30 17th St 2013 (vault) CITY OF
l�t�?cuctic �eac,� - ��vuda
800 SEMINOLE ROAD
ATLANTIC BEACH,FLORIDA 32233-5445
TELEPHONE(904)247-5800
FAX(904)247-5805
SUNCOM 852-5800
CHAPTER 489, FLORIDA STATUTES, PART I "CONSTRUCTION CONTRACTING" REQUIRES OWNER/BUILDER TO
ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489. 1 03(7), FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT
UNDER AN EXEMPTION TO THAT LAW. THE EXEMPTION ALLOWS YOU, AS THE OWNER OF YOUR PROPERTY, TO ACT AS YOUR
OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST SUPERVISE THE CONSTRUCTION YOURSELF.
YOU MAY BUILD OR IMPROVE A ONE - OR TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD OR
IMPROVE A COMMERCIAL BUILDING AT A COST OF $25,000.00 OR LESS. THE BUILDING MUST BE FOR YOUR USE AND
OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE. IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF
WITHIN ONE YEAR AFTER THE CONSTRUCTION IS COMPLETE, THE LAW WILL PRESUME THAT YOU BUILT IT FOR SALE OR
LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY NOT HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR.
YOUR CONSTRUCTION MUST BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. IT IS YOUR
RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE LICENSES REQUIRED BY STATE LAW AND BY
COUNTY OR MUNICIPAL LICENSING ORDINANCES.
ORDINANCES ALSO ALLOW AN OWNER TO IMPROVE THEIR OWN PROPERTY WHEN IT IS FOR PERSONAL OR FAMILY
USE, AND LIKEWISE REQUIRE ALL WORK (EXCEPT MAINTENANCE UNDER $2,000) BE UNDER A BUILDING PERMIT AND PASS
ALL NORMAL INSPECTIONS. THE ORDINANCE STATES OWNERS MAY PHYSICALLY DO WORK THEMSELVES; OR MAY HIRE
UNLICENSED WORKERS PROVIDED SUCH WORKERS BE UNDER "DIRECT SUPERVISION OF THE OWNER, WHO MUST BE ON
THE JOB AT ALL TIMES WHILE WORK IS IN PROGRESS BY UNLICENSED TRADES PEOPLE." THIS DOES NOT ALLOW USE OF
UNLICENSED CONTRACTORS.
SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE, THE BUILDING DEPARTMENT SUGGESTS
WORKERS COMPENSATION INSURANCE BE PURCHASED UNDER THE HOMEOWNERS INSURANCE POLICY CLEARLY PROTECTS
THE OWNER. 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.
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.
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.
5;iOPER�TY W4R/B�UILDER
,�& / L�� I
ADDRESS TELEPHONE
SWORN TO AND SUBSCRIBED BEFORE ME THIS (( DAY O Tg'
Al
N PUBLIC , PodaAM=ft
NOTE: PHRASE UNDERLINED UNDERLINED ABOVE MY COMMISSION EXPIRES: '•; .*_. MY COMMISSIONkCC553881EXPIRES
ARE EMPHASIZEp BY THE BUILDING 7 r. .•o¢`°•c August 27,2WO
?F F4+•
DEPARTMENT. BANDED THRU TROY FAIN INSURANGt INC.
CITY OF ATLANTIC BEACH
DEPARTMENT OF BUILDING
800 Seminole Road - Atlantic Beach, FL 32233 - Tel: 247-5826 - Fax: 247-5877
PLUMBING PERMIT
PERMIT INFORMATION — LOCATIOWINFORMATION
Permit Number: 19099 Address: 30 SEVENTEENTH STREET
Permit Type: PLUMBING ATLANTIC BEACH, FL 32233
Class of Work: ALTERATION Township: Range: Book:
Proposed Use: SINGLE FAMILY Lot(s): Block: Section:
Square Feet: Subdivision: NORTH ATLANTIC BEACH
Est. Value: Parcel Number:
Improv. Cost: OWNER-INFORMATIOkt-
Date Issued: 11/04/1999 Name: HICKMAN, D.E.
Total Fees: 25.00 Address: 30 17TH STREET
Amount Paid: 25.00 ATLANTIC BEACH, FL 32233
Date Paid: 11/04/1999 Phone: (000)000-0000
Work Desc: CONNECT TO CITY SEWER - IMPACT FEE $1250 PAID UNDER PAYMENT AGREEMENT
_CONTRA R ,..:4- PPCAOIFEE .
KELLOW'S RAPID RESPONSE PLUMBING PERMIT 25.00
.- - -
Itts ections;•�;R' .
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 ICE FOR BUILDING IMPROVEMENTS"
ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION
FOR VIOLATION OF PPLICABLE PROVISIONS OF LAW.
$25.0014
_ Date: 11/85/99 81 Receipt: 0098810
ATLANTIC BEACH BUILDING DEPT. 001005 738
08180883PP1898
1
CITY OF ATLANTIC BEACH
APPLICATION FOR PLUIMMING PERMIT
JOB LOCATION: 30 1-711, 54 - 114,C, 9,� �`
OWNER OF PROPERTY: �pn iC rngn TELEPHONE NO OY64CS0(%
PLUMBING CONTRACTOR S
CONTRACTOR' S ADDRESS : /015n Pff4gy)h7(, 131,J,4 &2( - 29'S
STATE LICENSE NUMBER: CT-(- 05-1014k TELEPHONE:
HOW MANY OF THE FOLLOWING FIXTURES INSTALLED
SINKS SHOWERS
LAVATORY WATER HEATERS
BATH TUBS DISHWASHERS
URINALS DISPOSALS
CLOSETS WASHING MACHINE
FLOOR DRAINS SHOWER PANS
f SEWER WATER
REPIPE OTHER
TOTAL FIXTURES: x $3 . 50 + $15 . 00
MINIMUM PERMIT FEE - $25. 00[?6 (�SIGNATURE OF OWNER:
SIGNATURE OF CONTRACTOR: l�--
-----------------------------------------------------------------
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
EWER CONNECTIONS MUST BE CALLED INTO PUBLIC WORKS FOR INSPECTIO
RIOR TO COVERING UP - (904) 247-5834
IAN6 Ike
ir
CITY OF
1atic Seac� - �Qcvu.'a�a
800 SEMINOLE ROAD
ATLANTIC BEACH,FLORIDA 32233-5445
TELEPHONE(904)247-5800
FAX(904)247-5805
March 10 , 1995
A. S .A. P . Plumbing
P . 0. Box 16631
Jacksonville , FL 32245
Attention: Larry Dean
Re : 30 17th Street
Dear Larry:
The sewer line adjacent to 30 17th Street was installed by Mr .
Richard M . Forbis to service his home at 1719 Beach Avenue .
Mr . Forbis has a sewer main extension agreement with the City
of Atlantic Beach. This agreement requires anyone connecting to
the lines installed by Mr . Forbis to pay a portion of Mr . Forbis '
costs for five years after completion. The cost submitted in Mr .
Forbis ' agreement is 93 . 26 per linear foot of sewer line . Assuming
the frontage foot at 30 17th Street is 25 feet , the cost to the
owner at 30 17th Street will be $2 , 331 . 25 .
The sewer impact fee is $1 , 250 . 00 . The total cost to the
owner will be $3 , 581 . 25 .
Please contact me at 247-5826 if you have any questions
concerning this matter .
Sincerely ,
Don C . Ford
Building Official
DCF/pah
cc : Cit Manager
Bob�Kosoy
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_
OFFICIAL RECORDS
NWMH Maim ESTU19109 -%0RZZXA=
THIS SEWER MA N EXTENSION AGREEMENT made and"entered into this
day of , x.992, by and between THE CITY OF
ATLANTIC BEACH, FI,O , 800 Saminole Road, Atlantic Beach, Florida
32233 (the "City" ) , and COASTAL-POAnTS, INC. , 615 Highway AIA,
Suite 104, Ponta Vedra Beach, Florida 32002 (the "Owner" ) .
K I T N E 8 S E T 8
WHE"AS, Owner owns the real property located in Atlantic
Beach, Duval. County, Florida (the "Owner's Property" ) located at
Q` 1719 Beach Avenue, Atlantic Beach, Florida, and more pa,rti,cularly
described in Exhibit "A" Attached hereto; s.nd
.A 4-4 WHERBAS, Owner wishes to extend a public se'w'er main from itsr
present location near the intersection of 17th Street and Beach
Avenue, along 17th Street and Beach Avenue to the Owner's Property
in order to obtain public sewer utility service (the "Sewer Main
�•t �� Extenaian ) , and
WHRREAS, the. Sewer lain Extension will pass adjacent to and in
•, ��`_= front of and run contiguous with several_ parcels of real property
( "intervening parcel"; collectively, intervening Parcels") ; an
WHEREAS, the Intervening Parcels currently have no public
- sewer utility service, and the Owner wishes to be reimbursed by the
owners of the Intervening Parcels when and if any owner hooker up to
the Sewer Main Extensions and
0
48 HEREAS, The City, having found that it is in the best
interest of the citizens of Atlantic Beach for private persons to
extend public utilities at their own expense, has agreed to assist
the Owner in obtaining reimbursement from the owner. of each
'i
Intervening Parcel on an equitable prorate basis at such time and
f E-4in the event the tn#ner of such Intervening Parcel hacks up to the
-q P4 Sewer Main Extension, and fpr that purpose enters into this
Agreement with the Owner.
Lz 0
H:i NOW, THEREFORE, for goad and valuable consideration, the
p, C-1Fa receipt and sufficiency of which inhereby acknowledged by the
tT (4 t4 " 7'7 r, agree as
-4 parties the Owner and the City, each with they othe
follows
1. $er taia. The foregoing recitations of fact are true and
correct.
2. Construction of -Sewer Main. They Owner shall, at Owner's
sole cost and expense, construct the Sewer Main Extension from its
current location to the Owner's Property in accordance with all
H applicable laws and regulet.ioner and shall obtain all necessary
permits for the construction and operation of same. The Owner's
work shall eoumernoe within one hundred eighty (180) ealsndar days'
of the date of this Agreement and, if such work is not comme;nood
VOL73" M06.33
OFFICIALRECOM
within that time, or if the work when commencesd is suspended,
abandoned or not in active progress at any time for a period of one
hundred eighty (180 ) calendar days, then any obligations, duties or
refunds of the City arising out of or prescribed by this Agreement
shall be null and void and unenforceable. For purposes of this
section, work shall be eonaidered to have commenced and/or be in
active progress when a full complement of workmen and equipxmerit is
present at the site to diligently pursue construction of the Sewer
Main Extension throughout the day on each full working day, weather
permitting.
3. Property of City Uoon Complest$.Qn. Upon camplotion of the
construction of the Sewer Main Extension, and subject to the City's
acceptance, it shall become the property of the City. Owner agrees
to execute such documents or instruments as may he reasonably
requested by the City including, but not limited to, a bill of sale
and/or quit claim deed evidencing the conveyance of the Sewer Main
Extension to the City.
4. znepection. The City shall have the right to refuse to
accept the Sewer Main Extension until is has passed tests arranged
by the City or those required by any agency or governmental body
having jurisdiction over such improvement, in order to determine
whether the Sewer Main Extension is constructed in accordance with
the approved engineering plans and specifications.
5. Reimbursement of Costs of 002r. The City, as a
condition to permitting these owner of any Intervening Parcel to hook
up to the Sewor Main Extension, shall reqguire from such owner a
signed, sealed release, evidencing satisfactory reimbursement
having been made to the Owner for that Intervening Parcel owner's
prorata share of the cost of construction. These casts of
construction shall include both hard and soft costs. The amount of
reimbursement shall be calculated on a front-footage basis measured
along the right-of-way of 17th Street and Beach Avenue in an amount
not to exceed THIRTY-TWO THOUSAND ONE HUNDRED SEVENTY-FOUR and
No/100 Dollars ($32, 174 .00) or NINETY THREE DOLLARS and 26/100
Dollars ($93.26) per lateral foot of each Intervening Parcel. The
reimbursement provision herein ahall expire five (5) years from the
dates ofthisthis Agreement, end the City agrees not to permit
Intervening Parcel ownors to connect to the Sewer Main Extension
before the expiration hereof without the signed, sealed release of
the Owner showing receipt of the Intervening Parcel owners prorates
share of the construction costs.
6. No Prec@ ent. The provisions of this Agreement shall not
be construed as establishing a precedent in connection with the
amount or basis of reimbursement to be made to the owner, or of any
of the other terms and conditions of this Agreement, and the City
reserves the right to make such agreement with private owners as it
may deem necessary and desirable on a cane-by-case basis.
2
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V00 39
OFF1GtAL REM03
7. Recording. This Agreement is being recorded in the
publics records of Duval County, Florida, for the Rarticular purpose
of placing the owners of all Tntervening Parcels, their successors
and assigns, upon notice of the provisions herein contained, and
the same shall be deemed covenants running with the Tntervening
Parcels.
TN WITNESS WHEREOF, the patties hereto have executed this
Agreement as of the day and year first above written.
Qa r,;Q,=_ L, Y , COASTAL--FORSIS, INC.
Gat" Byta,/e�--
Witnesses R D Ai. F'ORBI
Its: Preeident
"Owner"
.r
THE CITY TIC SSACH,
Maureen Kin
By:
itnee W311Qy lff-Ad
Alan Jensen Ita t )[a or
"City"
STATE OF FLORIDA
cOUNTY OF ST. ZR:+#A,tS
The foregoing instrument was acknowledged before me this WA
day of fid$. , 1992, by RICHARD M. FORBIS, President of
COASTAL-FORBIS, INC. , a>. Florida Corporation. RICHARD A. FORSIS is
personally known to me or has produced as
Identification and who did taloa an oat
Nota Pubic, State o! Florida
P apFloddo
Nd M �on UP 463 ?�Oqecj L P
JW 2, 1996 Print Name
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CITY OF ATLANTIC BEACH
DEPARTMENT OF BUILDING
800 Seminole Road - Atlantic Beach, FI 32233 - Tel. (904) 247-5826
ROOFING PERMIT
PERMIT INFORMATION _ LOCATION INFORMATION
Permit Number: 19035 Address: 30 SEVENTEENTH STREET_
Permit Type: RE-ROOF ATLANTIC BEACH, FL 32233
Class of Work: NEW Township: Range: Sook:
Proposed Use: SINGLE FAMILY Lot(s): Block: Section:
Square Feet: Subdivision: NORTH ATLANTIC BEACH
Est. Value: Parcel Number:
Improv. Cost: 2,000.00 OWNER INFORMATION
Date Issued: 10/26/1999 Name: HICKMAN, D.E.
Total Fees: 25.00 Address: 30 17TH STREET
Amount Paid: 25.00 ATLANTIC BEACH, FL 32233
Date Paid: 10/26/1999 Phone: (000)000-0000
Work Desc: REROOF
CONTRACTORS) — APPLICATION FEES-___
MCNAHAN ROOFING PERMIT 25.00
Inspections Required
NOTICE - INSPECTIONS MUST BE i:EOUESTED AT LEAST 24 HOURS PRIOR TO i;"iSPECTION
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.
X25.88 �4
Date: 10/26/99 01 Receipt: 0886662
CASH
CITY OF AT TIC BE 08188883221008
CITY OF ATLANTIC BEACH
ROOFING PERMIT APPLICATION
JOB LOCATION: 39 / 71�- SfiZ tri
OWNER OF PROPERTY: 17• e, tI l C K-01A✓ TELEPHONE:: 6 6 SDG
CONTRACTOR: Crna hC,.� 120c-; C)
CONTRACTOR'S ADDRESS: Zy l U x r pit C r` c- �
l Cap �c„. — (3 e ZI P 3
STATE LICENSE NUMBER: #Z C TELEPHONE.
DESCRIBE WORK TO BE PERFORMED: R r c -C
VALUATION OF PROPOSED CONSTRUCTION ()0(), C'
MATERIALS TO BE USED:
SIGNATURE OF OWNER: Za�
oLy-t�
SIGNATURE OF CONTRACTOR:
SWORN TO AND SUBSCRIBED BEFORE ME THIS7 QDAY OF 0Cf 19 '
AS TO OWNER:
NOTARY PUBLIC
ff
SWORN TO AND SUBSCRIBED BEFORE ME THIS �� ,y40X OF aaMclaAmonette _ 19
SSION M
-• «` August 27,2000
6��-
Fx NSU INC.
AS TO CONTRACTOR "
NOTARY PUBLIC
Liability Insurance Supplied AmawW
My COMMISSION M 005W1 EXPIRE$
Workers Compensation Insurance Supplied Mpg 27,00
�acmnrr►iaor rua�;
Contractor License Information Supplied
Occupational License Information Supplied
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PD=T ��PLIG11TICN ==DELI ADDITIONS, OR AI,TL'RATIONS
MOVING, DIOL I T TONS
Owner(s) : NC a-0 lyt
`
Job Addres 36 /
CITY OF ATLANTIC BEACH
DEPARTMENT OF BUILDING
800 SEMINOLE ROAD-ATLANTIC BEACH, FL 32233-TEL: 247-5826-FAX: 247-5877
PERMIT-INFORMATION -- -. LOCATION INFORMATION '=
Permit Number: 19440 Address: 30 SEVENTEENTH STREET
Permit Type: GARAGE DOOR ATLANTIC BEACH, FL 32233
Class of Work: NEW Township: Range: Book:
Proposed Use: SINGLE FAMILY Lot(s): Block: Section:
Square Feet: Subdivision: NORTH ATLANTIC BEACH
Est. Value: Parcel Number:
Improv. Cost: 800.00 OWNER INFORMATION
Date Issued: 1/12/2000 Name: HICKMAN, D.E.
Total Fees: 25.00 Address: 30 17TH STREET
Amount Paid: 25.00 ATLANTIC BEACH, FL 32233
Date Paid: 1/12/2000 Phone: (000)000-0000
Work Desc: REPLACE GARAGE DOO R
COhITRA R(SY, ICATION FEES
PROPERTY OWNER PERMIT 25.00
r -
tr - ect�ort R
R
FINAL BUILDING
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 ACCORDINGTO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION
FOR VIOLATION OF APPLICABLE PROVISIONS OF LAW.
$25.0014
Date: 1/12/00 81 Receipt: 0825779
ATH BEACH B ILDIN T. CHECKS 3816
00100003221000
PSR-3844 8 9 5 55
DEPARTMENT OF BUILDING
CITY OF ATLANTIC BEACH
----- PERMIT INFORMATION ------ -------- LOCATION INFORMATION --------
Feradit Number: 9955 ?% idress : 30 SEVENTEENTH ST
,Permit Type : PLUMBIN-C, ATLANTIC" BEACH , FLORIDA 3223
-lass of Work: NEW ---------- LEGAL DESCRIPTION
lonstr . Type , WOY.-.)r_' FRAME Block : section ;
Proposed Use: SINGLE FAMIL'.1, Township : RNG: 0
'Dwellincts , 0 Code -tivis
t i irt a t e d ':clue: so
Improv . Coat : �o . Oi,
Total
Arriou
APFL!'_I ION FEES
PERMIT fiIq . 5C
"WAT
ZNTEENTH C1
3WATER IMPACT FEE,,�lz
_
S E40l' T 0 . 1
iTN` Cli FLOR j 1 0 11RA" FEE E $
n tj TA
A
RADON GAS-,H.R. S .
T dlWfNF0r.mtTT RADON CAB 5% 00
ame v CAPITAL IMPROVE.
Addressw- SEWER TAP
JI 41L, CROSS CONNECTION $u
U
Tyr . SEC H IMPACT FEE
7ONST. SURCHARGE
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:
CITY OF ATLANTIC BEACH
APPLICATION FOR PLUMBING PERMIT
JOB LOCATION :
---------------------
OWNER OF PROPERTY :
BUILDING CONTRACTOR :
----------------
............................................
PLUMBING CONTRACTOR
AND 0DRESS: ,
---------------------------------------------
TELEPHONE NUMBER: � s'Jar 7
STATE LICENSE NO:
------ ------------------------
TYPE OF BUILDING: �-__-
------- ----------------
------------SINKS SHOWERS
LAVATORY _ F,�ajALWATER HEATER!
------------BATH TUBS DISHWASHERS
_____________
------------URINALS DISPOSALS
------------CLOSETS WASHING MACHINE
FLOOR DRAINS SHOWER PANS
OTHER
TOTAL FIXTURE COUNT:____ x $3. 50 $15. 00 =
-----------------------------------------------------------------
INSTALLATON OF PLUMBING AND FIXTURES MUST BE IN ACCORDANCE WITH
THE MOST SCENT EDITION OF THE SOUTHERN STANDARD PLUMBING CODE.
CALL A DA AHEAD TO SCHEDULE INSPECTIONS - (904 ) 247-5626
R
CITY OF No 1 2 6 8
ATLANTIC BEACH
FLORIDA
12/7/90 19
NAME Dona d E. Hickman
ADDRESS 30 '17th Street
CITY Atlantic Beach, FL 32233
Water Impact Fee $650.00
VALIDATION DA7--
Till
TOTAL
i B'DERED
^,' -
When Signed, Dated and Numbered, This Becomes an Official Receipt
MAKE CHECKS PAYABLE TO Received Payment
CITY OF ATLANTIC BEACH, FLORIDA TREASURER
0003215
DEPARTMENT OF BUILDING
CITY OF ATLANTIC BEACH
- -- rERITIT ITi RPtATIOPI ---_ _- LOCA'TIOtf IffrORPTATIM9 - ---- -
eermit Plumber : '321 dCjj-C-ss: 0 17TH t5TfffXrT
permit Type: ILITSL'!5 A'T'LANTIC BeACM, rLIORIDA-:1Z2"�"►
`isss o1' work: MEW --------- LLr'ClAL D"Cft1r'rI10N --
t.onst-r. Type: 1#00D PRANL of: Block* ttectlon%
proposed Use: rrWt L PAPIILY Tovnsktlp: RIM, O
vellings- 1 Code Subolvisioni
Estimated Value 1 'fin- 00
rmprov. cast . !00.001r
To-tal Feesr 1527e. n1
Amount Pald: 02'745. D1
Date raxal
?fork, Denc. :
OWNtt;ft INTtORIIIATION --------- ___. - APPLMA'T'ICH rEE-c% -----
Name: HISCKnA" rEmnx"T 9t].ClK1
Address: --iv S 7TH -Ivr tE1ST WATER 1 TPAl.'f FEE 30. 00
ATLANTIC=' ]BEACH, FLr►PtIDA '32233 t!5t EX XnPACT PEE: RAO.t_ICy
rnone I t > - WATER PIE T'ETt
RADDH f3A21-H- ft- :5- EDO. ne
------ COHTTtACT'OR INPrORMAT110H - ftADtON 13A14 - O7: 140. 013
Meme: PUBLIC WORKS D1rpATtTPfEH1r MATER 'rAr Cr1
Address: fJEWE'R TAP 50. bO
ffVVftAULrC !SHARE .5D• DO
Icense: TypeRe-I"PEC'T` rise 1*0. 00
t! SEC. H IPif"At.r PEE 150. 100
OTHER 010. 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."
ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR
VIOLATION OF APPLICABLE PROVISIONS OF LAW. .ti0
ATLANTIC BEACH BUILDING DEPARTMENT
n
By:
i1
City of Atlantic Beach
Fixture Unit Worksheet for Water Impact Fee
FIXTURE UNITS ARE ESTABLISHED AS THE MEASUREMENT OF WATER DEMAND
FOR EACH WATER FIXTURE UNIT INSTALLED AND CONNECTED TO THE CITY
WATER SYSTEM. THE WATER SUPPLY CHARGE IS HEREBY FIXED AT TEN
DOLLARS PER FIXTURE UNIT CONNECTED TO THE CITY WATER SYSTEM.
BATHROOM GROUP CONSISTING OF SERVICE SINK TRAP STAND
WATER CLOSET, LAVATORY & BATH (8)
TUB OR SHOWER STALL (6)
-WATER CLOSET VALVE
-----WATER CLOSET, TANK OPERATED (4) VALVE OPERATED (8)
~ BATHTUB/SHOWER (2) URINAL WALL LIP (4)
_Cj_-SHOWER GR UP PER HEAD (3) _FLOOR DRAIN ( 1 )
___SHOWER STALL DOMESTIC (2) _ -_LAUNDRY TRAY (2)
_ 2_ LAVATORY (1 ) COMBINATION SINK AND TRAY (3)
__WASHING MACHINE (3) _POT, SCULLERY SINK (4)
_ `__DISHWASHER (2) __WASH SINK EACH SET OF
O__KITCS NFAUCETS (2)
HEN K (2)
1 -_DENTAL LAVATORY ( 1 )
___KITCHEN S NK WITH WASTE
GRINDER ( ) __DENTAL UNIT OR CUSPIDOR ( 1 )
_BIDGET (3) _URINAL STALL, WASHOUT (4)
__FLUSHING �IM SINK (8) ^_COMBINATION SINK AND TRAY WITH
FOOD DISPOS. (4)
__URINAL, P DESTAL, SYPHON JET
BLOWOUT ( ) _DRINKING FOUNTAIN ( 1/2)
_ __LAVATORY, BARBER/BEAUTY - -
SHOP (2) _(f)_-LAVATORY, SURGEONS (2)
SURGEONS SINK (3) _ URINAL STALL, WASgOUT(4)
TOTAL FIXTURE �NITS_32 =S__ @ BEACH
JOB INFORMATION____ (__� A- C ________
DONALD E. MC&IAN 315_38-3238 1593
NANCY E. MCHMAN 2W"&0717
2803 OAKMN GLEN DR PH.(703)938-7187 88-7497
ANNA,VA 22180 ��9�) 2660
PAY
ORDT OF THE
s'- `'ti �L� .J
DOLLARS
V I E/N�NA.V I ROY
I
1: 2 0749741: S9 " 0076920 0100
14 Y� ,
2! �
J'
k
j
_- -- -- DONALD E. IHCEMAN 315-38-3338 1596 IRS
NANCY E. MCKMAN 264-68-0717 n
WM OAKIDN GLEN DR PH.(703)X938-7187 ,t l �ji 68 VMNXA,VA 22180 t// 19 (j256PAY TO EORDEDOLL
�L
--J VIENNA.IRGI; A
FkR 2 GL
i
x: 2560749741: L596 -0076920 ?0L"' L
A
1
IL
ar
�.
�� -
. �` ,
a r �
• t
1" WATER SERVIiC9 30 17Th STREET
AND
38 17TH STREET
JOB COST RECORD
:;;:'_--�DESCRIPTION.':;;;:•_'"`:. QTY. MATERIALS LABOR --TOTAL
2 PVC T 1 $2 .16
2" SCH 40 PVC PIPE 1 ' $0 .38
2" X 3/4" REDUCER PVC 1 $0 .60
3/4" SCH 40 PVC PIPE 1 ' $0 14
3/4" MALE ADAPTER PVC 1 $0.16 ,
3/4" CURB STOP 1 11 60
3/4" METER ENDS 2 $6I 60
3/4" RUBBER WASHERS 2 $050
3/4" X 5/8" METER 1 $85100
CONCRETE METER BOX/LI 1 $21[00
SUB TOTAL $128 .141
10% O.H. $12 .811
TOTAL $140 -95
2 MEN 27 .45/HR FOR 1 HR. $27 45
30% O.H. $8 23
TOTAL $35 68
MATERIALS LABOR TOTAL
TOTAL $140195 $35168 17663
< MISC.JOB EXPENSES A.MOUNT OTHER JOB EXPENSES $l0 00
1 TRUCK ($10.00/HR) FUR I H TOTAL COST 1
TOTAL SELLING PRICE
LESS TOTAL COST
GROSS PROFIT
LESS OVERHEAD COST
%OF SELLING PRICE
TOTAL 10 00 NET PROFIT $186163
ADD ON LTHIS ESTIMATE $89.88 FOR WATER((a_AP $276.51 TOTAL OWED
APPROV` b
1 1990
CITY OF ATLANTA, 8
*COST OF TAP TO BE SHARED BY THE FOUR ADDRESSES INVOLVED.* 2" WATER TAP LOCATED AT
0-38 17TH STREET
JOB COST RECORD
-t 4 " DESCRIPTION-`-= QTY. MATERIALS LABOR TOTAL
6" X 2" T.S PVC 1 $17190
2" CORP STOP 1 $35170
2" MALE ADAPTER PVC 1 $0 67
2" 90 L PVC 1 $0 80
2" SCH 40 PVC PIPE 20` $7 60
2" SCH 40 PVC T 1 $2 16
II
SUB TOTAL $66163
10% O.H. $6 ,66
TOTAL _ ,$73 ,29
2 MEN ($27.45/HR) FOR 5.5. IRS $150 97
30% O.H. $45 29
TOTAL $196 26
MATERIALS LABOR TOTAL
TOTALI S73 .29 8196126 $2691551
+ MISC.JOB EXPENSES AMOUNT OTHER JOB EXPENSES $90 00
HRS. TOTAL COST $359155
55 O TOTAL SELLING PRICE
1 BACKHOE ($35 .00/HR) FO HR. LESS TOTAL COST
35 O' GROSS PROFIT
LESS OVERHEAD COST
'b OF SELLING PRICE
TOTAL 390, 0' NET PROFIT $359 55
IZ 3
Ia
PJZICF. cQuosom
APPLICATION FOR WATER AND/OR SEWER TAP
APPLICANT NAME
--------------------------------------------------
MAILING A DRESS3L2-----LtO - -___-_
----------- ----------
PHONE HUM ERDATE---_1
SERVICE R QUESTED ---
-- <----Llis_4�`
-- --------------
-----------------------------------------------
, f't.
SERVICE LOCATION----------------- ------12___����� _________
------------------------------------------------
DATE
TO
PUBLICEWO�KSQcJ.0�� TTOTBUILD.DPTD__ __1a1�
DATE OWNER
NOTIFIED_____________________
0003216
DEPARTMENT OF BUILDING
CITY OF ATLANTIC BEACH
-- -- P'<r:�i}'�IT IHP"C_uti11?hTIClt4 -- - L)]CATIr3H 1Ht''1]!tl1AT1C1N -- -- ---
Pe mit Number: 3lit`f Ad rens% 345 17Th 'STREET
ermit Type! uT;LITIEt3 ATLANTIC 15MACH, F-LUftIDA 322-3-5
C1 ss of Mork: NEW -- LLCIAL Dt`-wtUF1rf*TXV" ----------
hBtr. Type: WOOD FRAA'E Lcc.t !Block. Z4--CtIon:
Proposed use: SINGLE 1'"An2-LY Township: RHO: O
D11 kings: i +Cade: C) btu division
°LA'S imated Value%
improv. Cost.: +t�. C1+U
Total VeEs:
Amount Paid:
Date paid: 2
Mo -k Desc. - -
-- --_-_ ___ OWNER v"f"0lttiATx0" -- -- ----- ---- Arl&LLXCATXOH 1 FMS ---- -
Name: 15013 LU'T UTAH YL°1t171T %0. 00
Ad IreSS. 13* 17TH `alTRery WATER IPIPACT rEL 50.00
ATLAH11C' MISACH, J-E LURIDA -3 2--Y-i 3TSWER I1IPACT rZE 1%0. 00
Aarie: 1 ) WATER ME'Y'Z_~.R 56-3. Ot'1
RADON OA!3-H. ft. t5. vo. oQ
cats T'RACTOI Implo tHATICIM - RAMM C9A3 - t1% 110.CO
Name: PuBLIC WORL".
KS DEPART!! HT MATER TAI' �1'�1. D1
Act Iress: SEINER TAY M1
HYDRAULIC 15HAftE ISO. 100
Li ease: Type: u RE-INSPItcT FEE tea, 013
SEC. H 1"PAI.T IrEE 1410. DO
OTHEIR '10fo• bC
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
CITY OF
ATLANTIC BEACH 12 ')
FLORIDA
December r' I9_
NAME :Zuberi L-21_ilmaaill
ADDRESS 171'.t Street
CITY atlantic Lieoch
Water Impact Fee
Account 40-34.3- 3700 --
YXIDA?ION EO-n 12w/ .;
TIIEt 02:32 1 ;
MTAL $570.
TFw_17D f57@.04
WMIPT '!! :p arm
When Signed, Dated and Numbered, This Becomes an O#icial Receipt
AKE CHECKS PAYABLE TO Remlyed Payment
TY OF ATLANTIC REACH, FLORIDA TREsUUR
City of Atlantic Beach
Fixture Unit Worksheet for Water Impact Fee
FIXTURE UNITS ARE ESTABLISHED AS THE MEASUREMENT OF WATER DEMAND
FOR EACH WATER FIXTURE UNIT INSTALLED AND CONNECTED TO THE CITY
WATER SYSTEM. THE WATER SUPPLY CHARGE IS HEREBY FIXED AT TEN
DOLLARS PER FIXTURE UNIT CONNECTED TO THE CITY WATER SYSTEM.
_ ,�--_BATHROOM GROUP CONSISTING OF ____SERVICE SINK TRAP STAND
WATER CL SET, LAVATORY & BATH (8)
TUB OR S OWER STALL (6)
WATER CLOSET VALVE
---WATER CLSET, TANK OPERATED (4) VALVE OPERATED (8)
�" BATHTUB/ ROWER (2) URINAL WALL LIP (4)
-7--- -----
SHOWER GROUP PER HEAD (3) _FLOOR DRAIN ( 1 )
SHOWER STALL DOMESTIC (2) _ _LAUNDRY TRAY (2)
LAVATORY ( 1 ) _ COMBINATION SINK AND TRAY (3)
____WASHING MACHINE (3) _ __POT, SCULLERY SINK ( 4)
____DISHWASHER (2) _ WASH SINK EACH SET OF
UFAUCETS (2)
KITCHEN INK (2)
__ __DENTAL LAVATORY ( 1 )
__L__KITCHEN INK WITH WASTE
GRINDER ;3) DENTAL UNIT OR CUSPIDOR ( 1 )
_ O__BIDGET (3 ) _ _URINAL STALL, WASHOUT (4)
___FLUSHING RIM SINK (8) ___`_COMBINATION SINK AND TRAY WITH
FOOD DISPOS. (4)
_-_URINAL, PEDESTAL, SYPHON JET
BLOWOUT 48) ____DRINKING FOUNTAIN ( 1/2)
___LAVATORY, BARBER/BEAUTY --` _ (« MFid yz
SHOP (2) 0-LAVATORY, SURGEONS (2)
_ _ _SURGEONS SINK (3) __URINAL STALL, WASUOUT(4)
— - _ S ✓+C u -z
TOTAL FIXTURE UNITS @ 4'14,90 EACH 0___v_
G
JOB INFORMATION____ v
- ----------- --------------------------
1" WATER SERVICE
30 17TH STREET
AND
38 17TH STREET
JOB COST RECORD
:.-DESCRIPTION. QTY. MATERIALS LABOR "NOTAL
2" PVC T 1 $2 .16
• 2" SCH 40 PVC PIPE 1 ' $0 .38
2" X 3/4" REDUCER PVC 1 $060
3/4" SCH 40 PVC PIPE 1 ' SO 14
3/4" MALE ADAPTER PVC 1 $0.161
- 3/4" CURB STOP 1 $11 .601
- 3/4" METER ENDS . 2 S6 60
3/4" RUBBER WASHERS 2 $0.50
3/4" X 5/8" METER 1 $85 .00
CONCRETE METER BOX/LI 1 $21 .00
SUB TOTAL 128 14
10% O.H. 12 81
TOTAL $140 -951
2 MEN 27 .45/HR FOR 1 HR. $27, 45
30% O.H. $8 23
TOTAL $35 68
MATERIALS LABOR TOTAL
TOTAL $140195 F$35168 $176 63
MISC.JOB EXPENSES AMOUNT OTHER IOB EXPENSES $10 00
1 TRUCK ($10.00/HR) FUR I H TOTAL COST S1 J6
TOTAL SELLING PRICE
LESS TOTAL COST
GROSS PROFIT
1
' LESS OVERHEAD COST
%OF SELLING PRICE
TOTAL ;10.00 NET PROFIT S 186 63
ADD ON L THIS ESTIMATE $89.88 FOR WATER(,:FAP $276.51 TOTAL OWED
APPROVEU
tl , C E C 1 1990
CITY OF ATLA C bUO
pI10!1f,vnpyr p,7L9koTr - _
-COST OF TAP TO BE SHARED BY THE FOUR ADDRESSES INVOLVED.* 2" WATER TAP LOCATED AT
0-38 17TH STREET
)OB COST RECORD
.� c�DESCRIPTION`-;= QTY.- MATERIALS LABOR " LTOTAL
6" X 2" T.S PVC 1 $17 90
2" CORP STOP 1 $35 70
2" MALE ADAPTER PVC 1 $0 67
2" 90 L PVC 1 $0 80
2" SCH 40 PVC PIPE 20' $7 60
2" SCH 40 PVC T 1 $2 ,16
SUB TOTAL $66 .63
10% O.H. 86 .66
TOTAL �$73�29
2 MEN ($27.45/HR) FOR 5 .5. IRS $150, 97
30% O.H. $45 , 29
TOTAL $196 26
MATERIALS LABOR TOTAL
TOTAL 73 .29 5196 26 $269 , 55
MISC.)OB EXPENSES AMOUNTI OTHER JOB EXPENSES $90 00
I TRUCK S HRS. TOTAL COST $359 55
55 FO TOTAL SELLING PRICE
1 BACKHOE ($35 .00/HR) FO 1 HR. LESS TOTAL COST
'35 , 00 GROSS PROFIT
' LESS OVERHEAD COST
X OF SELLING PRICE
TOTAL 90 NET PROFIT $359 55
�z
3�a
PRIC.L. QLkol":e
APPLICATION FOR MATER AND/OR SEWER TAP
APPLICANT NAME �`�_ �d�. ILS T�►'1 ^` 4
T. •i�..rr�rr�rL►ii�-rte r.�
MAILING ADDRESS„�
•_ _ 1
PHONE NUM ----------r
SERVICE REQUESTED_ -
_ 1� cs�^� �rwI............
----
SERVICE LOCATION--,
-rrr---------------------w------------------r-r
DATE SENT TO DATE RETURNED �p
PUBLIC WORKS_�Lp �d3��------ TO BUILD.DPT.r� 4�)J_��y
DATE OWNER
NOTIFIED
---------------------
*COST OF TAP TO BE SHARED BY THE FOUR ADDRESSES INVOLVED.* 2" WATER TAP LOCATED AT
0-38 17TH STREET
)OB COST RECORD
DESCRIPTION`- QTY.- MATERIALS LABOR _" -f'-,TOTAL
6" X 2" T.S PVC 1 $17 90
2" CORP STOP 1 $35 70
2" MALE ADAPTER PVC 1 $0 67
2" 90 L PVC 1 $0 80
2" SCH 40 PVC PIPE 20' $7 ,60 ,
2" SCH 40 PVC T 1 $2 . 16
SUB TOTAL $66`63
10% O.H. $6 ,66
TOTAL =$73 .29
2 MEN ($27.45/HR) FOR 5 .5. rRS $150, 971
30% O.H. $45 29
TOTAL $196 26
MATERIALS LABOR TOTAL
TOTALI $731.291 S196126 S269 55
+ MISC.JOB EXPENSES AMOUNT OTHER JOB EXPENSES $90 00
RS. TOTAL COST $359155
55 00 TOTAL SELLING PRICE
1 BACKHOE ($35 .00/HR) FOR 11 HR. LESS TOTAL COST
335 . 00 GROSS PROFIT
LESS OVERHEAD COST
'4 OF SELLING PRICE
TOTAL 90M NET PROFIT 1 $359 55
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Pelee Quomom
APPLICATION FOR MATER AND/OR SEWER TAP
APPLICANT NAME :. � �..�.. '�Ca
1/ I
MAILING ADDRESS__p2 __j, 7
---------- -------
PHONE HUMBER�,,.,,{, _ ------------ DATE___/
SERVICE REQUESTED_„�_ xl�- (w/ti
( i ^ --
--- !L--------
SERVICELOCATION___� -----------:...-
---------------------------------------------�---
DATE SENT TO DATE RETURNED
PUBLIC WORKS I�103/-------- TO BUILD. DPT. --
DATE OWNER
NOTIFIED
PRICE QUOTE
APPLICATION FOR WATER AND/OR SEWER TAP
APPLICANT NAME
MAILING ADDRESS 17t�
PHONE NUMBER � _ �Oe , DATE 9
SERVICE REQUESTED !o
SERVICE LOCATION-5 0
DATE SFT TO PUBLIC WORKS —
DATE RETURNED TO BUILDING DEPARTMENT
PUBLIC WORKS DEPARTMENT
PRICE QUOTE RESPONSE
WATER.-
SEWER:
ATER:SEWER:
OTHER:
PRICE QUOTE PREPARED BY:
Signature - Title
DATE NOTIFIED OWNER IrA
i
L �3
k
f
3s �� CITY OF ATLANTIC BEACH
1r 800 SEMINOLE ROAD
Jy _►s ATLANTIC BEACH, FLORIDA 32233
>% INSPECTION PHONE LINE 247-5826
Application Number . . . . . 03-00027067 Date 10/10/03
Property Address . . . . . . 30 17TH ST
Tenant nbr, name . . . . . . REPL AIR-GOND
Application description . . . MECHANICAL ONLY
Property Zoning . . . . . . . TO BE UPDATED
Application valuation . . . . 0
Owner Contractor
-- -------- ----- ----- - --- -- ---------- ------ ------
GANG, YSOBEL UNITED RESTORATION, LLC
30 17TH STREET 5821 N. ANDREWS WAY
ATLANTIC BEACH FL 32233 OAKLAND PARK FL 33309
(904) 998-9804
-------------------------------- - ---- - ------ --------------------------------
Permit . . . . . . MECHANICAL PERMIT
Additional desc . .
Permit Fee . . . . 51 . 00 Plan Check Fee . 00
Issue Date . . . . Valuation . . . . 0
Fee summary Charged Paid Credited Due
------- ------- --- ---------- - --------- -- -------- ----------
Permit Fee Total 51 . 00 51 . 00 . 00 . 00
Plan Check Total . 00 . 00 . 00 . 00
Grand Total 51 . 00 51 . 00 . 00 . 00
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.
BUILDING OFFICIAL
Oct 09 03 12: 22p Information Systems 247-5045 p• 1
' C�-7
CITY OF ATLANTIC BEACH
r s)i
MECHANICAL PERMIT APPLICATION
Date:
Owner f Propertv: S n L C I �� — --
Job Ad ess: J�J �7 % �47641 T<< /-"g
Contractor: UN r j1(_rz)
In consideration of permit given for dning 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 City ofAtlantic B?och
ordinances and standards of good practice fisted therein. --
III. GENERAL INFORMATION
A. tins fuel: B.
V=Eic IS OTHER CONSTRUCTION BEiNO DONE ON THIS
❑ Gas _LP _Natural „_Central Utility BUILDINCTORSITE? O —
❑ Oil
❑ Other-Specify 1F YES,U E NUMBER OF COKSTRUCTION
PERMIT
IV.
MECHANICAL EQUIPMENT TO BE ATtiRE OF WORK
�Residentini or Commercial
INSTALLED ❑ Ncw Building
(Prov de complete list of components on back of this form) V Existing Building
,[7,/ Heat Space __Recessed _Central Floor Q/ Replacement of existing system
st Air Couditicnint Room - n" ❑ Now Installation IN*system previously installcd)
❑ DwA System: Material Thickness p Extension or udd-ou to exist.pg system
Maximum capacity ofm ❑ Other-Specify ____
❑ Ra gem[ion
❑ Cooling tower: Capacity ___ ____APm
❑ Fire sprinklers: number of heads THIS SPACE FOR OFFICE USE ONLY
❑ Elevator- Manlift Escalator (Number) (Received)
❑ Gasoline pups_(Number)
(Number)
* Tanks (Numbet) Remarks
❑ LPG containers (Number)
U Unfired pressure vessel Permit approved by Date
—
13 Boilers
O Other-Specify Permit Fee
LIST ALL EQUIPMENT --
AIR CONDITIONING AND REFRIUkKA.TION EQUIPMENT
Number Units Description Model Number Manu$cxurer Capacity Approving
(Toru) A encu
�,�.�rctac s/ll1T� O 2�GY�o gx„�� o? TU UG AJ
HEATIN -FURNACES,BOILERS,FIREPLACES I
Number Units Description Modet Number Ma.iufao Lrer Capacity Approving
(BTU) Agency
TANKS
How Maay Nomi utl Capacity Type Liquid NWnt of Sena) Approving
And Dimensions Contained Manufacrurer No. Agency
8(,0 Seminole Road•Atlantic 13each,Florida 32233-5445
Phone:;504)247-5800•Fax:(904)247-5845• htip:)Iwww.ei.atlantic-beach il.us 11./03
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