62 W 10TH ST Sj City of Atlantic Beach APPLICATION NUMBER
Building Department (ro be assigned by the Building Department.)
800 Seminole Road p
�. Atlantic Beach, Florida 322335445
Phone(904)247-5826 - Fax(904)247-5845 Date nested:
E-mail: building
-dept@coab.us
City web-site: hffp:/Mww,coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: IDL �d T W �"✓ rtment review required Yes No
Applicant: izn-r--S 6t&—�T- Planning &Zoning.)
Tree AdMinistratOr
Project: Public Works
u
tc
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt of Permit Verified t Date
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:
APPLICATION STATUS
Reviewing Department First Review: []Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: Date:
TREE ADMIN. Second Review: QApproved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: []Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH F
800 Seminole Road, Atlantic Beach, FL 32233 FILE
Office (904) 247-5826 Fax (904) 247-5845
Job Address: rti.5%h,e1 we5 7— Permit Number:
is S`` �``� 't/�
Legal Description 4
Floor ea o q. t. Pt
Valuation of Work S a Proposed Work heated/co ed 11 n n-heated/cooled 3 '
�2 000. �� u r T1 h
Class of Work(circle one): New Addition Alteration Repair ove 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 Approval #
For multiple products use product approval form
Describe in detail the type of work to be performed: ut L ��"n"� ''`'��X `''��ti `��"
Property Owner Information: //
Name: Seat ,_S #AGiTt9T' �4'Z //U1_M11K1�f Address: 747 th?Ay T (-4,40
City *a±Ll4H�TC f.3 e a-e. _State ELZip 12 Phone 90�/-•Aw —1.2-22 --
E-Mail or Fax# (Optional)
v
Contractor Information:
Company Name: 13eAcke< Qualifying Agent:
Address: 7`17 J20!A A City xyyatibg; g CAeA State _Zip W 3 3
Office Phone Job Site/Contact Number ► Fax#
State Certification/Registration#
Architect Name&Phone#
Engineer's Name &Phone#
Fee Simple Title Holder Name and Address ,
Bonding Company Name and Address
Mortgage Lender Name and Address '
rior
he
s commenced
Application is hereby nd that obtain will bent to do
t he to a the standards of altallations a l lak s regulairtifyot ruction in his jut no work or risdiction.ionllation •This permit becomesonull
issuance of a permit a P mgg
and void if work is not commenced within six(6)months, or if construction or work is sitspended�r 4bandoned fora period of six 16)months o lei time after
work is commenced. 1 understand that separate permits must be secured for Electrical Wor�Plupibtng,Signs, Wells, Pools, f urnaees, Boilers, Heaters,
Tanks and Air Conditioners,eta
WARNING TO OWNER: YOUR FAILURE TO .RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWJCE FOR IMPROVEMENTS
TO YOUR PROPERTY. IF YOU INTEND TO OR'T .I-N-FINANCING, CONSULT WITH
YOUR LENDER OR AN ATTORNEY BEFO•RX�RECQ ING YOUR NOTICE OF
COMMENCEMENT,
1 hereb certify that 1 have read and examined this application and know the same tp l e:true anf-c,'rec�`ti 911 provisions of laws and ordinances governing this
nape of work will be complied with whether s�eci red herein or not. The granting"pf Q.:p ermit .des.r?*.pK4qSGhre, to gree authority to violate or cancel the
provisions of any otherfederal,state, or local law regulating construction or the pehfdrti4ir3rce of c4*t ;0.f A•+
Signature of Owner Signature of�pontractor
"" oto PrittName'=.•.. {21'i�...Q........_ 5,./. FS ....................................
Print Name (zN���.......... .._..(s a.7�.............................................. .:..:;..,.,.......,.
Sworn t and subscribe before me Sworn to and subscribed before me 20
this ?O'Day of �cr ,
201-3this -Day of /,� t—
Notary, ub ;;y�.�,;���
Notary Public - T . '.. . .
"� KYLE HURRAY R �,? ��; ••: MY CO�IlJfIj I�Nu" 83&
•'c MY COMMISSION 10 EE18S723 �• ;•
r EXPIRES April 02,2016
EXPIRES April 02.2016 40133- Fbnd&N0Wy68rViW CM
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