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1655 Sea Oats Dr garage too living space 2014 11 SS CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH,FL 32233 INSPECTION PHONE LINE 247-5814 Application Number . . . . . 14-00000634 Date 5/02/14 Property Address . . . . . . 1655 SEA OATS DR Application type description RESIDENTIAL ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 75000 ---- ---------- - ------ - - -- ---- ----- -- -- --- --- - --- - ----- - --- - --- -- ------ ------ Application desc chg garage to living space -------------- ------------- --- ----- -- -- ------- ------ - -- - ---- --- -- --- --- ----- Owner Contractor ---- -- --- ------ - -------- ---------- -- --- -- -- ----- BUCHWALTER, ANDREW J ROSS QUALITY INC 10453 HUNTER CREEK CT 1518 6TH ST FL 32250 JACKSONVILLE FL 32256 JACKSONVILLE BEACH --- Structure Information 000 000 CHANGE GARAGE TO LIVING SPACE occupancy Type . . . . . . RESIDENTIAL -- - - --------- -- ----- -- -- --- - --- - ----- ---- ---- --- - - - -- - -- - ----- --- ---------- Permit RESIDENTIAL ALT/OTHER Additional desc - - 190 . 00 Permit Fee . . . . 380 . 00 Plan Check Fee Issue Date . . . . Valuation . . . . 75000 Expiration Date . . 10/29/14 -- ---- ------------- --- - - ------ -------- -- ----- - - -- ------- - ----- - ------- -- - -- - Special Notes and Comments 2010 FLORIDA BUILDING CODE, 2008 NATIONA1 ELECTRIC CODE *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. WINDOW AND DOOR INSPECTION: *INSTALLATION INSTUCTIONS REQUIRED *ALL STICKERS ARE TO REMAIN ON THE WINDOWS *PROVIDE ACCESS TO ALL WINDOWS TO INSPECT FASTENERS * IF SMOKE ALARMS ARE NOT CURRENTLY INSTALLED IN HOME, INSTALLATION OF THEM IS REQUIRED NOW, PREFERABLLY HARDWIRED THROUGHOUT; IF THERE IS A FOSSIL FUEL APPLIANCE IN THE HOME A CARBON DIOXIDE DETECTOR IS REQUIRED WITHIN 10 FT. OF EVERY BEDROOM DOOR. * - - --- ------ -- ----- --- - - ---- - - - --- -- --- ----- -- -- --- - --- - ---- - - --- - --- - -- --- 5 . 70 Other Fees . . . . . . . . . STATE DCA SURCHARGE DEV REVIEW-SINGLE & 2-FAM 50 . 00 STATE DBPR SURCHARGE S . 70 ---- - - ------ --- --- -- -- -- --- ---- ----- ----- - --- - -- - -- --- ---- ------ -------- -- -- Fee summary Charged Paid Credited- Due--- ------ --- - -- --- -- --- --- ---- - - -- - ------- . 00 Permit Fee Total 380 - 00 380 . 00 . 00 Plan Check Total 190 . 00 190 . 00 . 00 . 00 PERMIT ISOAjine(n,l�IiEf)51,Tolt-BdCORDANCF WIf*LAADCITY OF AT61-1-1i'Q3EACH ORDINANC"AND THE FLORIDQO BUILDING CODES. �-711 If ss CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH,FL 32233 X INSPECTION PHONE LINE 247-5814 Page 2 Application Number . . . . . 14-00000634 Date 5/02/14 Grand Total 631 . 40 631 . 40 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. RECORDING $10 - 00 NOTICE OF COMMENCEMENT (PPEPARE IN DUPLICATE) Permit No. TaxFolioNo State of County of To whom It may concern: The undersigned hereby Informs you that improvements will be made to certain real property,and In accordance with Section 7113 of the Florida Statutes,the following Information Is stated In this NOTICE OF COMMENCEMENT. Legal description of property being improvcd # —7- 1—V A% rty b Address of propel ing improved� /(o jdz�,J r7 S 2 I-e-_. c2 - I?lvo A&�nt. General description of improvements: 40 etierp—s - Owner Address owner's interest in site of the improvement Fee Simple Titleholder(if other than ownen Name Address contractor ("Ll,mr- ------------- Address Phone No. Surety(if any) —Amount of bond$ Address ------ Phone No. ------ Name and address of any person making a loan f construction of the improvements. Name Address Phone No. Fax No. Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may be rved: Name Adl7dress Fax No.- Phone No In addition to himself,owner designates the following person to ieceive a copy of the Lienor's Notice as provided in Section 713.06(2)�(b),Florida Statutes,(Fill in at Owner's option). Name Address Phone NO. Expiration date of Notice of Commencement(ttle expi[ati date t-� year from e date of recording unless a different date is specifled)� 'E ONL��—j 0 NE THIS SPAGE 1-UK KI:UWm— DATE i the Be re P; th'. County Du flamtFIM,has Personally app�wed rein by AM WILLIAMS -i-sell/ e oit,ira aft—s that Oil statements ano'de—lat............. MICHAEL -nd il,', of FI O"d' p State of Florida 7A Notry Public It E.7,rSel 1 0.9 201 'p 4 my Comm Expires Apr 8.2018 Commission III FF 110931 R—,t 0 County of ic at 1 3,90 State-f my oam iss n expireti--41 - or P�.m.r Hy Kn. PfodLIC d tdentiri,�Ton R BUILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH FILE COPY 800 Seminole Road, Atlantic Beach, FL 32233 Office (904) 247-5826 Fax (904) 247-5845 `7 Job Address: 6 5 "I"z2_53 Permit Number: 3q_'e-1 01 ZS 2 .�jF Legal Description & Parcel# L07 VQMor Area of Sq.P't. Sq Ft Valuation of Work S Proposed Work heated/cooled non-heated/cooled Class of Work(circle one): New Addition (A:I:te:—ra:ti:on) Repair Move Demolition pool/spa window/door Use of existing/proposed structure(s) (circle one): Commercial esidenti CE]��No If an existing structure,is a fire sprinkler system installed? (Circle one). es 1� (2D Florida Product Approval 4 For multiple products use product approval form Describe in detail the type of work to be performed: FAICCOS6 6om+m- Vfacr C1&4.,,v6s amm Avoc # Ar-A&f Property Owner Information: I Rrtr W - Name: Address: City State ip go-Phone (i—<—Z.S�_ — ooet9 E-Mail r 4:p� cut lee- -n U4 erg Contractor Information: CONTRACTOR EMAIL ADDRESS: I AJ 1" 5_se5,)u4tL Company Name: C111; Qualifying Agent: 1,V7— eJOS S at.)Rt to�, Address: Citv_V&K&w-j1qC AC4c-q State Ft. Zip 3Z-7-5-0 Office Phone _qCq- aU- g2;77 Job Site/Contact Number 96q-911- 94 71 Fax State Certification/Registration# Architect Name&Phone# D FA1 At t_5 W1 L 1- 5 4/7 -877 50 Engineer's Name&Phone 4 Fee Simple Title Holder Name and Address Bonding Company Name and Address Mortgage Lender Name and Address 0 F�;�—gp—tio a ere ade a,*n a ermit to do he work rtify that no work or installation has commencedprior to the m t, 0 o't 0, p, 0 'd to in ng construction in this jurisdiction. This permit becomes null 8su ' as h nu by d a k epe "c io 'in s f six(6)months at any time after f h Or, or aWeriod o APP t an at "c'0 per d v 'd i o'k is ot 0_,e ed w thin (6 t or abandonedf t i at on p ",is .. 'k f me "d e'st d h ep ate e Plumbing,Signs, ells,Pools, Furnaces, Boilers,Heaters, is 0 Ta k,a dA 1� et 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 FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. I here certify that I have read and examined thi's application and know the same to be trite and correct. Allprovisionsofl sandordinances ov=this type �Iwork will be c lied wi th whether speccit'ied herein or not. The granting of a permit does not presume t ive thority to violat or the al,state, o la regulating co stri tion or provisions ofany oth4e,7e� theperformance ofconstruction. Signature of Ow Signature of Contractor Print Name ::::krint Name 1.A............. .............. ... ..........I........................................ .................... Before me PR 't- \ B this Day of 2COA jiWAA01M Of 20 104 6100 t.**' ,0110 51,1e, ;1040 V, M w .0 . I S:0S,6iqA2*-,V13 I A/*\- �AfiAll 4 zA '4 40 fell V 4 Revised 01.26.10 C>) tp 00 -0 Cd E Lo 40, Z 4, 0 C) 42 vi U 4L > 0 0 2. +, -ld cd qu Cd vi 7EL C) 4-4 V) v cd -C� 00 kn 0 C) Cd 0 0 Q. Cd 0 7:3 m �Ei 15 0 cd m 2 -0 0 un u a) PLO < 42 1 . A I f I F:A ct CA vi V) bh C,3 u 0 'n 0 cf) bc bf cn tb al ct zs C'3 C) oj tj) V) Ln tD C) C) cr C�3 in CD un 1_0 Lf-) Co C, M kr) 00 (7, 21 rF �4 X cn 7:; u C� 111.) 4� r:� a) C�3 Cd El 0 c5 r4 u cr; 4 En 40 Q U 03 rA C) 41.1 cz :2 4, oc 0 0 Ln to 43 cd c1n, cz Cd 14 V-1 03 a C�3 C',j Q Ci rn u ul APPENDIX 13-D FILE COPY-, " FLORIDA ENERGY EFFICIENCY CODE FOR BUILDING CONSTRUCTION LF�R M 60DC-.041R, Residential Limited Applications Prescriptive Method C NORTH 1 2 3 UA in _!_2cn��ons I�Ijuuildrn�_Systems +Compliance with Method C of Sub-Chapter 6 of the Florida Energy Efficiency code maybe demonstrated by the use of Form 60OC-04 for add itions of 600 square feet of less,sue-installed components of manufactured homes,and renovations to single-and multiple-famity residences.Alternative methods are provided for additions by use of Form 60OB-04 or 60OA-04 PROJECT Nfi BUILDER:!Z_P'�J 1� --- --- 'M CM AND ADDRESS�: PERMITTING IIMATE CL -IFICE: AffLAI�) c:- ONE: 1 3 OF me"'. IT No JURISD'CT'O PER NO. TION NO.:! OWNER- AOA�)��_tJ M - -i-I- SMALL ADDITIONS TO EXISTING RESIDENCES(600 square feet of less of conditioned area) IF.in T�"as'C-' 'C-'and"-3 apply only to the--'p tion,not to c 1; s five retrannen s allial fly I._ I the add"on or the existing building.Space heating,cooling,and water heating equipment efficien"a I on. nly-h n uupore-' mst spe"-_r_i - level , O'T'O ntial I sp- the met 0 p a a's sc lat El as from cond d s a s .I_ p a "'ad-in nus. n s conjunct Kan with the add ition construction.Components separating uncondgio.ned the ruldrug)"a'hore rve'.- no aa't'a ' _, n ,apply iarly to the ca parents an being s un an. s 'c a. n le 6 a it in buildings undergoi ug renovations costing more than 30%of the assessed valu o b 'I s I "is farm But NG ..TE"Comply ,a.conap am Is r I'd components a 'p lure a vae th LDI renovated or replaced.MANUFACTURED HOMES AND BUILDINGS.Only sile-insla I lea a it by installed P182SG Print CK 1. Renovation,Addition,New System or Manufactured Home 1. 2. Single-family detached or Multiple-iamily attached 2. V4 &F�AAI 3. 3. It Multiple-family-No.of units covered by this submission 4. 4. Conditioned floor area(sq.ft.) 5. 5. Predominant eave overhang(ft.) Single Pane Double Pane 6. Glass type and area: 6a. 4;906c- sq.ft. Ill sq.ft. a.Clear glass 6b. _sq.ft. _sq.ft. b.Tint,film or solar screen % 7. Percentage oi glass to floor area 8. Floor type and insulation: 8a R= lin.ft. a.Slab-on-grade(R-value) b.Wood,raised(171-value) 8b. R sq.ft. c.Wood,common(R-value) 8c. R sq.ft. d.Concrete,raised(13-value) 8d. R sq.ft. e.Concrete,common(PI-value) Be. R=- sq.ft. 9. Wall type and insulation: ga-1 R sq.ft. a. Exterior: 1. Masonry(Insulation R-value) sq.ft. 2. Wood frame(insulation R-value) ga-2 R- b. Adjacent: 1- Masonry(Insulation R-value) 9b-1 R sq.ft. 2. Wood frame(Insulation R-value) 9b-2 R sq.ft. c. Marriage Walls of Multiple Units*(Yes/No) 9C 10. Ceiling type and insulation: 0 a.Under attic(Insulation R-value) 10a. R= sq.ft. b.Single assembly(Insulation R-value) 10b. R= -sq.ft. 11. Cooling systeni 11. Type: 5- (Types:central,room unit,package terminal A.G.,gas,existing,none) SEERtEER:- 12. Type: '-"`j C 5; 12. Heating system* HSPFICOP/AFUE: (Types:heat pump,elec.strip,natural gas,LP-gas,gas h.p.,room or PTAC, existing,none) 13. Air distribution system* 1,3a. a.Backflow damper or single package systems*(Yes/No) b.Ducts on marriage walls adequately sealed*(Yes/No) 13b. 01A 14. Hot water system: 14. Type: f f�t� (Types:elec.,natural gas,other,existing,none) EF: Pertains to manufactured homes with site-installed components. covered by this calculation indicates compliance with the Florida I herab plans and specifications covered by the calculation are in compliance with Revie of plans and specifications a Energy Code.Before construction is completed,this building will be inspected for compliance in the R.y re"ify fhat Ih L're t"Tore L F S, ida ne,, Code. accordance with Section 553 908T PREPARED BY: _ DATE:� L� - kHz _� , N i�*� BUILDING OFFICIAL:- I hereby certify that this building is in compliance with the Florida Energy Code: OWNER AGENT: DATE:- DATE: 13-D.33R FLORIDA BUILDING CODE-BUILDING Job: Project Summary Date: Apr 15,2014 + wrightsoft Entire House By: Aaron Thacker Donovan Heat&Air 315 6th Ave S,Jad(sonville Beach,FL 32250 Phone�904-241-3785 Fax:904-241-3745 Ernail:aaron@donovanac.com Web:www.WnovanAC.com Proiect Information For: Andrew Buchwalter 1655 Sea Oats Dr, Atlantic Beach, FL 32233 Notes: Design Information Weather: Jacksonville Mayport Naval, FL, US Winter Design Conditions Summer Design Conditions Outside db 39 'F Outside db 95 'F Inside db 70 'F Inside db 75 oF Design TD 31 'F De§ign TD 20 oF D ally range L Relative humidity 50 % Moisture difference 53 gr/lb Heating Summary Sensible Cooling Equipment Load Sizing Structure 7745 Btuh Structure 5963 Btuh Ducts 60 Btuh Ducts 239 Btuh Central vent (0 cfm) 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 7805 Btuh Use manufacturer's data n Rate/swing multiElier 1.00 Infiltration Equipment sensi le load 6202 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average 0 Structure 978 Btuh Fireplaces Ducts 31 Btuh Heating Cooll Central vent (0 cfm) 0 Btuh Area(ft') :�M 0 Equipment latent load 1009 Btuh Volume (ft') 4031 4031 0.61 0.32 Equipment total load 7211 Btuh Air changes/hour at 0.70 SHR 0.7 ton Equiv.AVF (cfm) 41 21 Req. total capacity Heating Equipment Summary Cooling Equipment Summary Make Make Trade Trade Cond Model Coil AHRI ref no. AHRI ref no. 0 SEER Eff iciency 80AFUE Eff iciency Sensible cooling 0 Btuh Heating input 0 Btuh 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 'F Total cooling 276 cfm Actual air flow 276 cfm Actual air flow 0.045 cfm/Btuh Air flow factor 0.035 cfm/Btuh Air flow factor 0 in H20 Static pressure 0 in H20 Static pressure Space thermostat Load sensible heat ratio 0.86 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 2014-Apr-1 5 20:51 34 wrightsoft Righl-SuiteO universal 8 0.24 RSL)05995 Pagel Project2sup Calc=MJ8 Front Door faces. N APPENDIX 13-D Climate Zones 1,2,3 IMLE BC-1:PRESCRIP11WE REQLNREMENTS FOR SMALL ADDITIONS(600 Sq-Ff.and Low),RENOVATIONS TO EMSTING BUILDINGS AND S"IE-INSTALLED COMPONENTS OF MANUFACTUREO HOMES MINIMUM INSULATION EOUIPMENT MINIMUM INSTALLED COMPONENT INSULATION INSTALLED EFFICIENCY EFFICIENCY Concrefe Block R-7 (9 Frame,Z x 4! R-11 z Central A/C Split SEER=13.0- SEER= 110 Frame,Z x 6' R-19 zi Single Pkg. SEER=13.0* SEER=- 8 Room unit or PTAC EER �8.5* EER = Common,Frame R-11 0 Common,mesa" R-3 - Under Affic R-30 Electric Resistance ANY = 0 Fleal pump-Split FISPF=7.r FISPIF Single Assembly;Enclosed K -Single Pkg. HSW-7.7- W-W=- Z Frame R-19 Room unit or PTHP COP=2.7* FISPFWP W Metal Pans R-13 M: 0 Single Assembly;Open R-10 W () Gas,natural or propane AFUE=.78 AFUE= Common.Frame R-11 if AFUE=.78 AFUE= Fuel 0 (0 Slab-on-grade No Minimum u) X Raised Wood R-19 0 ,0 Raised Concrete R-7 C: Electric Resistance EF=.92 EF Common,Frame R-11 w Gas;natural or LP EF=.59 EF=- C-N Fuel Oil EF=.54 EF=- In uncondiboned space R-6 in conditioned space No minimum 4ny 0 e 9 1 See Table 13-607.1.ABC.3.2 and 13-608.1.ABC.3.2 TABLE 6C-2:PRESCRIPTIVE REaUIREMENTS FOR GLASS AREAS IN ADDITIONS ONLY efficient.Maximum% Installed Ma)dmtxn percentage glass to floor area allowed is selected evelf,"kVh,arid solar heat gain co GLASS TYPE, ERHANG, EAT GAIN FFICIE[fr REQUIRED FOR GLASS PERCENTAGE ALLOWED LIPTO20% UP TO 301% UPTO40% UPTOSO% Single Double Single Uwe Single Double Single Double OH-SHOC OH-SHGC OFI-SHGC OHISHOC OFI-SHGC OH-SHGC Ol OFISHGC -(Z.78:T NOT ALLOWED 3-78 T-87 a-.78 7-87 V-78 NOT ALLOWED 2-Al 0'-75 T-75 Or-.61 11 a-.57 Ir-35 Got cortified SHGC from the manufacturer or use defaults:Single clear SHGC=.75,double clear SHGC .66,and single tint SHGC .64 TABLE 6"MINIMUM REGUIREMENTS FOR ALL PACKAGES CHECK COMPONENTS SECTION REQUIREMENTS Exterfor Joints&Cradw 606.1 To be caulked.gasketed,weather-stripped or otherwise seale7d. Exterior Window &Doom 606.1 Max 0.3 cfmlsq.ft.window area;.5 chm/sq.1t.door area. r m be sealed. sale a-top Plates 606.11 Sole planes and penetrations through top plates of exterior walls must be Recessed Lighting 606.1 Type IC rated with no penetrations(two afternatives allowed). Multistory Houses Air barrier on perimeter of floor cavity between floors. Exhaust Fans 606.1 Exh ust tans vented to unconditioned space shall have dampers,except for combustion devices with integral OVA d u7 exhaust ductwork. ar vided with outside combustion air,except for direct vent Camle istion Heeling 606.1 Combustion space and water heating systems must be pro appliances. ., :c Water"&atom 612.1 Comply,with efficiency risiquirommits in Table 612.1.ABCA.2.Switch or clearly markDd circuit breakair electric or us rov cutoff(gas)must be p ided.External or built-in heat trap required for vertical pipe nsers. Swimming Pools&Spes 612.1 Spas&heated pools must have covers(except solar heated).Noncommercial pools must have a pump timer.Gas We&poot heater.muet hes mmmum thermal efficiency of 78%. V Hot Water Pliess 612.1 Insulation is required for hot water circulating systems(including heat recovery units). 2.5 gallons per minute at 80 ps,g At Shower Heads 612-1 Water flow must be restricted to no more than HIVAC Duct Construction, 610.1 All ducts,fift ings,m echa nical eq u ipment and plenum chambers shall be mecha n i ca Ity atta ched,sea led,insulated Insulation A Insilialleflon and installed in accordance with the criteria of Section 610.1.Ducts in attics must be insulated to a.rn.ininnum of R-6. accessible manual or automatic thermostat for each system. HVAC Controls GENERAL DIRECTIONS levels of the ecirpment being installed.Ali R-values and efficiencies installed must meet or exceed 1. On Table 6C-1 indicate the R-value of the insulation being added to each component and the efficiency the minimum values listed.Components and equipment neither being added nor renovated may be left blank follows.Total the areas of all glass windows,sliding glass doors and glass door panels.Double the 2, ADDITIONS ONLY.Determine the percentage of new glass to conditioned floor area in the addition as, he addition,an amount equal to the total area of this glass may be area of all nonvertical roof glass and add A tothe previous total.When glass in existing exterior walls is being removed or enclosed by t subtracted from the total glass area.Divide the adjusted glass area total by the conditioned floor area of the addition.Mulliply by too to get the pecent Find the largest glass percentage under which YOur heat gain coefficient SHGG).For a given glass type age falls on Table 6C-2.Pre walls of the house and being reinstalled in the addition do riot have calculated percent scriptivesare given bythe type of glass(single or double pane)and the overhang(OH)paired with a solar and overhang,the minimum solar heat gain coefficient allowed is specified.Actual glass windows and doors previously in the exterior ss in the addition must meet the requirement for one of the options in the glass peurdage category to comply with the overhang and solar heat g in coefficient requirements on Table 6C-2.All new gla a you indicated.The overhang(OH)distance is measured perpendicularly from the face of the glass to point directly under the outermost edge of the overhang. 3, RENOVATIONS ONLY.Replacement glass needs to meet the following requirements.Any glass type and solar heat gain coefficient my be used for glass areas which are under at least a 2-foot overhang and whose lowest edge does not extend further than 8 feet from the overhang.Glass areas being renovated that do not meet this criteria must Neither single-pane tinted,double-pane clear or double-pane tinted. 4 BUILDING SYSTEMS.Comply when new system is installed for system installed. 5. Complete the information requested on the top hall of page 1 6 Read"Minimum Requirements for Small Addilions and Renovations,"Table SC-3,and check all applicable items 7 Read,sign and date the"Owner/Agent"certification statement on page 1. FLORIDA BUILDING CODE-BUILDING 13-D.34R City of Atlantic Beach AP.PL CATION NUMBER Building Department rFo be assigno d b the Building Department.) F;7- 800 Seminole Road Atlantic Beach, Florida 32233-5445 Phone(904)247-5826 - Fax(904)247-5845 Date routed: E-mail: building-dept@coab.us City web-site: hftp://www.coab.us APPLICATION REVIEW AND TRACKING FORM ent review required Yes No Property Address: B Applicant: 70.5.5 C�At A- annins&Zoning-N 1'ree hlfs�or Project: Public Works Public Utilities Z Irl Public Sa fety Fire Services Review fee $ Dept Signature Other Agency Review or Permit Required Review or Receipt Date of Permit yerffiedj3y 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: E36-p/roved. [:]Denied. (Circle one.) Comments: BUILDING PLANNING &ZONING Date- Reviewed by,4zrTAe^ TREE ADMIN. Second Review: FlApproved as revised. F-]Denie,-; PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: FlApproved as revised. [—]Denied. Comments: Reviewed by: Date: Revised 05114/09 13UILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Road, Atlantic Beach, FL 32233 Office (904) 247-5826 Fax (904) 247-5845 ok 1'1�1 1, Job Address: SZ71-93 —Permit Number: timir Lor I�L Legal Description & Parcel# WoMor Area ot Sq.Ft. - Proposed Work heated/cooled -7 Valuation of Work$ n-henfi-d/cooled Class of Work(circle one): New Addition (:A�lte�ration Repair Move Demolition pool/spa window/door Use of existing/proposed structure(s) (circle one): Commercial esident* <: EE5 No If an existing structure,is a fire sprinkler system installed? (Circle one). es'DDI� GD Florida Product Approval# For multiple products use product approval form Describe in detail the type of work to be performed: FAICGOS6 VAVt7- C-1-fZ1xiAS p" &44E 41e . &F_4d tAxxy Fc4aAS 91AC16our. AIW CM1x,&r5&ND AW4&SM1_5 X�/Mor,6a_ 9*rq PropertV Owner Information: Name: Address: —ei Q��K C city L_ 'State ip Phone E-Mail or e Contractor Information: CONTRACTOR EMAIL ADDRESS: Company Name: r,-s aoot /r/,79!�/C Qualifying Agent: )t�OS S Address: &-t* 1911R, Al —City_"WK5M%/XtC AC" State FI. zip 3?,Z,5-0 Office Phone �qjjq� gV-:g2_7? Job Site/Contact Number q6q-9171- JZ 71 Fax State Certification/Registration 4 Architect Name &Phone 4 'DFAIAII-S Engineer's Name&Phone# Fee Simple Title Holder Name and Address Bonding Company Name and Address Mortgage Lender Name and Address 4pplication is hereby inade to obtain a perinit to do the work and installations as indicated I certifi,that no work or im tallation has commenced prior to the issuance ofapermit and that all work will be peiforined to ineet the standards ofall laws regulating construction in t.hisj,trisdiction. This permit becomes null and void ifivork is not cominenced within six(6)months, or i(construction or work is suspended or abandonedfor a per,od ofsix�6)months at any thne after work is commenced I understand that separate perinits must be sectiredfor Electrical-Work, Plumbing�Signs, ff,'elh,Pools, urnaces, Boilers, 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 FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YO UR NOTICE OF COMMENCEMENT. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions ofl sandordinances overningthis type of work will be c plied with whether specified herein or not. The granting of a pernn't does not presume ta—an 6 thority to violat or cancel the .a,,sta mance a provisions ofany othe,-7,", te, o law regulating co stri tion or the perfoi fconstruction. Signature of Owj AA Signature of Contractor lintName Print Name C).A .......... ..... . ..... . ................. Before me this " ---Day of PRC\1 204"V t i y of 20 A A If PJA 114A 41 % of;P�t, � I — -1 �Z-ca�-Vul)rid V w W _VV Revised 01.26.10 City of Atlantic Beach APPLICATION NUMBER Building Department (To be assigned b the Building Department.) 800 Seminole Road Atlantic Beach, Florida 32233-5445 Phone(904)247-5826 - Fax(904)247-5845 Date routed: 27, E-mail: building-dept@coab.us City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: 7 nt review required Y No Applicant: At &I Planning Zoning I ree 701111111S or Public Works Project: Public Utilities AiN;b Z '31 Public Safety /Y AU Fire Services Review fee $ Dept Signature Review or Receipt Other Agency Review or Permit Required of Permit Verified By Date Florida Dept. of Environmental Protection Date— Florida Dept. of Transportation St.Johns River Water Management District m Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: E�Approved. E]Denied. (Circle one.) Comments: ILDING PLANNI ZONING Reviewed by: Date: TREE ADMIN. rflied. Second Review: RApproved as revised. nied. PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: RApproved as revised. E]Denied. Comments: Reviewed by: Date: Revised 05/14109 NOTICE OF COMMENCEMENT 0 iPPEPARE IN DUPLICATE) 1-- Permit No.___ Tax Folio No State of County of a- 0 To whom it may concern: The undersigned herelv informs you that improvements wilt be made to certain real property,and In M C) accordance with Section 7jr ofthe Florida Statutes,the fo(loyvinc information Is stated In this NOTICE OF 16 COMMENCEMENT. Legal description of property being improved: 3'�—S10q25'-2-I r:- -j 0 (JAJ 17 �p C', ow U Address o pro ing improved: 2 2!z 0 E 10 5 W :3 in z cc X 0 X General description of improvelfflents: nt�t,,.,v I#vo eeFwcion-c PjgAj ev!�� ptc)-09-5 Owner. Addre.ss ic I lk�� Owner's interest in site of the in iprovement Fee Simple Titleholder(if other than ovaner) Name A-1 Address ContractorC L-I IN r Address PS 6(y F1.3 Phone No. 90q— RL tq. Surety(if any) 2-77 Fax No Address --Amount of bond$ Phone No. Fax No, Name and address of any person making a to construction of the improvements. Name Address Phone No. Fax No. Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may belp d Name e4-7�44kljVC— RocJ,6� Address Phone No. In addition to himself,owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 713.06(2)(b),Florida Statutes.(Fill in at Owner's option). Name 6&AKA"#;1 .T Address Phone No. Fax No. Expiration date of Notice of Commencement(the expirati date is year frole date of recording unless a different date is specified): THIS SPACE FOR RECORDER'S USE ONLY 1 0 NE le A DATL B 'e me this ay of ct P I" daler, "" me qhFR 4ege I: I,of 7 or '0� I Coun 1 ias personalty appeared hater by himself/hen MICHAEL WILLIAMS are true and vo,W Notary Publit:-State of Florida My Comm Expires Apr 8,2018 ,ommission # FF 110931 ----fy Public at Large.,State of Note I Couirty Of My commission expires, Personally Known or Produced Identificallon 7r, . V A . CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 r lilt Application Number . . . . . 14-00000634 Date 5/20/14 Property Address . . . . . . 165S SEA OATS DR Application type description RESIDENTIAL ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 75000 ---------------------------------------------------------------------------- Application desc chg garage to living space ---------------------------------------------------------------------------- Owner Contractor ------------------------ ------------------------ BUCHWALTER, ANDREW J ROSS QUALITY INC 10453 HUNTER CREEK CT 1S18 6TH ST JACKSONVILLE FL 32256 JACKSONVILLE BEACH FL 32250 --- Structure Information 000 000 CHANGE GARAGE TO LIVING SPACE Occupancy Type . . . . . . RESIDENTIAL ---------------------------------------------------------------------------- Permit . . . . . . ELECTRICAL PERMIT Additional desc . . Sub Contractor . . RIGHTWAY ELECTRICAL CONT. INC Permit Fee . . . . 76 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 11/16/14 ---------------------------------------------------------------------------- Special Notes and Comments 2010 FLORIDA BUILDING CODE, 2008 NATIONA1 ELECTRIC CODE *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. WINDOW AND DOOR INSPECTION: *INSTALLATION INSTUCTIONS REQUIRED *ALL STICKERS ARE TO REMAIN ON THE WINDOWS *PROVIDE ACCESS TO ALL WINDOWS TO INSPECT FASTENERS * IF SMOKE ALARMS ARE NOT CURRENTLY INSTALLED IN HOME, INSTALLATION OF THEM IS REQUIRED NOW, PREFERABLLY HARDWIRED THROUGHOUT; IF THERE IS A FOSSIL FUEL APPLIANCE IN THE HOME A CARBON DIOXIDE DETECTOR IS REQUIRED WITHIN 10 FT. OF EVERY BEDROOM DOOR. * ---------------------------------------------------------------------------- Other Fees . . . . . . . . . STATE ELEC DCA SURCHARGE 2 . 00 STATE ELEC DBPR SURCHARGE 2 . 00 ---------------------------------------------------------------------------- Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 76 . 00 76 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 PERMIT IS0JP-hWEIF0RL)TAtA*�ORDANCE WITH4A-LV:hTV OF ATLA4-PIOCAEACH ORDINAN(!AOAND THE FLORID100 BUILDING CODES. CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 Page 2 Application Number . . . . . 14-00000634 Date 5/20/14 Grand Total 80 . 00 80 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. ELECTRICAL PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd, Atlantic Beach, Fl, 32233 Ph(904) 247-5826 Fax (904) 247-5845 JOB ADDRESS: I�,SS _S rj od -T S J)I PERMIT # lj - 6 J,/ JEA INFORMATION REQUIRED ON ALL PERMITS AMPS VOLTS PHASE VALUE OF WORK S NEW SERVICE El Overhead Fj Underground ED Underground up Pole LIResidential(Main) Service [10-100 amps El 10 1-15 Oamps 0 151-200amps El_____amps #of Meters 0 Commercial(Main)Service El 0-100 amps El 101-1 50amps El 151-200amps O_ amps OCT Service amps Conductor Type Size OMulti-Family(Main)Service 110-100 amps 11101-1 50amps El 151-200amps 0 amps of Unit Meters OTemporary Pole 0 amps SERVICE UPGRADE El_____amps El CT Service amps NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES,ETC.) 0100amps E150amps E1200amps El amps OCT Service amps ADDITIONS,REMODELS,REPAIRS,BUILD-OUTS,ACCESSORY STRUCTURES,ETC. Outlets/Switches: __I(e_0-30amps 31-100amps 101-200amps Appliances: __A_0-30amps 31-100amps 101-200amps A/C Circuits: 0-60amps 61-100amps Heat Circuits: # circuits Number of Lighting Outlets, Including Fixtures: I OTHER ELECTRICAL PROJECTS El Swimming Pool 0 Sign El Smoke Detectors_Qty El Transformers KVA EMotors hp FIRE ALARM SYSTEM (Requires 3 sets of plans) Qty_volts/amps VALUE OF WORK$ REPAIRS[MISCELLANEOUS Ei Replace Burnt/Damiaged Meter Can El Safety Inspection OPanel Change COH to UG El Other: Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction. Property Owners Name Phone Number Electrical Company R14147-t�IA-� ftjFc1-n1CA( CcNTAACr01--j —Office Phone �-r i -I 16 1— Fax ?Ti- ) 2c,7- Co.Address: I_S-�j S.4mrrrjAjv-1 t.,IA-r � _ City 14--f CC14 State Ft Zip 3,22 ,� C License Holder(Print): _j&oi3 T,4N.tj4:L1(2 State Certification/Registration#j 3OCelle-11- Notarized Signature of License Holder Before me this 020 Zdayd Signature of Notary Pub CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 Als) Application Number . . . . . 14-00000634 Date 5/29/14 Property Address . . . . . . 1655 SEA OATS DR Application type description RESIDENTIAL ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 75000 ---------------------------------------------------------------------------- Application desc chg garage to living space ---------------------------------------------------------------------------- Owner Contractor ------------------------ ------------------------ BUCHWALTER, ANDREW J ROSS QUALITY INC 10453 HUNTER CREEK CT 1518 6TH ST JACKSONVILLE FL 32256 JACKSONVILLE BEACH FL 32250 --- Structure Information 000 000 CHANGE GARAGE TO LIVING SPACE Occupancy Type . . . . . . RESIDENTIAL ---------------------------------------------------------------------------- Permit . . . . . . MECHANICAL HVAC PERMIT Additional desc . . Sub Contractor . . DONOVAN HEATING & AIR Permit Fee . . . . 83 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 11/2S/14 ---------------------------------------------------------------------------- Special Notes and Comments 2010 FLORIDA BUILDING CODE, 2008 NATIONAl ELECTRIC CODE *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. WINDOW AND DOOR INSPECTION: *INSTALLATION INSTUCTIONS REQUIRED *ALL STICKERS ARE TO REMAIN ON THE WINDOWS *PROVIDE ACCESS TO ALL WINDOWS TO INSPECT FASTENERS * IF SMOKE ALARMS ARE NOT CURRENTLY INSTALLED IN HOME, INSTALLATION OF THEM IS REQUIRED NOW, PREFERABLLY HARDWIRED THROUGHOUT; IF THERE IS A FOSSIL FUEL APPLIANCE IN THE HOME A CARBON DIOXIDE DETECTOR IS REQUIRED WITHIN 10 FT. OF EVERY BEDROOM DOOR. * ------------------------------------------------------------- other Fees . . . . . . . . . STATE MECH DCA SURCHARGE 2 . 00 STATE MECH DBPR SURCHARGE 2 . 00 ---------------------------------------------------------------------------- Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 83 . 00 83 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 PERMIT isaLfeheNEIFOIRLVI'OtAXiLORDANCE WITHUIaQATY OF ATLA4110 CAEACH ORDINANCAOAND THE FLORIWQ 0 BUILDING CODES. 1..0 , P C, CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 ills) Page 2 Application Number . . . . . 14-00000634 Date 5/29/14 Grand Total 87 . 00 87 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. MECHANICAL PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd Atlantic Beach, FL 32233 Ph (904) 247-5826 Fax (904) 247-5845 IoB ADDRESS: kuss :5e-A 0 a_�5 PERMIT#_L412j— PROJECT VALUE $ 5000 so ARI# -7004104 —REQUIRED Air Handling Equipment Only X Air Handling Unit & Condenser Condenser Only NEW AIR CONDITIONING & HEATING SYSTEM INSTALLATION Air Conditioning: Unit Quantity I Tons Per Unit I Seer Rating Heat: UnitQuantity_ BTU'sPerUnit 11000 REQUIRED Duct Systems: Total CFM REPLACEMENT AIR CONDITIONING & HEATING SYSTEM INSTALLATION Air Conditioning: Unit Quantity Tons Per Unit Heat: Unit Quantity BTU's Per Unit Seer Rating REQUIRED Duct Systems: Total CFM FIRE PREVENTION Fire Sprinkler System Quantity (Requires 3 sets of plans) Fire Standpipe Quantity (Requires 3 sets of plans) Underground Fire Main Value (Requires 3 sets of plans) Fire Hose Cabinets Quantity (Requires 3 sets of plans) Commercial Hoods Quantity (Requires 3 sets of plans) Fire Suppression Systems Quantity (Requires 3 sets of plans) FIRE PLACES MISCELLANEOUS: Prefabricated Fireplace Qty Automobile Lifts Gas Piping Outlets Boilers BTU's Elevators/Escalators ALL OTHER GAS PIPING Heat Exchanger Quantity of Outlets Pumps #Vented Wall Furnaces Refrigerator Condenser BTU's Water Heaters Solar Collection Systems Tanks (gallons) Wells OTHER: Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months.I hereby certify that I have read iis application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified or ot. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction. Property Owners Name, y C)r%yv q Phone Number I I Office Phone Zql-51,tlr Fax 7-11 319f Mechanical Company _�)&yA 9Y 4--_ LC Co. Address: 2515 (,4—j\ AIrt city—YUX 9 C-4, State fl zip S-gro License Holder (Print): State Certification/Registration# Notarized Signature of License Holder RICHAk Before me thiVs day of 1)1 20 �D TOMPKINS j.- TA Commission#FF 040399 Expires July 29,2017 Signature of Notary Public awded Tin Tmy Fain[=Kam$8"5-7019 CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 lit ,C)AI Application Number . . . . . 14-00000634 Date 6/12/14 Property Address . . . . . . 1655 SEA OATS DR Application type description RESIDENTIAL ALTERATION Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 75000 ---------------------------------------------------------------------------- Application desc chg garage to living space ------------------------------------------------------------- Owner Contractor ------------------------ ------------------------ BUCHWALTER, ANDREW J ROSS QUALITY INC 10453 HUNTER CREEK CT 1518 6TH ST JACKSONVILLE FL 32256 JACKSONVILLE BEACH FL 32250 --- Structure Information 000 000 CHANGE GARAGE TO LIVING SPACE Occupancy Type . . . . . . RESIDENTIAL ---------------------------------------------------------------------------- Permit . . . . . . PLUMBING PERMIT Additional desc . - Sub Contractor . . FOSTER PLUMBING, INC. Permit Fee . . . . 111 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 12/09/14 --------------- ------------------------------------------------------------- Special Notes and Comments 2010 FLORIDA BUILDING CODE, 2008 NATIONAl ELECTRIC CODE *REPORT ANY UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT IMMEDIATELY. WINDOW AND DOOR INSPECTION: *INSTALLATION INSTUCTIONS REQUIRED *ALL STICKERS ARE TO REMAIN ON THE WINDOWS *PROVIDE ACCESS TO ALL WINDOWS TO INSPECT FASTENERS * IF SMOKE ALARMS ARE NOT CURRENTLY INSTALLED IN HOME, INSTALLATION OF THEM IS REQUIRED NOW, PREFERABLLY HARDWIRED THROUGHOUT; IF THERE IS A FOSSIL FUEL APPLIANCE IN THE HOME A CARBON DIOXIDE DETECTOR IS REQUIRED WITHIN 10 FT. OF EVERY BEDROOM DOOR. * ------------------------------------------------------------ -------- Other Fees . . . . . . . . . STATE PLBG DCA SURCHARGE 2 . 00 STATE PLBG DBPR SURCHARGE 2 . 00 ---------------------------------------------------------------------------- Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 111 . 00 111 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 PERMIT IS4AfKEIFSqLYT1RWORDANCE WITH4A'LqOCITY OF ATLA#49EACH ORDINANcAOAND THE FLORIDAOO BUILDING CODES. ss CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH, FL 32233 INSPECTION PHONE LINE 247-5814 5111s) Page 2 Application Number . . . 14-00000634 Date 6/12/14 Grand Total 115 . 00 115 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. PLUMBING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd Atlantic Beach, FL 32233 Ph(904) 247-5826 Fax(904)247-5845 JOB ADDRESS: (a_3Z2S -��A nizr< PERMYr# SL4 NEW OR REPLACEMENT INSTALLATION: Project Value TYPE oF FixTuPm QTY TYPE oF FIXTURE QTY Bathtub _t — Septic Tank&Pit Clothes Washer Shower Dishwasher q Shower Pan Drinking Fountain Slop Sink Floor Drain Three Compartment Sink Floor Sink Toilet Hose Bibs Urinal Kitchen Sink Vacuum Breakers Laundry Tray Water Connected Appliances Lavatory Water Heater Other Fixtures Water Treating System RE-PIPE: TYPE oF FIXTURE QTY TYPE oF FIXTURE QTY Bathtub Septic Tank&Pit Clothes Washer Shower Dishwasher Shower Pan Drinking Fountain Slop Sink Floor Drain Three Compartment Sink Floor Sink Toilet Hose Bibs Urinal Kitchen Sink Vacuum Breakers Laundry Tray Water Connected Appliances Lavatory Water Heater Other Fixtures Water Treating System MISCELLANEOUS: • Sewer Replacement D Back Flow Preventer El Grease Interceptor(Trap) gallons(Requires 3 sets of plans) • Lawn Sprinkler System-Number of Heads— Ei Well ** SJRWD Well Completion Form. Completed form to be submitted to the Building Department for final inspection." i-i Other hereby certify that I have read Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months.I this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction. �oe Property Owners Name A rJ OR rf—E-0 =_T�' Phone Number -0-20'7 Fax<55?J-0"70_"7 Plumbing Company Office Phone 4Z e_:WC1(3S p Co. Address: '---I Cit,_4 I�StateiE,(—n Zip ion# CfC- License Holder(Print): n-e-1 State Certification/Registrat Notarized Signature of License Holder 20 eo' Nouary putoic Stat&of FIxide e this of ShIdey L Graham My COMM1881on FF 0 %nat e of Notary Pub EXPIMS 02/14/2018