30 17th St 13-3137 City of Atlantic Beach
Building Department APPLICATION NUMBER
FF(Tobe a=signed by the Building Department.)
800 Seminole Road
Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 - Fax(904)247-5845
V i i 19 E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1-7 7-W Q nt review req ired Yes No
uildin
D nt review re
7- annin & �7oi n�g���
Applicant:
stq red
ree Admini trator
JcW
Project: Public Works
r
It
Public Utilities
Public Safety
j
Fire tServices
Review fee Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
Florida Dept. of Environmental Protection of Permit Verified By
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: DApproved. FIDenied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: Date:
TREE ADMIN. Second Review: [:]Approved as revised. ElDenied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by.- Date:
FIRE SERVICES Third Review: RApproved as revised. RDenied.
Comments:
Reviewed by: Date:
Revised 05114/09
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC 113EACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904) 247-5845
9'2013T
Job Address: 7 Permit Nu r: 2013
Legal Description
q.
Hoor Area of Sq.Ft. Parcel# Itt
10
Valuation of Work$ Proposed Work heated/cooled non-Lated/coole
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s)(circle one): Commercial Residential
If an existing structure,is a fire sprinkler system installed? (Circle one): Yes No N/A
Florida Product Agproval 4
For multiple pro ucts use product ap_p_ro_vVaH®rffi
Describe in detail the type of work to be performed:-7) hL71 )09 L/I CC A)R-t JL 1010
Proverty Owner lnfor�niatidi
Name: Addrz4- 3n 7 7,v S7
city S t ate)�FZ i p
—7 2 23-1;hone A
E il Fax#( gp
-Mail or Fax 4 ( ptional It U42 - A Id 7
Contractor Information:
Company Na zr) A)'� , A16 146-"0 CQualifying,,4gent:
Address: MP 1,Ufr7- lhfi_
_�City__..,;&v State Zip 2 d
Office Phone Job Site/Contact Number Fax#
State Certification/Registration 4 �2
Architect Name &Phone# L/ I r-- cw
Engineer's Name&Phone#
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and Address
4pplication is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commencedprior to the
issuance o ermit and that all work will bepe�jbrmed to meet the standards of all laws regulating construction in thisjurisdiction. This permit becomes null
f�a P
and void vorkis not commenced within six(6)months, or if construction or work is suspended or abandonedfor a period ofsixo)months at any time after
j
work is commenced I understand that separate permits must be securedfor Electricar Work,Plumbing,Signs, Wells, pools, urnaces,Boileis,Heaters,
Tanks andAir Conditioners,etc.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS
TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING9 CONSULT WITH
YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
I hereby certi
jfy that I have read and examined this qpplication and know the same to be true and correct. All provisions of laws and ordinances governing.this
work will be co�nplied with whether sfecifTe ere' or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of any otherfederal,state, or local aw re at' construction or the performance ofconstruction.
-:247
SignAure of n w�v
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Xature of Contractor������
Print Name Print Name
...............A................................................................... ......
... ...................... ..... ..... ..........................................................................
Before me Befbf,��e
this D of/ 20 ay of 20
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30 17TH ST EXISTING ISA RATE TOTAL
HOUSE 953.38 100.00% 953.38
DRIVEWAY 492.20 100.00% 492.20
WALKWAY 56.25 100.00% 56.25
PATIO 174.00 100.00% 174.00
A/C PADS 27.00 100.00% 27.00
1702.83
TOTALLOT 2750.00
ISA COVERAGE 0.62
PROPOSED ISA RATE TOTAL
HOUSE 953.38 100.00% 953.38
DRIVEWAY 492.20 100.00% 492.20
WALKWAY 329.15 50.00% 164.58
PATIO 174.00 50.00% 87.00
A/C PADS 27.00 100.00% 27.00
1724.16
TOTALLOT 2750.00
ISA COVERAGE 0.63