signed: Date: Signed: Date:
Before me this_day of 2009 in the county of Before me this_day of 2009 in the county of
Duval,State of Florida,has personally appeared Duval,State of Florida,has personally appeared
herin by himself/herself and affirms that all statements and declarations are herin by himself/herself and affirms that all statements and declarations are
true and accurate. true and accurat .
Notary Public at Large,State of County of Notary Public at Large,State of County of
0 P rsonally K 0 Personally Known
11 Produced[dent catio 11 Produred Identification-
Notary Signature: L" t UNANAM Notary Signature:
Otary Public-State of Florida
Y Commission Expires Feb 14,2010
Commission#DD 518533 C�w
Bonded By National Notary Assn.
BLDG01 Permit Application BI g: ISTD.-rZTWUNP 4-
City of Atlantic, Beach APPLICATION NUMBER
(To be assigned by the Building Department.)
Buildind Department
IMAP 3 2003
800 Seminole Road
z Atlantic Beach, Florida 32233-5445 9
Phone(904)247-5826 - Fax(904)247-5845
E-mail: building-dept@coab.us Date routed: L12
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
papartmpnt review required Yes No
Property Address: ��anninq &Zo-ning_:::)
Tree Administrator
Applicant: 0&J A/f Je- �70�ublficW�®rk
�eV_ublic
Project: L17- Jin 6 Public Safety
V 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 B averages and Tobacco
Other:
APPLICATION STATUS
XpReviewing Department Hirst Review-: pproved. DDenied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: (9� —Date:
TREE ADMIN.
PUBM VV(VK Second Review: FlApproved as revised. DDenied.
Comments:
PUB IC IES
PUBLIC SAFFTY
FIRE SERVICES Reviewed by: Date:
Third Review: FlApproved as revised. r-]Denied.
Comments:
Reviewed by: Date:_
APPLICATION NUMBER
City of Atlantic.Beach
Building Department (To be assigned by the Building Department.)
800 Seminole Road
i� Atlantic Beach, Florida 32233-5445 9
Phone (904)247-5826 - Fax(904) 247-5845
E-mail: building-dept@coab.us Date routed: -2112 h 2
City web-site: http://Www.coab.us
APPLICATION REVIEW AND TRACKING FORM
t review re uired Yes No
Property Address: '�/S' an inq &Zonin
Tree Administrator
Applicant: W A/f ublic or
ublic Utili
Project: Public Safety
Fire Services
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By._
Florida Dept. of Environme ital 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. F�Denied.
(Circle one.) Comments: k?l �, _55/r2-) Va I vct
PLANNING &ZONING
TREE ADMIN. Reviewed by: Date: 311 2/Oq
PUBLIC WORKS Second Review: FlApproved as revised. DDenied.
Comments:
PUBLIC UTILITIES
PUBUCSAFFTY
FIRE SERVICES Reviewed by: Date:
Third Review: F_]Approved as revised. F-IDenied.
Comments:
Reviewed by: Date:
.41 CITY OF
C Sew-CA-&;k"4
Office Ot Building Official
REQUEST FOR INS
Date 7 PECTION
Time
Received
A.M. Permit No.
M.
J b ss;
Owner'
Nam,
BUILDING CONCRETE cality,
Framing 'ac��t5
Re Rooting Foot LECTRI, L
ng L
Insulation D, Slabi a�A LUM13ING
C Lintel ED Rough iring
7emP Pole 0 Rough MECHANICAL
Final Top out Air Cond &
Mon. Sewer Heating
Fire Place
7bes. RE��OR I�SpEcTiON Pre Fab
Inspectio M Thurs.
F
Friday
Inspecto
r
A.M.
Final 1
nspectio
er I Icate of
OccuPancY E-,
Date
CITY OF ATLANTIC BEACH
DEPARTMENT OF BUILDING
800 Seminole Road -Atlantic Beach, FL 32233 - Tel: 247-5826 - Fax: 247-5877
ELECTRICAL PERMIT
PERMIT INFORMATION LOCATION INFORMATION
Permit Number: 18446 Address: 315 SKATE ROAD
Permit Type: ELECTRICAL ATLANTIC BEACH, FL 32233
Class of Work: ALTERATION Township: Range: Book:
Proposed Use: SINGLE FAMILY Lot(s): Block: Section:
Square Feet: Subdivision: ROYALPALMS
Est. Value: Parcel Nu.mbe,r-
Improv. Cost: L OWN E 111 N_F0 R M ATI 0_N_
Date Issued: 7/01/1999 i
Name: ASTON, CLYDE
Total Fees: 25.00 Address: 315 SKATE ROAD
Amount Paid: 25.00 ATLANTIC BEACH, FL 32233
Date Paid: 7/01/1999 Phone: (000)000-0000
Work Desc: REPLACE WIRE-TO Aj_C_
CONTRACTOR(S) APPLtCAMT ON FEES
MCDONALD ELECTRIC
PERMIT 25.00
,�4 -7 .Anspecdons,Requtred
FINAL ELECTRIC
NOTICE - INSPECTIONS MUST BE REQUESTED AT LEAST 24 HOURS PRIOR TO INSPECTION
BUILDING MATERIAL, RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE, AND
MUST BE CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER
"FAILURE TO COMPLY WITH THE CONSTRUCTION LIEN LAW CAN RESULT IN THE PROPERTY
OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS"
ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION
FOR VIOLATION OF APPLICABLE PROVISIONS OF LAW.
$25.0014
Date: 7/01/99 01 Receipt: 0068536
45.74
ATLANTIC BEACH BUILDIN CHECKS
80100003221000
CITY OF ATLANTIC BEACH, FLORIDA
Apprc)v*d APPLICATION FOR ELECTRICAL PERMIT
L
TO THE CHIEF ELECTRICAL INSPECTOR: DATE:_:D:� 19
imponTANT NOTICE:
IN CONSIDERATION OF PERMIT GIVEN FOR DOING THE WORK AS DESCRIBED IN THE FOLLOWING, VyE
HEREBY AGREE TO PERFORM SAID WORK IN ACCORDANCE WITH THE ATTACHED PLANS AND SPECIFICATIONS,
WHIC14 ARE A PART HEREOF, AND IN ACCORDANCE WITH THE ELECTRICAL REGULATIONS, CODES AND CITY OF
ATLANTIC BEACH ORDINANCES.
R
ELECTRICAL FIRM:
MASTER ELECTRICIAN SIGNATURE J()I
N AM E A D D R E SS:
-5" -1 - , _RFD_Box�
BLDG.SIZE
BETWEEN:-f--d2'r�
RES. ART. I comm. ( PUBLIC INDUS. ( NEW OLD REW.
ADDITION ( ) TRAILER ( TEMP. ( SIGNS ( ) S 0 F
SERVICE: NEW ( ) INCREASE ( REPAIR ( FEE
CONDUCTOR SIZE
SOPPER I L--t�LUM,
SWITCH On BREAKER AMPS
PH W VOLT RACEWAY
EXIST.SERV.SIZE I cz—z AMPS PH W ;'-YOVOLT RACEWAY
FEEDERS NO. SIZE NO. qz!ZE No.
SIZE
LIGHTING OUTLETS
RECEPTACLES CONCEALED OPEN TOTAL
CONCEALED OPEN
0-30 AMPS.
SWITCHES I-IQC) AMPS. TOTAL
INCANDESCENT
FLUORESCENT& M. V.
FIXEL) 0-100 AMPS, OVEn
APPLIANCES
Air ELL TRA
cr 'r)NING H*P* RATING H.P. RATING
COMP-MOTOR OTHER MOTORS
ANIPS CEIL HEAT: KW-HEAT
OVER
PHS No. I II.P. VOLTAGE PHS
7/
_00 V.
F'LASHERI
C IT Y 7
Yq&44914-c Beaa,4 jb
office of Building Official 121 a e rr
REQUEST FOR INSPECTION
Date.
Time
Received A.M. Permit No.
RM.
VUU Acloress
Owner's
Name Locality
CONCRETE
BUILDING CONCRETE ELECTRICAL
Framing Footing PLUMBING
R Roof S
a ing E Slab MECHANICAL
insulation L, tel L Te 0, r ng �'E Rough
Lintel e Top out Air Cond. &
Final El Sewer Heating
READY FOR INSPECTION Fire Place
Mon. Tues. We Pre Fab
Inspection M a 10 Thurs. Friday A.M
10�� A.M.
inspector Z�L �Rlvl.
— Final inspection
(S S./0 Certificate Of Occupancy E�:
Date
-pe
CITY OF
AWAafzz Vead 57&UW4
800 SEMINOLE ROAD
ATLANTIC BEACH,FLORIDA 32233-5445
TELEPHONE(904)247-5800
iAA1 FAX(%4)247-5805
March 1, 1996
Tammy L. & Blair E. Whitney
315 Skate Road
Atlantic Beach, FL 32233
Dear Mr. and Mrs. Whitney:
Our records indicate that you are the owner of the following property in the City of Atlantic
Beach, Florida:
315 Skate Road
a/k/a Lot 11, Block 24, Royal Palms 2A
RE#1 71679-0000
Investigation of this property discloses that I have found and determined that you are in
violation of City of Atlantic Beach Ordinance Chapter 12, Section 12-1-(1) i.e. dead bird in front
yard-, Section 12-11�3), i.e, Outside storage detrimental to the health of the community, Section
12-1-(7) i.e., Outside storage of household appliance; Chapter 24, Section 24-163, Outside
storage of boat in front yard-, Section 12-148), Unsanitary conditions-, Unpermitted shed on north
side of property, Chapter 24, Section 24-65. Please feel free to call me for further clarification.
You are hereby notified that unless the condition above described is remedied within
fifteen (15) days from the date of your receipt hereof, this case will be turned over to the Code
Enforcement Board.
Under Florida Statute 162.09, the Code Enforcement Board may impose fines of up to
$250.00 per day for a first violation and $500.00 per day for a repeat violation.
Sincerely,
48 d�W. G r
Code Enforcement Officer
KWG/pah
cc: Public Safety Director
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
PSR 3844
DEPARTMENT OF BUILDING
CITY OF ATLANTIC BEACH
PERMIT INFORMATION ------ -------- LOCATION INFORMATION ---
Permit Number : 8558 Address : 315 SKATE ROAD
Permit Type : MECHANICAL ATLANTIC BEACH , FLORIDA 32233
Class of Work : ALTERATION --- LEGAL DESCRIPTION ----------
Constr . Type : WOOD FRAME Lot : Block: Section:
Proposed Use : SINGLE FAMILY Township : RNG: 0
Dwellinos : 1 Code - 0 Subdivision: ROYAL PALMS
Estimated Value : $0 . 00
improv. Cost : $0 . 00
Total Fees : 874 .01-1
I,T--+- 7 4 .0 0
194
IN 2111jr) UPIAT P1114y
1- -------- OWNER INFORMATION ---------- ---- APPLICATION FEES -----
Ad, Name: BLAIF WHITING PERMIT $74 . 00
dress : 315 SKATE ROAD WATER IMPACT FEE $0 , 00
ATL7-,NTIC BE�ACH , FLORTDA 322-1-3 SEWER. IMPACT FEE S0 . 00
7-'hone -. ( 901 " 241-6727 WATER METER/TAP 80 � 00
RADON GAS-H . R. S . S0 . 00
CONTRACTOR INFORMATION ------ RADON CAB 5% $0 .00
ESTES HEATING & AIR CONDIT T I
Ad fa r 1E ITN
JAC-FISONVILLE BEACH , FL 3225T CROSS CONNECTION SO . 00
License , CACC-!5664-1 Type : 3 SEC H IMPACT FEE 80 .00
CONST . SURCHARGE S0 . 00
NOTES: SCHARGE/ATL . BCH . 0 .
NOTICE —ALL CONCRETE FORMS AND FOOTINGS MUST BE INSPECTED BEFORE POURING
PERMIT VOID SIX MONTHS AFTER DATE OF ISSUE
BUILDING MATERIAL, RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE,AND MUST BE
CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER
"FAILURE TO COMPLY WITH THE MECHANICS' LIEN LAW CAN RESULT IN
THE PROPERTY OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS.99
ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR
VIOLATION OF APPLICABLE PROVISIONS OF LAW.
BUILDING AND ZONING INSPECTION DIVISION
CITY OF ATLANTIC BEACH
ATLANTIC BEACH, FLORIDA 32233 � '5 �
APPLICATION FOR MECHANICAL PERMIT CALL-IN NUMBER
IMPORTANT — Applicant to complete all items in sections 1, 11, Ill. and IV.
LOCATION Street Address: Am, =Z'�6/r zfv
OF Intersecting Streets: Between And Irf
BUILDING
Sub-division
11. IDENTIFICATION — To be completed by all applicants ,
In consideration of permit qi�en for doing the work as described in the above statement we hereby agree to perform said work in accordance
with the attaclILecl plans and specifications which are a part hereof and in accordance with the City of Jacksonville ordinances and standards
of good practice listed there;n.
Nem* of Mechanical Contractors
Contractor (Print) C Master Z//
Name of
Property Owner 1611f,(r r-7
Signature of Owner Signature of
or AwAorized Agent Architect or Engineer
III. GENERAL INFORMATION
A, Ty"of ting fuel: E3. IS OTHER CONSTRUCTION BEING DONE ON
Bectric THIS BUILDING OR SITE? <;07 -7 'c!�-
(3 Gas—[3 LP [j Natural 0 Central Utility
IF YES, GIVE NUMBER OF CONSTRUCTION
C3 Oil PERMIT
E] O+her — Specify
IV. MICKANIC-All. EQUIPMENT TO BE INSTALLED NATU E-011F WORK
(Provide complef*list of components on back of this form) 7"Sesidential or El Commercial
0 H at Space 0 Recquod 0 Central 0 Flow El New Building
Condrfioning: [3 Room ".trel 3---E.isting Building
0 Duct System: Maf,9641 a67 L 0&4 1'e4'0� Thick acement of existing system
Maltifflum capacity C.f.m. Zw Installation(No system previously Installed)
13 lefrigrenst;on Extension or add-on to existing system
C) Cooling towff: Capacity 9-pi". Other — Specify
[3 Rre sprinkl*rs: Number of hoads
13 Elevator 0 manliff 0 Escalate_11num1w) THIS SPACE FOR OFRCE USE ONLY
0 Gasoline pumps -Inumber)
Cl Took. (number) Remarks
(3 LPG contain (numbor)
C] U*fired pmuure vasw
0 Boilers Permit Approved by Date_
13 Oths, — Specify Permit
LIST ALL EQUIPMENT
AM CONDITIONING AND REFRIGERATION EQUIPMENT
Number'Unitm Description XodW Number C!_qutdty Approving 7
Xaftufaetulw (TOM) ASeney
0'�-0 .19
2, 6
HEATING - FURNACES, BOILERS, FIREPLACES Capacity Approvillitlig
Number'Units D"Crtptim No"NUMber 111"Aufactow (am) Agency
/_U�/7.7-0 S ,V014Z
TANKS
Now X"y Nowinal Capwlty Type Liquid NIS1111111110111 at Serial Ap=g
&W Dblawsions Contained 3camdwtww No.
CITY OF ATLANTIC BEACH, FLORIDA
Approved by APPLICATION FOR ELECTRICAL PERMIT
TO THE CHIEF ELECTRICAL INSPECTOR: DATE:-- 19
IMPORTANT NOTICE:
IN CONSIDERATION OF PERMIT GIVEN FOR DOING THE WORK AS DESCRIBED IN THE FOLLOWING, WE
HEREBY AGREE TO PERFORM SAID WORK IN ACCORDANCE WITH THE ATTACHED PLANS AND SPECIFICATIONS,
WHICH ARE A PART HEREOF, AND IN ACCORDANCE WITH THE ELECTRICAL REGULATIONS, CODES AND CITY OF
ATLANTIC BEACH ORDINANCES.
ELECTRICAC FIRM: 15-(- 15%? MASTER ELECTRICIAN SIGNATURE JOURNEYMAtJ
NAME- -ADDRESS: RFD-BOX
BLDG.SIZE BETWEEN:
RES. (>4 APT. ( COMM.i PUBLIC INDUS. NEW( I OLD REW.
ADDITION ( TRAILER TEMP. SIGNS ( SQ. FT.
SERVICE: NEW( INCREASEtA REPAIR FEE
CONDUCTOR SIZE 2;Z6 AMPS /_5_Q COPPER ( ALUM. ('�<j
SWITCH OR BREAKER /S-10 AMPS PH '3 w -;-Y6 VOLT �YRACEWAY
EXIST.SERV.SIZE 0 AMPS PH .3 W VOLT RACEWAY
FEEDERS NO. SIZE IND. SIZE I NO. SIZE
LIGHTING OUTLETS CONCEALED OPEN TOTAL
RECEPTACLES CONCEALED OPEN TOTAL
0.30 AMPS. .100 AMPS.
SWITCHES
INCANDESCENT
FLUORESCENT&M.V.
FIXED 0-100AMPS OVER
APPLIANCES BELL TRANSF.
AIR H.P. RATING H.P. RATING
CONDITIONING COMP. MOTOR OTHER MOTORS AMPS CEIL HEAT: KW-HEAT
0-1 OVER
MOTORS H.P. VOLTAGE PHS NO. 1 H.P. VOLTAGE PHS
MISCELLANEOUS
TRANSFORMERS: UNDER 600 V. OVER 600 V.
NO. I KVA _j�NO. JKVA
NO. NEON TRANSF. NO. VA. MOTOR SIZE SWITCH FLASHER
EACH SIGN MA.
FORWARDED
$
TOTAL FE!�j
CIT'i' OF
24&,a4d& AC444-erm a- 1
Office of Building Official
REQUEST FOR INSPECTION
Date 7- 7-5? Permit No.
Time A V-1
Received PM
C_
Job Addr Locality
Owner's
Name -Contractor
BUILDING ELECTRICAL PLUMBING
Framing L7- Footing Rough Wiring Rough El Air Cond. &
Re Roofing L71 Slab Temp Pole Top Out Fj Heating
Insulation I-- Lintel Final 7� Sewer
Fire Place 71
Pre Fab
READY FOR INSPECTION
Mon. Tues. Wed. Thurs.
A.M.
Inspection Made P.M.
Inspector Final Inspecti rl
Certificate of ?ccu(.,ancy
Date
5371
DEPARTMENT OF BUILDING
CITY OF ATLANTIC BEACH
----- PERMIT INFORMATION LOCATION INFORMATION ---
Permit Number: 5371 Address: 315 SKATE ROAD
Permit Type: ELECTRICAL ATLANTIC BEACH, FLORIDA 3223,:
Class of Work: ADDITION ------ LEGAL DESCRIPTION ---------
Constr. Type: CONCRETE Lot : Block: Section :
Proposed Use: POOL/SPA Township: RNG: 0
Dwellings: 0 Code: 0 Subdivision :
Estimated Value: $0. 00
Improv. Cost : $0. 00
Total Fees: $35. 00
Amount Paid: $35. 00
`9 2
MMING Pool
OWNER INFukMATION - APPLICAT10i4 1-,EES -----
Name: W14ITNFY PERMIT $35. 00
Addresf,, 315 SKATI ROAD WATER IMPACT FEF $0. 00
ATLA111C REACH, FLORIDA _;EWER IMPACT FEE $0.00
(90-4 )247-2126 4ATER METER $0. 00
RADON GAS-H. R. S. $0. 00
CONTRACTOR INFORMATION RADON GAS - 5% $0. 00
Name: HABITAT ELECTRICAL CONTRACT WATER TAP $0. 00
i�ddress: 1.628 HAMMOCK CIRCLE WEST SEWER TAP $0. 00
JACKSONVILLE, FL 32225 HYDRAULIC SHARE $0. 00
icense i EPOC� Type: 0 RE-INSPECT FEE $0. 00
SEC. H IMPACT FEE
OTHER
NOTES:
NOTICE —ALL CONCRETE FORMS AND FOOTINGS MUST BE INSPECTED BEFORE POURING
PERMIT VOID SIX MONTHS AFTER DATE OF ISSUE
BUILDING MATERIAL, RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE,AND MUST BE
CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER
"FAILURE TO COMPLY WITH THE MECHANICS' LIEN LAW CAN RESULT IN
THE PROPERTY OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS."
ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR
VIOLATION OF APPLICABLE PROVISIONS OF LAW.
ATLANTIC BEACH BUILDING DEPARTMENT
By:
3-7
CITY OF ATLANTIC BEACH, FLORIDA
Approvod6y---� APPLICATION FOR ELECTRICAL PERMIT
TO THE CHIEF ELECTRICAL INSPECTOR: DATE:-5—1Z --lq /"z
IMPORTANT NOTICE:
IN CONSIDERATION OF PERMIT GIVEN FOR DOING THE WORK AS DESCRIBED IN THE FOLLOWING, WE
HEREBY AGREE TO PERFORM SAID WORK IN ACCORDANCE WITH THE ATTACHED PLANS AND SPECIFICATIONS,
WHICH ARE A PART HEREOF, AND IN ACCORDANCE WITH THE ELECTRICAL REGULATIONS, CODES AND CITY OF
ATLANTIC BEACH ORDINANCES.
�I�lq� �e-104r i�4 L c1"ernT'bra c 4o,.,-5
ELECTRICAL FIRM: MASIJIFR ELECTRICIAN-'--01 IRE JOURNEYMAN
RFD—BOX—
NAME ADDRESS: 21S'
BLDG.SIZE BETWEEN:
RES. (4< APT.( comm.( PUBLIC ( INDUS. NEW( OLD ( REW.
ADDITION TRAILER ( TEMPA SIGNS SQ. FT.
SERVICE: NEW( INCREASE ( REPAIR FEE
CONDUCTOR SIZE AMPS COPPER ALUMJ
SWITCH OR BREAKER AMPS PH W VOLT RACEWAY .
1.1.1,)2 Y-6 5*F–.(!I ,
EXIST.SERV.SIZE ,Zee) AMPS PH 3 W VOLT RACEWAY
FEEDERS NO. SIZE NO. SIZE NO. SIZE
LIGHTING OUTLETS CONCEALED OPEN TOTAL
RECEPTACLES CONCEALED OPEN TOTAL
0.30 AMPS. 31-100 AMPS.
SWITCHES
INCANDESCENT
FLUORESCENT&M.V.
FIXED 0.100 AMPS. OVER BELL TRANSF.
APPLIANCES
AIR H.P. RATING H.P. RATING
CONDITIONING COMP.MOTOR OTHER MOTORS AMPS ICEIL HEAT: KW-HEAT
I I I I
0-1 OVER
MOTORS H.P. VOLTAGE PHS NO. 1 H.P. VOLTAGE PHS
MISCELLANEOUS
11�00 Z--
TRANSFORMERS: UNDER 600 V. OVER 600 V.
N
INO. KVA 110. lKVA
..........E-j-[ ---
NO.NEON TRANSF. MA. MOTOR SIZE SWITCH FLASHER
EACH SIGN
FORWARDED
TOTAL FE!!j
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5826
Application Number . . . . . 08-00001154 Date 8/25/08
Property Address . . . . . . 315 SKATE RD
Application type description PLUMBING ONLY
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
----------------------------------------------------------------------------
Application desc
sewer connection
----------------------------------------------------------------------------
Owner Contractor
------------------------ ------------------------
LANAN, J. V. F.W. FAIR PLUMBING CO.
315 SKATE ROAD P.O. DRAWER 51558
ATLANTIC BEACH FL 32233 JAX BEACH FL 32250
(904) 241-7191
----------------------------------------------------------------------------
Permit . . . . . . PLUMBING PERMIT
Additional desc . .
Permit Fee . . . . 42 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 2/21/09
----------------------------------------------------------------------------
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 42 . 00 42 . 00 . 00 . 00
Plan Check Total . 00 . 00 . 00 . 00
Grand Total 42 . 00 42 . 00 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
-* - �0� '
CITY OF ATLANTIC BEACH ......T-F_
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233 08-
OFFICE:(904)247-5826 a FAX NO.:(904)247-5845
F7 BUILDING-DEPT@COAB.US
PLUMBING PERMIT APPLICATION DUVAL COUNTY
1.JOB ADDRESS: 2.IS THIS A SUB PERMIT: 13.DATE:
-71 A� ANO 0
0 YES PERMIT#:
PROPERTY OWNER:
4.NAME: 5.ADDRESS IF DIFFERENT FROM JOB ADDRESS 6.PHONE:
PLUMBING CONTRACTOR:
7.NAME OF gaWP 8.ADDRE
JP ' 4 'J
11-EQ , III % ft
9.STATE!aPA Llc� 1�pl_PH901:e - L
_ i _7 _ 4�J Y'V
syo: 3
12,EMAIL ADbFZESS: 13.OFFICE Ph7V 14.
L
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify 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 cQmmenced.
CONTRACTORS SIGNATURE: 7ZQ12
15.NATURE OF WORK: 6. 7. 18.CURRENT CODE:
El NEW 0'06 FLORIDA BUILDING CODE-
El RE-PIPE PLUMBING
0 OTHER:
19.NUMBER OF FIXTURES:
BATH TUB SEWER CONNECTION
BIDET SHOWERS
DISH WASHER SHOWERS PANS
DISPOSAL SINK
DRINKING FOUNTAIN WATER CLOSET TANK
FLOOR DRAIN WATER CLOSET VALVE
HOSE BIB WASHING MACHINES
ICE MAKER WATER CONNECTION
INTERCEPTOR WATER HEATER
LAVATORY URINALS
LAUNDRY TRAY OTHER (SPECIFY):
ROOF DRAIN
20.PLUMBING PERMIT FEES:
PERMIT ISSUING FEE: $35.00
TOTAL FIXTURES: x $7.00 (PER FIXTURE) + $35.00
COAB FORM BLDG03:REVISED:1/10/2008
CITY OF
4&4a4'CBe4W,4-0;&U'J,
Office of Building Official
REQUEST FOR INSPECTION
Date
Time� A.M. Permit No.
Received P.M. District No.
z2
Job Aclarees—
Owner's
Name &)XI-6;
ContractorAL4-/1—/ <1
BUILDING CONCRETE PLUMBING MECHANICAL
Framing Footing 0
Re Roof I ng El Rough 0 Air.Cond.& 0
Slab 0 Temp Pole 0 Top out El Heating
Lintel 0 Fire Place
-!�/ -- Pre Fab
READY FOR INSPECTION
Mon. Tues. Wed. Th u rs. A.M.
P.M.
Inspection Made A
Inspector
Final Inspection 0
Certificate of Occupancy
Date
CITY OF
Office of Building Official
REQUEST FOR INSPECTION
Date Permit No.
Time
eceived A
R
.M
M. District No.
Job Address
Owner's L lity
Name Contrac
BUILDING CONCR E ELECTRICAL P MBING MnE�CH�ANICAL
Framing 0 Footing 0 FloughWiring [0 ough 0 Air.Cord.& 0
Fie Roof I ng 0 Slab 0 Temp Pole D. Top Out 1:1 Heating
Lintel Fire Place
READY FOR INSPECTION Pre Fab
Mon. lfu�.sl Wed. Thurs. A.M.
C—f-�— z Friday_P.M.
Insvwtion Macie A.M..
Inspector Final Inspection 0
Certificate of Occupancy
Date
DEPARTMENT OF BUILDING
CITY OF ATLANTIC BEACH
PERMIT INFORMATION LOCATION INFORMATION
Permit Number: 5297 Address: 315 SKATE ROAD
Permit Type: SWIMMING POOL ATLANTIC BEACH, FLORIDA 32232.1
��lass of Work; NEW ------ LEGAL DESCRIPTION ---------
Constr. Type: WOOD FRAME 11 Block : 24 Section:
Proposed Use: SINGLE FAMILY Township: RNG: 0
Dwellings: I Code: 0 Subdivision: ROYAL PALMS UNIT 2A
Estimated Value: $0. 00
Improv. Cost: $0. 00
Total Feest $30. 00
Amount Pild ; $30. 00
PRIC 47307-92
4urk Vesc. 1_:L1Nb11hUL, 1 SWIMMIP10 POC L. TER Pr.AN7
OWNER !NFORMATION ---- - APPLICATION FEES ---
Name-, BLAIR E. WHITNEY PERMIT $30. 0u
Addresze: 315 SKATE ROAD WATER IMPACT FEE $0. 00
ATLANTIC BEACH, FLORIDA �?2232 SEWER IMPACT FEE $U. 00
F-Ijot,e-. (904 )2.46-2666 WATER METER IS0. 00
RADON GAS-H. R. S. $0. 00
CONTRACTOR INFORMATION RADON GAS - 5% $0. 00
Name; SURFSIDE POOLS WATER TAP $0. 00
Address: 321 BEACH AVE. SEWER TAP $0. 00
ATLAUTIC BEACH, FL 32233 HYDRAULIC SHARE $0. 00
t $0. 00
t,icen,7,r-t RP0030299* Type- 5 RE-INSPECT FEE
SEC. H !MPACT FEE $0. 00
OTHER $0. 00
NOTES:
NOTICE —ALL CONCRETE FORMS AND FOOTINGS MUST BE INSPECTED BEFORE POURING
PERMIT VOID SIX MONTHS AFTER DATE OF ISSUE
BUILDING MATERIAL, RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE,AND MUST BE
CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER
"FAILURE TO COMPLY WITH THE MECHANICS' LIEN LAW CAN RESULT IN
THE PROPERTY OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS.99
ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR
VIOLATION OF APPLICABLE PROVISIONS OF LAW.
ATLANTIC BEACH BUILDING DEPARTMENT
By:
CIT'i OF ATLANTIC BEACH
APPLICATION FOR POOL PERMIT
Job Address-
Lot # Block It Subdivision&
zx
Owner
Address 0
e
C ontractor—SbZC51116 A6(-� f-V4f-'!�
Address
License Number 0-rcc) W68b
Valuation, $ L90 Gallons
"rob
SITE PLAN
front.
(D 1:xi e (D
rear
Signature Owne
Date
Signature Contractor ' ate cp
50
APR 30 7992
Building and Zoning
FL.A. '967 L-AWS
FS 713,13
RAMCO FORM 4061
of
To ft1110111 it Mau rialtreril: WREPARE IN OUPLICATEb
The undersigned hereby informs all concerned that improvements will be made to certain real
property, and in accordance with section 713.13 of the Florida Statutes, the following information
is stated ill this NOTICE OF COMMENCEMENT.
Description of property..................
.........OA
Z,1 4
.................
.................... .. .....
.................. .............................................................
/-07 jp�c <. 0 J-A WAI 44/1VjX10jC..........................................................................................................
............................. .6 -
15�:.f............................. a
..........................I A191A 7
...........................................................................
................................
...................................................... )jW
_r /&/6 C/a /,-' U.94 45 4 9
............................... ......./.......4 -J
General description of improvements ..................................................................
.......... ........................................................................ . .........................................................................................I..........
Wz...........4,
..... ...................................................................................................
.......................................................................................................I...................................................I....................................................................................
Owner....
............................... .........................................................................................................
4c,r,4//, /6 w1a
......................-
............ ...................................................................... ..........................................................................................
Owner's interest in site of the improvement...............fi�4 1�/'
.....................................................................................
Fee Simple Title holder (if other than owner)
Name. ....................................................................................................................
Address
Contractor.
Address............. ...................... ..........................I.......
...........
........................ ......
. ...............................................................................................
Surety (if any)
Address.......................................................................................................................................................Amount of bond $
Name of person within the State of Florida designated by owner upon whom notices or other documents may
be served:
Name ............
Address
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice
as provided in Section 713.13 (1) (F), Florida Statutes. (Fill in at Owner's Option).
Name
Address. ................
THIS SPACE FOR R E C 0 R 0 E R S U 5 E ONL.Y.............................................................................................................................................
......................... .........
....... ..............I...... .......7..
Owner
Sworn to and subscribed before me this..................................
.........................dayof........ ...........................
.....19..........
................... .... ................................................. ..............
:P
MY C'.,'All
27, li35
FLA. 1967 LAWS
FS 713.13
RAMCO fromm 409
'E'a "'110111 it rang mureent: I" 0UPL1Cj%-rZj
The undersigned hereby informs all concerned that improvements Will be made to certain real
property, and in accordance with section 713.13 of the Florida Statutes, the following information
is stated in this NOTICE OF COMMENCEMENT.
Description of property..........
................................................................................................................................................................................................
f.....................................................................
......I....... ...... 9/4/iW�� *
............. .... ................
................................
..................... 01................. ............
..............
14,'U'llsloll,14d 40C 111g116
...............................z......ie.......I..........................................
General description of improvements ........................
.............................................................................. .............................................................................................................................
.....................................................................................................
..................... ...................................................................................................................................................................................................................
Owner.......41*141W-46
Address...91!�- ....I. .........................................................................................................
.......... '5�;t —
......... .....................oo'Nf 4
..............
......................................
.................... ..............................................................
Owner's interest in site of the improvement...............)W.- 1�/'M
Fee Simple Title holder (if other than owner) .....................................................................................
Name
Address .......................................................................................................
Contractor.646c,�,l ........ .........................................
...........- ........
......................................................
Address....3- 41 ......
..................
..........
.. .... ..................
Surety (if any) ..... ...........................................................................................
............................................................................
..............................Amount Of bond $.......................
Name of Person within the State ..........
be. served: of Florida designated by owner upon whom notices Or other documents may
Name..............
......................................I....................................................................... .......................................
Address
In addition to himself, owner designates the following person to**r*ec'el've*a**co'p*y0*f**the"L*ie,n,o,r'sN,0*t,ic*e
as provided in Section 713.13 (1) (F), Florida Statutes. (Fill in at Owner's Option).
Name.
Address
THIS $PACK FOR RECORDER's USE ONLY ...........................................................................................
?
........................................
. . ............
Owner
Sworn to and s
�?p6r ubscribed before me this..................................
...........................dayof......... 1q..
.................................
. ............. .................. .............
47-�121475
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