1163 BEACH AVE WDO 2015CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL ALT/OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID:
15-RAAR-166
Job Type:
RESIDENTIAL ALTERATION
Description:
wdo
Estimated Value:
$1,200.00
Issue Date:
1/30/2015
Expiration Date:
7/29/2015
PROPERTY ADDRESS:
Address:
1163 BEACH AVE
RE Number:
170272-0000
PROPERTY OWNER:
Name:
ADAMS, CHARLES P
Address:
1163 BEACH AVE
GENERAL CONTRACTOR INFORMATION:
Name:
WORSHAM CONSTRUCTION CO INC
Address:
2329 URBAN RD QA RONALD E WORSHAM
Phone: - -
PERMIT INFORMATION:
FEES:
STATE DCA SURCHARGE
$2.00
STATE DBPR SURCHARGE $2.00
BUILDING PERMIT FEE $56.00
Total Payments: $60.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITU OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904) 247-5845
Job Address: %/�_ � r+� ,4ye-- Permit Number:
Legal Description
Valuation of Work $ 60 . so
Parcel #
oor rea o
Proposed Work
q. t.
heated/cooled
t
non-heated/cooled
Class of Work (circle one): New Addition AlterationRepair
Use of existing/proposed structure(s) (circle one): Commercial
If an existing structure, is a fire sprinkler system installed? (Circle one):
Florida Product Approval #
For multiple products use product approva orm
Describe in detail the type of work to be performed:
Propertv Owner Information•
Name: [„r q,l.L�� (, 2410421,<S t
j� Address:
City AngA.Xe_ t 1, State )'C Zip 3z�Phone
E -Mail or Fax # (Optional)
Move Demolition pool/spa window/door
Residential
Yes No N /A
�4S- zs s7
Contractor Information: CONTRACTOR EMAIL ADDRESS: WOA5A4✓14
Company Name: Qualifying Agent: t� raj
Address: City 1 State Zip3zZ..-y
Office Phone Job Site/ Contact Number Fax #
State Certification/Registration # /, L
Architect Name & Phone #
Engineer's Name & Phone #
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and Address
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the
issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. This permit becomes null
and void of work is not commenced within six (6) months, or if construction or work is suspended or abandoned for a period of six 6) months at any time after
work is commenced. I understand that separate permits must be secured for Electrical Work, Plumbing, Signs, Wells, Pools, Furnaces, Boilers, Heaters,
Tanks and Air 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 YOUR NOTICE OF
COMMENCEMENT.
I hereb certify that I have read and examined this application and know the same to be trate and correct. All provisions of laws and ordinances governing this
type o work will be complied with whether sped ted herein or not. The granting of a permit does not presume to gave authority to violate or cancel the
provisions of any other federal, state, or local law regulating construction or the performance of construction.
Signature of Owner rw_ Signature of Contract
Print NameC�Q r� �.......... ....r ........................... Print Name Rob
Before me Before
this .12. Day of a is ay of
4? "ty Notary Public State of Florida
Notary Ub11C7uly Commission EE112987 Ota P tate of Florida
rj' i le aham
dor n°'F Ex4*0 10/24/2015 < om i FF 086990
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