395 6th St (vault) CITY OF ATLANTIC BEACH
DEPARTMENT OF BUILDING
Boo Seminole Road-Atlantic Beach, FL 32233 -Tel: 247-6826- Fax: 247-6877
PLUMBING PERMIT
Permit Number: 22130 Address: 395 SIXTH STREET
Permit Type: PLUMBING ATLANTIC BEACH, FL 32233
Class of Work: REMODEL Township: Range: Book:
Proposed Use: SINGLE FAMILY Lot(s): Block: Section:
Square Feet: Subdivision:
Est Value: Parcel Number:
777777�;"—
Improv. Cost:
Date Issued: 6/11/2001 Name: DR. AND MRS. PEEK
Total Fees: 32.50 Address: 395 SIXTH STREET
Amount Paid: 32.50 ATLANTIC BEACH, FL 32233
Date Paid: 68/11/2001 Phone: (904)246-5561
Work Desc: RF-PIPE
7,
MOO I
32.50
PERMIT
STYLES SMITH PLUMBING
BE REQUESTED AT LEAST 24 HOURS PfYObR TO NSPECTION
NOTICE- INSPECTI
BUILDING MATERI�L, RUBBISH I AND DEBRIS FROM THIS WORK MUST BE PLAZED IN PUBLIC
SPACE, AND MUST 136,,CLEAREEI�W,AND HAULED AWAY BY EITHE, NTRACTQ'R OR OWNER
RE, LT IN THE
"FAILURE TO C Ly W1 R
OMP TH;1j
PROPERTY OWNER PAYINQ VICItFO"UiLWN I P E
MIT AND SUBJECT
P WvvrPiWQWWWAR11�4
ISSUED ACCORDING TO APPROVED RJP,49��F TO REVOCATION
:)V�
ISIO
FOR VIOLATION OF APPLICABLE PROVISIO
$32.50 1�
tet Receipt: 096384
Da I
AT NTIC BE) CH BUILDING DEPT. q�qs
gag
uv�lai
CITY OF ATLANTIC BEACH
APPLICATION FOR PLUMBING PMRMIT
JOB LOCATION:
OWNER OF PROPERTY: TELEPHONE NO.
PLUMBING CONTRACTOR C.,
CONTRACTOR' S ADDRESS : 1-$-,? 7
STATE LICENSE NUMBER: of,C�, 0
______TELEPHONE: Z,5;00/ 131
HOW MANY OF THE FOLLOWING FIXTURES INSTALLED
SINKS —SHOWERS
—LAVATORY WATER HEATERS
BATH TUBS DISHWASHERS
URINALS DISPOSALS
CLOSETS WASHING MACHINE
FLOOR DRAINS SHOWER PANS
SEWER WATER
REPIPE OTHER
TOTAL FIXTURES: x $3.50 + $15. 00
MINIMUM PERMIT FEE — $25. 00
SIGNATURE OF OWNER: Z7
SIGNATURE OF CONTRACTOR
-----------------------------------------------------------------
INSTALLATION OF PLUMBING AND FIXTURES MUST BE IN ACCORDANCE WITH
THE MOST RECENT EDITION OF THE SOUTHERN STANDARD PLUMBING CODE.
CALL A DAY AHEAD TO SCHEDULE INSPECTIONS — (904) 247-5826
SEWER CONNECTIONS MUST BE CALLED INTO PUBLIC WORKS FOR INSPECTION
PRIOR TO COVERING UP — (904) 247-5834
TIC BEACH
CffY OF ATLAN
800 SEMINOLE ROAD
AnAtMC BEACH,FLORMA 32233
INSPECTION PHONE LINE 247-5826
Application Number . . . . . 03-00025379 Date 1/13/03
395 6TH ST
Property Address . . . . . . INSTALL SEWER
Tenant nbr, name . . . . . . PLUMBING ONLY
Application description . . . To BE UPDATED
Property Zoning . . . . . . . 0
Application valuation
Contractor
Owner ------------------------
-------------- --------- STEEG PLUMBING
PEEK P.O. BOX 330536
395 6TH STREET ATLANTIC BEACH FL 32233
ATLANTIC BEACH FL 32233 (904) 249-5191
--------------------------- ------------------------------------------------
Permit . . . . . . PLUMBING PERMIT
Additional desc . - 42 . 00 Plan Check Fee . 00
Permit Fee . . . . Valuation . . . . 0
Issue Date . . . .
Fee summary Charged Paid Credited- Due---
----------------- --- ------ ------- -------- . 00
Permit Fee Total 42 .00 42 . 00 . 00
Plan Check Total . 00 * 00 . 00 . 00
Grand Total 42 . 00 42 .00 .00 . 00
BUILDING MATERIAL,RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE,AND MUST BE CLEARED
OR OWNEPL "FAILURE TO COMPLY WITH THE CoNSTRUCTION LIEN LAW CAN
UP AND HAULED AWAY BY EITHER CONTRACTOR APPROVED PLANS
RESULT IN THE PROPERTY OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS"ISSUED ACCORDING To
WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR VIOLATION OF APPLICABLE PROVISIONS OF LAW.
mni n1Wr.017PICIAL
CITY OF ATLANTIC BEACH
APPLICATION FOR PLUMBING PERMIT
JOB LOCATION:
OWNER OF PROPERTY: e TEL.
PLUMBING CONTRACTOR: _7" c_
CONTRACTOR'S ADDR ESS:
STATE LICENSE NUMBER: . 1>12 14, W
.HOW MANY OF THE FOLLOWING FIXTURES
RE-PIPED OR NEW
SINKS SHOWERS
LAVATORY WATER HEATERS
BATH TUBS DISHWASHERS
URINALS DISPOSALS
CLOSETS WASHING MACHINE
FLOOR DRAINS SHOWERPANS
SEWER WATER
RE-PIPE (LIST FIXTURES BEING REPIPED)
OTHER
TOTAL FIXTURES: X$7.00 +$35.00=
MINIMUM PERMIT FEE: $35.00
SIGNATURE OF OWNER:
SIGNATURE OF CONTRACTOR:
INSTALLATION OF PLUMBING AND�IIXTURES MUST BE IN ACCORDANCE WITH
THE MOST RECENT EDITION OF THE SOUTHERN STANDARD PLUMBING CODE.
CALL A DAY AHEAD TO SCHEDULE INSPECTIONS —(904) 247-5826.
Application Number . . . . . 02-00024869 Date 9/24/02
Property Address . . . . . . 395 6TH ST
Application description . . . ROOF
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 2000
Owner Contractor
------------------------ ------------------------
PEEK, CONWAY JOE BROOKS & SONS INC
395 6TH STREET 10621 NORMANDY BLVD
ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32221
(904) 246-5561 (904) 781-1739
----------------------------------------------------------------------------
Permit . . . . . . BUILDING PERMIT
Additional desc . . REROOF
Permit Fee . . . . 20 . 00 Plan Check Fee 10 . 00
Issue Date . . . . Valuation . . . . 2000
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 20 . 00 20 . 00 . 00 . 00
Plan, Check Total 10 . 00 10 .00 . 00 . 00
Grand Total 30 . 00 30 . 00 . 00 . 00
BUILDING MATERIAL,RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE AND MUST BE FLE RE D
b§W§qkt3W1 �30
X&F&W T �V �&Aq�N
§T,f%ARku L�
6fVX(�VED PLANS
WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR VIOLATION OF APPLICABLE PROVISIONS OF LAW.
6,570
0sq
00
VED
City of Atlantic Beach a 800 Seminole Road 9 Atlantic Beach, Florid
8CWMATIC BEACH
Phone: (904)247-5800 9 FAX (904)247-5805 9 http://www/ci.atiantic-b8WDMGSOFFICE
PERMIT APPLICATION FOR ROOFING SEP 2 0 2002
JOB LOCATION-,-�':� By: L
OWNEROFPROPERTY PHONE#
CONTRACTOR 2 0
CONTRACTOR ADDRESS Mb 9
zip
CONTRACTORS LICENSE NO. PHONE
P.L 0 0 # 791-1 zi
SCOPEOFWORK r
'wjF
DECK SLOPE GREATER THAN 2 : 12 LESS THAN 2 : 12 ACTUAL
VALUATION OF WORK $ 22QQ7
PRODUCT N f, &!
PATEPIAL
TO BE USED� 1-714 Iq 9, /t ESIG1jATIQN(S)--1�) 1n.11 11
kL.-I-,e e-o" e ASTM
i V,
REQUIRED INSPECTIONS SHEATHING FlU
LIBILITY INSURANCE POLICY SUPPLIED t---"YES NO
WORKERS CONT. POLICY SUPPLIED YES NO
CONTRACTOR LICENSE SUPPLIED L-�YES NO
OCCUPATIONAL LICENSE SUPPLIED YES NO
SIGNATURE OF OWNER
SIGNATURE OF CONTRACTO
SWORN TO& SUBSCRIBED B ME HIS 6/DAY OFQY4�/tv 200,;�.
THIS
AS TO OWNER NOTARY PUBLIC(:�PaAe�UE�iA'
Patricia Amonette
AS TO CONTRACTOR NOTARY PUBLIC MYCOMMiSSION# CC947012 RES
August 27,2004
R-s'0.".olkqe BONDED THRU TROY FAIN INSUeANCE,INC
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FLORIDA 32233
INSPECTION PHONE LINE 247-5826
Application Number . . . . . 02-00024869 Date 9/24/02
Property Address . . . . . . 395 GTH ST
Application description . . . ROOF
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 2000
Owner Contractor
------------------------ ------------------------
PEEK, CONWAY JOE BROOKS & SONS INC
395 6TH STREET 10621 NORMANDY BLVD
ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32221
(904) 246-5561 (904) 781-1739
----------------------------------------------------------------------------
Permit . . . . . . BUILDING PERMIT
Additional desc . . REROOF
Permit Fee . . . . 20 . 00 Plan Check Fee 10 . 00
Issue Date . . . . Valuation . . . . 2000
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 20 . 00 20 . 00 . 00 . 00
Plan Check Total 10 . 00 10 . 00 . 00 . 00
Grand Total 30 . 00 30 . 00 . 00 . 00
BUILDING MATERIAL,RUBBISH AND DEBRIS FROM THIS WORK MUST NOTBE PLACED IN PUBLIC SPACE,AND MUST BE CLEARED
UP AND HAULED AWAY BY EIT14ER 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 OFTHIS PERMIT AND SUBJECTTO REVOCATION FOR VIOLATION OF APPLICABLE PROVISIONS OF LAW.
BUILDING OFFICIAL
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FLORIDA 32233
INSPECTION P14ONE LINE 247-5826
Application Number . . . . . 02-00024869 Date 9/24/02
Property Address . . . . . . 395 6TH ST
Application description . . . ROOF
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 2000
Owner Contractor
------------------------ ------------------------
PEEK, CONWAY JOE BROOKS & SONS INC
395 6TH STREET 10621 NORMANDY BLVD
ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32221
(904) 246-5561 (904) 781-1739
----------------------------------------------------------------------------
Permit . . . . . . BUILDING PERMIT
Additional desc . . REROOF
Permit Fee . . . . 20 . 00 Plan Check Fee 10 . 00
Issue Date . . . . Valuation . . . . 2000
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 20 . 00 20 . 00 . 00 .00
Plan Check Total 10 . 00 10 .00 . 00 . 00
Grand Total 30 . 00 30 . 00
. 00 . 00
BUILDING MATERIAL,RUBBISH AND DEBRIS FROM THIS WORK MUST NOTBE 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 SUBJECTTO REVOCATION FOR VIOLATION OF AP13LICABLE 13ROVISIONS OF LAW.
BUILDING OFFICIAL
CITY OF ATLANTIC BEACH PERMIT . CALCULATION SHEET
Address c,,—,
D a t eA I
Heated Square Footage _per sq ft = $
V3
Garage/Shed @ $ per sq ft = $
Carport/Porch _per sq ft = $
Deck @ $_per sq ft
Patio $_per sq f t
TOTAL VALUATION: $
o0c). $
Total Valuation 1st $
$
Remaining Value per thousand
or portion thereof
TOTAL BUILDING FEE ;L,0
+ 1/2 Filing Fee $
Fireplaces @ $15 . 00 $
BUILDING PERMIT FEE $
WATER IMPACT FEE $—
SEWER IMPACT FEE $
WATER METER/TAP $
CAPITAL IMPROVEMENT. $
SEWER TAP $
�( ) RADON (HRS) . 0050. $
SECTION H PAVING $
HYDRAULIC SHARES $
CROSS CONNECTION $
) SURCHARGE . 0050 $
OTHER $
GRAND TOTAL DUE
ADDITIONAL PERMITS OR FEES : Mechanical_; plumbinci
Electric/New Electric/Temp_; SwimmingPool
Septic Tank Well Sign Finish Floor Elevation
Survey Other
CALCULATIONS and/or NOTES :
CITY OF ATLANTIC BEACH
ROOFING PERMIT APPLICATION
JOB LOCATION:
;nr/�
OWNER OF PROPERTY:4n,22�-,
CONTRACTOR: -JELEPHONE..-Ci�L&-
CONTRACTOR'S ADDRESS.'
zip:
STATE LICENSE NUMBER.
,��TELEPHONE:__Z&—�/,73�-
DESCRIBE WORK TO BE PERFORMED:
(1AA y
VALUATION OF PROPOSED CONSTRUCTION
C)C)
MATERIALS TO BE USED:
SIGNATURE OF OWNER:
SIGNATURE OF CONTRACTOR:
SWORN TO AND SUBSCRIBED BEFORE ME THIS— DAY OF_S
BEVERLY DAMS
My COMMISSION#DD143308
AS TO OWNER. EXPIRES:AUG 19,2006
(9 t
Bonded through Advantage Notary ARY PWLI
SWORN TO AND SUBSCRIBED BEFORE ME THIS_j
DAY OF___j',�
AS TO CONTRACTOR
Rd N ARY PUBLIC
RY PUBLIC
Liability Insurance Supplied BEVERLY DAVIS
My COMMISSION#DD143308
Workers Compensation Insurance Supplied EXPIRES:AUG 19,2006
Bonded through Advantage Notary
Contractor License Information Supplied
Occupational License Information Supplied
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5826
r f 19
J
Application Number . . . . . 09-00001351 Date 9/28/09
Property Address . . . . . . 395 6TH ST
Application type description MECHANICAL HVAC ONLY
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
----------------------------------------------------------------------------
Application desc
1 HEAT PUMP 3 TON ; 1 A/H 36K BTU
----------------------------------------------------------------------------
Owner Contractor
------------------------ ------------------------
PEEK, JOHN DONOVAN HEATING & AIR
395 6TH STREET 315 SIXTH AVENUE SOUTH
ATLANTIC BEACH FL 32233 JAX BEACH FL 32250
(904) 241-3785
----------------------------------------------------------------------------
Permit . . . . . . MECHANICAL HVAC PERMIT
Additional desc . . 1 CU 3 TON ; 1 A/H 36K
Permit Fee . . . . 55 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 3/27/10
----------------------------------------------------------------------------
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 55 . 00 55 . 00 . 00 . 00
Plan Check Total . 00 . 00 . 00 . 00
Grand Total 55 . 00 55 . 00 . 00 . 00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
CITY OF ATLANTIC BEACH 09-
8W SEMR40LE ROAD,ATLANTIC BEACK FL
OFFICE:(W,1)247-SM a FAX NO.-PD4)247-5W
BUILDOCI)EKOCOMUS
MECHANICAL PERMIT APPLICATION DUVAL COUNTY
1.JOS ADDRESS: I Z IS THIS A SUB PERMIT- DAM-
0+ �13YES PERMIT#: Ct—.A?1-011
PROPERTY OWNER:
ItNAME: ADDRESS IF DIFFERENT FROM JOB ADDRESS: PHONE:
1) fe z �_ r
MECHANICAL CONTRACTOR:
7.NAM OF COMPANY* &ADDRESS.:
Dwovav) *Wct-4 4 At_ 3(,� S-.
STATE OF FLORIDA UC43M Nor 10.CELL PHONE 11.FAX NO-
([4C&-3j-j L 24 1-3-7
12 EMAILADDRR& 13.OFFICE PHONE 14.
2_�q I-3 8S_ I
Application is hereby made to obtain a permit to do the work and installations as indicated. I car*that all wo*vvill be pefformed to meet the
standards of all lam regubft construction in this jurisdiction. This permit becomes null and void If work is not commenced Wfln six(6)
months,or 9 construction or vmrk Is suspended or abandoned ibr a period of sb((6)months at arry time after wink is commenced.
ARI# *3 0 3'/j>)0 CONTRACTORS SIGNATURE 6d' -J,- J��
I&CLASS OF VVORK: 16.BUILDING: LLSER� 10.CURRENT CODE'
D NEW INSTALLATION 0 NEW XRESIDENTIAL—X70-7 FLORIDA BUILDING CODE-
VREPLACEMENT OF EXISTING SYSTEM kFEXISTING D COMMERCIAL MECHANICAL
0 ALTERATION I ADDITION TO EXIST SYSTEM
[3 REPAIR 0 OTHER
MECHANtlEQUIPWIEWTOBEINSTALLED'
19.HEAT: 0 SPACE E3 RECESSED g(CENTRAL [3 FLOOR BURNERS:
—20.AIR CONDITIONING: E3 ROOM XCENTRAL
21.DUCT SYSTEM: MATERIAL THICKNESS: MAX CAPACITY:. —Cffn
22.REFRIGERATION: MAX CAPACITYt cfm
23.COOLING TOWER: CAPACITY: gpm
24.FIRE SPRINlQ.EW. NUMBER OF HEAD&
25.LIFT SYSTEM: ELEVATOR: MANLIFT- ESCALATOR. AUTOLIFT-
2&COWNERCIAL HOOD NUMBER:
27.FIRl3nACe- PREFABRICATED: MASONRY:
2B.IRRIGATION: 0 PUMP 0 WELL [3 PIPING
29.GAS PIP91W. OF OUTLETS: 0 GAS AHU: 0 GAS WATER HEATEP_
30.OTHER-SPECFY:
SOLAR HEOITIN(l BOILERS,UNFIRED
PRESSURE VESSEL,HEAT 8MW&GER VALUE FOR OTHER ITEMS'
OR COIL IN DUCTS ETr-
31.COOLING EQUIPMENT'.
AIR CONDITIONING.REFRIGERA EOUIPMENT,CONDENSORS,ETC.
NUMBER I APPROVING
OF UNITS DESCRIPTION MODEL# MANUFACTURER TONS AGENCY
nAe L6 M t V, LA ,L
__f2 I
32.HEATING EQUIPIMUT.
FURNACES.BOILERS R PLA HANDLERS ETC.
AWNUViffti
OF UNITS DESCRIPTION MODELf MANUFACTURER BTU AGENCY
i k J(t ftq(nfV*-'Ij I-1A M'�e
_T9 33.TANKS:
TYPE LIQUID APPKUVING
NUMBE GALLONS CONTAINED MANUFACTURER SERIAL# AGENCY
BLOG04 Permit Applicatan Mech:REVISED:1211W008
CITY OF ATLANTIC BEACH
DEPARTMENT OF BUILDING
800 Seminole Road-Atlantic Beach, FL 32233-Tel: 247-5826-Fax:247-5877
ELECTRICAL PERMIT
------------
PERIM MON LOCATK, UPON
Permit Number: 22339 Address: 395 SIXTH STREET
Permit Type: ELECTRICAL ATLANTIC BEACH, FL 32233
Class of Work: ADDITION Township: Range: Book:
Proposed Use: SINGLE FAMILY Lot(s): Block: Section:
Square Feet: Subdivision:
Est. Value: Parcel Number:
Improv. Cost:
Rh%TION
Date Issued: 7/17/2001 Name: DR. AND MRS. PEEK
Total Fees: 25.00 Address: 395 SIXTH STREET
Amount Paid: 25.00 ATLANTIC BEACH, FL 32233
Date Paid: 7/17/2001 Phone: (904)246-5561
Work Desc: OUTLETS, RECEPTACLES, SWIT HES-
FEES
CORT=RACf���ff' APTP
ERICKSON ELECTRICAL CONTRACTOR —-PERMIT
NOTICE- INSPECTIO T BE REQUESTED AT LEAST 24 HOURS PIZIOR TO INSPECTION
_A
BUILDING MATERIAL,�`,,RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BOLACED IN.01UBLIC SPACE,AND
MUST BE CLEARED UP AND HAUL80 AWAY BY EITHER CONTRACTOR OR gWNER
ee
W,-ICAN RES
"FAILURE TO COMPLYWITH �N&TBUCTION � *CK OLT IN THE
j 4
PROPERTY OWNER PAYING 4MCf�*OR,,6QXtW'0 IMPI, VE
RO
47-
ISSUED ACCORDING TO APPROVED'PLAN1t*4jjQ T_bF,314
"R "I IT AND,SUBJECT TO REVOCATION
P�f
J,FOR VIOLATION OF APPLICABLE PROVIdi?)N&-Q�16_
__J
L—ATLANTIC B CH BUILDINd DEPT. SMN 14
kte3 Rweipt: U73M
W11
3
CITY OF ATLANTIC BEACH PERMIT CALCULATION SHEET
Address- S'7-- V,
Date 2-
Heated Square Footage rk @ $_per sq f t
Garage/Shed @ $_per sq ft
Carport/Porch @ $—per sq f t
Deck @ $_per sq ft
Patio @ $_per sq ft
TOTAL VALUATION :
S-0,6 0 6 C146 0
$
Total7Valuation ist $ T-6 N)0
Remaining Value $ per thousand
or portion thereof
TOTAL BUILDING FEE s—
+ 1/2 Filing Fee $ / 30
Fireplaces @ $15 . 00 $ — 0 —
BUILDING PERMIT FEE $........... 3?n
WATER IMPACT FEE $ n 0
SEWER IMPACT FEE ,- $
WATER METER/TAP $
CAPITAL IMPROVEMENT $
SEWER TAP $—
) RADON (HRS) . 0050 $
SECTION H PAVING $
HYDRAULIC SHARES $
CROSS CONNECTION $
) SURCHARGE . 0050 $
OTHER
GRAND TOTAL DUE
ADDITIONAL PERMITS OR FEES : Mechanical Plumbing
Electric/New Electric/Temp_; SwimmingPool
Septic Tank Well Sign Finish Floor Elevation
Survey Other
CALCULATIONS and/or NOTES:
CITY OF ATL-A-N-) IC BE.,kCH
Fixcure Un'c Wcrksheec for Wacer impacc Fee
FIX7tTRE UNITS ARE ESTABLISHED AS THE MEASUR-EXEN7 OF WATER DE%tAXD
T
EACU WA7SR FIXTURE UNIT INSIALLZD AND CONNECTED TO THE C77V
Sy STE21- THE' WA7E.i SUPPLY CHA-RGE 13 HEIRE3Y FlXr - -- ,
HE Cl- D AT WEN Y DOLLARS
PER FIXTURE UNIT CONNECTED TO 71 L : WATER SySTE.,�.
t BAMO(�kf GROUP CONSISTING OF SERVIC:Z S7NK 7RAP S7AND
WATER CLOSET. UVATORY & BA7H
TUB OR SHOWER S7.�,L.L (6) (5
WATER CLOsr7
WA7Z2 CLCS,-L1, TANX OPERATZI) (4) 1
I VALVE OPER.;INTED
URINAL WALL I-'?
SHOV'E-1 CROUP PER HE.A.D (3) 3 t�
—F-, OOR
SHOWEX STALL DC14
.ESTIC (2) --LAUNDRY (Z)
LAVA70RY (1)
WASHING MACHINE (3) 0 T
DISHWASHER (2) WASH, SINK ZACH E-77 Oz
X:7CHEN SINX (2) FAUCETS (2)
.-DEN7� LAVA70RY
117CH SIXX WIT3 WASTZ
GRIXI)EX (3) -DE-f7AL UN17 OR CUSp7DCR (1)
URINAL STALL" WASHOU77 (4)
lim SINX (8) C-014-BINATICIN SIM< AND TR.AY WIT*-
FOOD DISPOS. (4)
P=ES7A.L. SY?HCN jE7
BLOWOUT (2) ORINKING FOUN-.Z'%Z.N (1/,)
LkVA7ORv, LkR3L"
R/3FAUj-
SHOP (2) ICE YAKER (1/2)
SURGWNS S:xx (3) LAVATORY, SURGEONS
.JACUZZI (2)
URINAL STALL, WASHOUT (4)
TOTAL FIX-LURE UN175-------- $20-00 EAC'H 0 (%
JOB INFOP-MATION
RECEIVED
MAY 1 7 2001
CITY OF ATLANTIC BEACH
PERMIT APPLICATION REMODEL,ADDITIONS.ORALTERAIWiof Atlanzic Coach
MOVING, DEMOLITIONS �3uilding and Zofdill�,,,
owneqs) Mr. and Dr. Peek
Job Address-325-fitt-Street,—Phone_-:2E4--6--51561
Lot S Block or UnIt# Subdivision
Contrador Millenium Contractirig/jAu o state License# OGCO22042
Address IL639 Beach BoulLevard Phone 246-7050 -7sq-?151
City jackannuille Beach State FL Zip -12250
Describe work to be done Remodel existing clownstairs garage into a maz+-ez
bedroom/master bath
Present use of building residentialL
Valuation of Proposed Consbwflon 50,000
Proposed use residentiAl
is this an addition? If yes,what are the dimensions of the added space: x
WIN the added area be heated and cooled? yes New electrical(or increase)--Le—s
New plumbing fbdures? y= — New fireplace? g.� - New HeaVAC? no
SUBMIT THREE (CO ekE� IAL COMPLET ET LAN N
�SIDENT ES SOFP S.8 INCLUDI G
MER
SITE PLAN,SURVEY�, ENEICI�9;f^DEE NOT
jPE OF COMMENCEMENT,AND ZOWN
CONTRACTOR AFFIDAVIT F E 46NT OR.
Signature of OWNER Date:
Signature of CONTRACTOR Date
STATE OF FLQ81DA.
COUNTY OF L-AL VCL
Sworn to(or affinried)and subscribed before me this.,],L�jj�day of .2001
AS To OWNER: pt Notary's Signature
Personally krK)wn
[I Produced Identification
AMANDA K.SMITH
MY COMMI,99!r)N 4 CC 865852
Type of identification produced
EXPIRES:August 23,2003
"aw Bonded Thru Notary Public Underwriters
Sworn to(or affirmed)and subscribed before me this day of Vn0,k4,--,2W
V
AS TO CONTRACTOR: Notary's Slgnatureeo:Ya�4�
Personally known
Ujana B. Witherspoon [I PnxUwd Identificabon
()OMMIssion No' CC 932253 Type of identification produced
Expiration: April 30, 2004
Book 9992 Page alfi
A09(w 17 0 6 a
Page: S IS
N F,#�i�_ NOTICE OF COMMENCEMEN-17F"e' & Recurded
05/17/2001 09:01:15 AN
JIM FULLER
CLERK CIRCUIT COURT
DUVAL COUNTY
TO WHOM IT MAY CONCERN: TRUST FUND t 1.00
I RECORDING S 5.00
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 6111 7�
General Description of Improvements
Owner
Address:
Ownerjs interest in site of improvements:
Fee Simple Title Holder(if other than owner)
Name
Address
Contractor
Address
_10 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 qek� to receive a copy of the Leinor's
Notice as provided in Section 713.13(l)(F), Florida St6tutes�TTF2t1n-zt-0w.ner`s option).
Name
Address:
Owner
Sworn to and subscribed before me this_jj-�+J'A day of HO �_j
AAX-t AC( _�J
AMANDA K,Sm"_ ry Public
4,W COMMISSION';; �658,52
Ai,mo 'A'01i
M4P SHOWEVG BOUNDARY SURTTY OF
PARCEL A: The Eaot So f ect 'of Lot 1, DOWMY1 S REPLAT, according to plat
thereof an recorded in Plat Book 20, Page 22 of the current
public records of Duval County, Florida.
PARCEL 13- The West 25 feet of Lot 30, Bloc" 8, SUBDIVISION "A", ATLANTIC
BEACH, according to plat thereof as recorded in Plat Book 5,
CER 77FIED FOR:e page G9 Of the current public records of Duval County, Ploricla.
1119CA-1 �--.
5-7
0\
�Y)
1,183' 42' Co"67.
ez:�,j 4---14
s-r-
14-o'
Q
Me
Co(a.74'
!S-E 7-
THE PROPERTY SHOW HEREON APPEARS TO LIE WMIN FLOOD HAZARD ZONE AS SCALED FROM FLOOD
/NSURANCF RA7F' MAP F()p T;qF' r/n' nr A7'�-4--rl.ep rl r)plr),d /)A rr-r) el - 1.-7- %=N C-D A AM
�A
T", "F :xr:
DEPARTMENT OF BUILDING
,n!- !7-;;rf
al -ea,A.
P
L el: Z4
'302b frav 247-5877
ELECTRICAL PERMIT
PERMIT WFORMATION - ----- --
LOCATION-IN--FOR-------
MATION
Permit I ype: ELECT RiCAL �i Address.- 390 �;�jk�tEf
ATLANTIC BEACH, FLORIDA 32233
C-!aSe of VVC.-!t: AITERATION
Proposed Use: I ownship: t) Kange: o Book-
Lot(s): Block: Section:0
square Feet: Subdivision: ATLANTIC BEACH
Est. Value:
Mi pr a V. C 0 i L.- _Rarce!-_N-umber:-
Date Issued: 4/11/2000 OWNER ]INFORMATIOU
Name: dik-Na-ro—N
I TOW Fees; ZZ).UU ArldraSS: 396 SIXTH STREET
I Amount Paid: 25.00
ATLANTIC BEACH. FLORIDA322.'ri
Daie Paid: 4/11/2UUU tonmnnn nrinn
il�v I———- Phone:
or, uesc: E- __ — -- --- --- - I
K—,-- ---,j��,,UUAMP81PH3224OVSEURW- RE(:�-ROCJRD-kT—MC-TEk------- - ,
CONTRACTOR(S)
APPL!CA7!ON rl=i=Q
'_VV_1R_EW(�_kKS/DAVID THIES
ins
PeCtions-Required
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
BE CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER
"FAILURE TO COMPLY WITH THE CONSTRUCTION LIEN LAW CAN RESULT lug 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 L&.W.
Dat Receipt; 0048E%
DEPTI.
ATL.ANTI BEE
CIBEACLh— GLO
B U CHECKS
4
140 4 ,
DEPARTMENT OF�BUI
LOING,
COY Ol
F ATLANTIC BEACH
PORAhTION -------
LOCATION INFORMATION
Periii t Number: 114,104 Address : ,-.195 SIXTH STREET
Permit Type PLUMBit4d '
C1448 of Work.- ALTERATION ATLANTIC BEACH,, i
FLORIDA 3223�
Co#ttr., T�po: loot F,r LZQAL DESCRIPTION �--------- -
RAMP,
Lot : :4 1 ock
Proposed I)se SI ' , I I Sect'i on-
mmu Ly
Township, RNG:
Dwe 111 in gs 0
Es t ij.ma t ed Value. Subdivision: ATLANTIC BEACH
np rov, cost '0.00
Total Fees:
$25 .00
Work, D'.
CIMOROUT
'T I-ON APPLICATION FEES
PERMIT
F
-c)
Ad T! 4;25 .00
ET
WATER IMPACT FEE
S'0 -00
PLORTID 3
P 33 PEZ
S IMPAC 0 0'9
0
7
e!WA
A N",3,XMS-H
R.S. $0 .00
I SPORKA ON CAB' 5%
RADON
R L S 'PLUM WOO:
CAPITAL IMPROVE. $0 00
A(idr#s,s S
22:17
ILL" I' ll, 3
Ty - CROSS CONNECTION $0.00
Lioe CPC �pe
0 sEC 'a IMPACT
FEE
CONST-SURCHAROE
.00
Sg
$0 0
N TES-
0
!� OTICE ALL-CONCRETE FORMS AND FOOTI ST
NGSMU BE[NOPECTED BEFORE POURING
-RMIT Volt)six MONTH
PE
S AFTER DATE
OF ISSUE'
BUILDI
N MATERIAL,RUBBISH,rAND'DEBRIS F130M TH TNOTS PUBLIC S
IS WORK MUS
'AW
Ay" 'r , ' EjpLACED IN PACE,ANQ MUST BE
CLEARE9 UP AND HAU�tD� BY EITHER CONTRACTOR OR OWNER'
F RE TO C OMP N�,
AILU TNEVECHANIVS, LHE LAW C NAESULT IN
PE 0 PAYINGTWICE' A
E` 0 RT� U mo
F0RTNEe8 ,,1LD#N(; PROVIEMENTV
Ue
CORDING To,APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT To REVOCATION
FOR�
OF APPLICA -EIPROVIMONS,OF LAW.
Wow=
oat#: 1/30/%01
Rq*..
TIANTIC 01EACH BUILDING DEPARTMENT rn
'A
toy,
CITY OF ATLANTIC BEACH
APPLICATION FOR PLUMBING PERMIT
JOB LOCATION:
OWNER OF PROPERTY:
PLUMBING CONTRACTOR /4 r
CONTRACTOR'S ADDRESS: (K
STATE LICENSE NUMBER:--/ TELEPHONE:-Z,7a 9�Z7,7
HOW MANY OF THE FOLLOWING FIXTURES INSTALLED
SINKS SHOWERS
--LAVATORY WATER HEATERS
BATH TUBS =DISHWASHERS
-URINALS DISPOSALS
-CLOSETS -WASHING MACHINE
FLOOR DRAINS SHOWER PANS
OTHER
TOTAL FIXTURES: - x $3. 50 + $15 .00
MINIMUM PERMIT FEE - $25 .00
SIGNATURE OF OWNER:
SIGNATURE OF CONTRACTOR:
-----------------------------------------------------------------
INSTALLATION OF PLUMBING AND FIXTURES MUST BE IN ACCORDANCE WITH
THE MOST RECENT EDITION OF THE SOUTHERN STANDARD PLUMBING CODE.
CALL A DAY AHEAD TO SCHEDULE INSPECTIONS - ( 904) 247-5826
SEWER CONNECTIONS MUST BE CALLED INTO PUBLIC WORKS FOR INSPECTION
PRIOR TO COVERING UP - ( 904) 247-5834
I I IIrlL-L- r-1i E- joUn ItL NO .24?5805
Jan 16,96 11 :16 No -003 P.01
AW
CITY OF ATLANTIC Ozacm
PERMIT APPLICATION REMODEL, ADDITIONS OR ALTERATIONS
DEMOLITIONS
Owner(s): %�Qa
Address: IT
- �Lk'llr— bch E, Phone:
Lot #---. Block or Unit # .. Subdivision;
Contractor —"RUCSA�00 "
1�j
State License -7
- 0 j? 5
Addresst 15!Aw JQ_c" ffi�01-1& :�I" 21�$hone No: I to-9 UVI
Describe work to be done 4- 'V"�X�6-j
Present us a 0 f bui I d i
V&Iuktion of 'Proposed Construction:-4/ov A, IF V
Proposed use:___
Is this an addition?-140 it Yes, what are the dimensions of
the added space:---- ft. X ft. Will the added area
be heated and cooled?-",",-- NOW electrical (or Increase)?.
NOW plumbing fixtures?. Now fir*P1*c6?—N*w Heat/AC?
SUBMIT THREE COMPLETZ SZTS OF Pukno, INCLUDING SITE PLAN, SURVKY,
ENERGY CODN FORMS, NOTICE OF COMMENCEMENT, AND OWNXR/COXTRhCTOR
AFFIDAVIT, IF OWNER CONTRACTOR,
r
Signature OWNER:*NER
CTO
Signature CONTRACTO
License supplie4:_,
Liability Insurance:
Worker's -ComPensation Insurance:
D&AWMENT OF:BUILD11W
CITY OF ATLANTIC BEACH
PERMIT INFORMATION, ------- LOCAT I ON INFO --------
RMATION ,
4r:' 12947 Address:
Permit Nur4b 305 SIXTH ' STREET
Perinit Type,,#*IMMOPIRLINd ATLANTIC, BEACH, FLO
RIDA 32233,
f ,.Work-,AL1rZRATI,0N ------
----------
LZOAL DESCRIPTION
Block: Lot: ' Twp,
Prop6sed. 5se* sectiont,
0 Subd:O Rn
Subdivision4*ATLANTIC BEACH
value: 0,00
'Co
Imprbv
41
996'
T ,�:AN15 71MR
ION --- APPLICATION PES -----------
FL
PERMIT 25.00
Addr I 1�
AST,
u le
�'Pho
FORMAT I - -----
X"z.
-ddr 5 0 LVD #1
'"A WN
DA
FLORI 32205
AU C'mcpan AND FOOTWGs MUST
BE INSPEII�MD,WORE POURNG
PERMIT V01)$IX,MONTHS AFTER DATE OF ISSUE
OUILDIN4 MATEAIAL
RUBBISH AND,DEBRIS FROM THIS woRK MUST NOT BE PLACED IN PUBLIC SPACE,AND MUST BE
-CLEAAF-I LIP AND,:IHAUL90,:*�*6Y*�*ER,CONTRACTOR OR OWNER
MECHANIC$ UEU LAW, CAN RESULT IN
FORTHE'SVILDING
IMPROVtMENTV
RE PART OF THIS PERMIT AND SUBJECT To AEVOCATION FOR
'of
'OF OW OF LAW.
T 14s---
OR
BUILDING DEMRTMENT
i'A
BUILDING AND ZONING INSPECTION DIVISION
0 d
CITY OF ATLANTIC BEACH, FLORIDA z
0
Ld
a. C\J
ELECTRICAL PERMIT
z
Date -5/10/74 —Fee $ 2.40 Permit No.1237 3r
0
UJ
Location 395 Sixth txvatt
Between and
This is to certify that CL
Electrical Contractor) U. E
(Master Electrician)
has permission to install Electrical Construction as described herein in Ix
accordance with the provisions of the Electrical Code and regulations 'U
z
of the City of Jacksonville, and subject to the information shown on the ma
application, drawings and specifications which are made a part of this
permit.
for Johns ten
T
LOW
Type of work:
SERVlCE:W[i*ti"q II.Ko A"S
>
U
Feeders: &U
:E
Outlets: 2 0
U
Receptacles: 2 LU
ca
Switches: ft Ln
Incandescent:
Fluorescent:
Appliances:
Air Conditioning:
Motors:
Transformers:
Signs.
Miscellaneous:
IF NO WORK IS DONE UNDER
THIS PERMIT DURING ANY SIX ISSUED BY: 1- C. Vfta't
Electrical Insp4;c 7--
MONTHS PERIOD, PERMIT tion Supervisor
BECOMES VOID.
FOR OFFICE USE ONLY
Date--------f _�!AQ_-_-19
70/
CIT" Y OF ATLANTIC BEACH Permit I...fk...........Fee
Valuation ...11,500
FLORIDA House
.37-5 ..... .........................
............................................................................
APPLICATION FOR BUILDING PERMIT
............................................................................
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the
building or other structure described. This application is made in compliance and conformity with the Building Ordinance of
the City of Atlantic Beach, Florida, and all provisions of the Laws of the State of Florida, all ordinances of the City of Atlantic
Beach and all rules and regulations of the Building Department of the City of Atlantic Beach, shall be complied with, whether
herein specified or not.
The Contractor or Owner-Builder who has been issued a Building Permit is automatically responsible to ascertain that all sub-
contractors engaged by him are duly licensed in the City of Atlanfic Beach, Florida. To prevent delay or embarrasment regard-
ing intermediate or final inspections it is suggested that a list of sub-contractors be submitted to this office so that licenses can
be verified.
Date........7.0......... ..... 19.6f...
Owner-------- ............Address..... -------------_--Telephone
........... -------
Architect...............--------------------------------------------------------------------------------Addres&...........................................................Telephone No----------------------------
Contractor Builder -----------5.............-n-------------Addrels-----X. -A-_A7±0 n e 9.........
t------
Lot No._p g sion../
---------------------------Zo!:.�O.LABIoR I--------------–---------..-�Sub ivi -----------------------------------------------------------------------------Zone.................
--------------------------------------------------------Street....-----_-- -----Side Between...__...................----_-------------------and-----------------------------------------------------Sts.
Valuation $--------------------------------For what purpose will building be used.... Type of construction..._,�Qmr
------------ --------------------"",
Dimensions of Building_._4 X...Z.%----------Dimensions of ize of Footings.le&.1-_---------_----
Size of Piers----------- --------------_-..-.--Size of Sills-.---------------------------.-.GTeatest Sill Span in ft...........................Type Roof`.4;!!v!�?4��OAI
How will Building be Heated?---_OeA�.........................------------_-_Will Building be on Solid or Filled Ground?---- ................
Size of Ceiling Joists---- Distance on Centers-----�3�_.......................... Greatest Span....../;��.......................... po
Size of Floor Joists.------------------------------------__...... Distance on Centers......... --------------------------- Greatest Span............................................ 1P
Size of Rafters.... ---_--------------I------------ Distance on Centers..... ------------------------- Greatest Span........................................... go
This rectangle is to represent the lot.
!�Fate e, building or buildings in the
r hi
g t ! It on. Give distance in feet from
14
CoMpuam -a I lot-Ines and existing buildings.
AOG 13 1970 REAR LOT LINE
Two copies of plans and specifications shall
be submitted with application.
Inspections required.
1. When steel is in place and ready to pour footing.
2. When steel is in place and ready to pour columns and/or lintel. – zs--, Z,
46— 6 0
3. When steel is In place and ready to pour beam. ss�_l
4. When framing is completed. tols-v
5. When rough plumbing is completed,and ready to cover up. j7! f
6. When septic tank drain field or sewer is laid but before it is covered.
'T,
rn4
7. Electrical inspection by City of Jacksonville. Air 1*41
8. Final inspection.
Note: In case of any rejection,re-inspection MUST be called for after
corrections are made.
FRONT OF LOT
In consideration of permit given for doing the work as described in the above statement, we hereby agree to perform said
work in accordance with the attached plans 9d specifications, which are a part hereof, and in accordance with the building
regulations of the City of Atlantic Beach. I .
Signatureof Builder-------------- -------------- Address........................--------- ---------_----------_----------_--_- _---------------
' / --- ---- -- -- -- ------ -? , ��w ��
Signature of Owner----- ------_77-7--t-1 Address......_f,�
`--- ---------"'` ... .........................................................................
FOR OFFICE USE ONLY
Date . ...........19
........�/ � 11�4
Permit *........................Fee
CITY OF ATLANTIC BEACH Valuation $ / )_
FLORIDA House
APPLICATION FOR BUILDING PERMIT
...........................................................................
............................................................................
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the
building or other structure described. This application is made in compliance and conformity with the Building Ordinance of
the City of Atlantic Beach, Florida, and all provisions of the Laws of the State of Florida, all ordinances of the City of Atlantic
Beach and all rules and regulations of the Building Department of the City of Atlantic Beach, shall be complied with, whether
herein specified or not.
The Contractor or Owner-Builder who has been issued a Building Permit is automatically responsible to ascertain that all sub-
contractors engaged by him are duly licensed in the City of Atlantic Beach,Florida. To prevent delay or embarrasment regard-
ing intermediate or final inspections it is suggested that a list of sub-contractors be submitted to this office so that licenses can
be verified.
Date........... ...............49..................119.75'-
Owner............4-R /..................... .....:5r7 ..........Telephone No.e.el'Ir-.—AW3
Architect...............................................................................................Address,...........................................................Telephone No.............................
ContractorBuilder------------------------------------------------------------------------------Address................------------------------------------------Telephone No................ ..........
LotNo---------------------------------------------------Block No-------------------------------Sub Division................................................................................Zone--- .......-
-------------------------------------------------------....Street.--------------- ---Side Between.................................. ............and------------------------------------------------------Sts.
Valuation $-------- 1P.-ell For what purpose will building be used.......AW ............Type of construction.-..,,,—,R.,qw7*�;r—------
X sz>
Dimensions of Building---10�4� "'Dimensions of Lot.......17.............../1----------------------Size of Footings----
Size of Piers--------___--_------_----------Size of Sills..._------------------------Greatest Sill Span in ft..........................Type Roof.... ...............
....................
How will Building be Heated?--------- .......................-------..............Will Building be on Solid or Filled Ground?........................................
Size of Ceiling Joists.-----ZX6..................... Distance on Centers...........A�.."07...................... Greatest Span------ ................ ..
e., tp
Size of Floor Joists--- Je---X__6.................. Distance on Centers.........A!�....I....................... Greatest Span........V...�'_A
......................
Size of Rafters--------_----Z-)
C.4.. ---------- Distance on Centers...-.. ................. Greatest Span-------t�e.....................
This rectangle is to represent the lot.
Locate the building or buildings in the
right position. Give distance in feet from
all lot-lines and existing buildings.
REAR LOT LINE
Two copies of plans and specifications shall
be submitted with application.
Inspections required.
1. When steel is in place and ready to pour footing.
2. When steel is in place and ready to pour columns and/or lintel. Z Z
3. When steel is in place and ready to pour beam.
4. When framing is completed.
5. When rough plumbing is completed,-and ready to cover up.
6. When septic tank drain field or sewer is laid but before it is covered.
7. Electrical inspection by City of Jacksonville. W
S. Final Inspection.
Note: In case of any rejection,re-inspection MUST be called for after
corrections are made.
FRONT OF LOT
In consideration of permit given for doing the work as described in the above statement, 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 building
regulations of the City of 4dan ach
Signature of Builder_. .............. ............. Address.... ......
7-- fiy�17/ ...........................
Signatureof Owner.................--_-__-----_ --------_----------- .......... Address..................................................................................................