88 Nicole Ln 2015 Screen room CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
J ;r ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL ADDITION
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-SB14
JOB INFORMATION:
]Ob ID: 15-SCRN-132
Job Type: SCREENED ENCLOSURE
Description: REMOVE EXISTING, ENLARGE PATIO, NEW SCRN
ENCLOSURE
Estimated Value: $6,000.00
Issue Date: 2/11/2015
Expiration Date: 8/10/2015
PROPERTY ADDRESS:
Address: 88 NICOLE LN
RE Number: 169519-0715
PROPERTY OWNER:
Name: PEARLMUTTER, NEIL S
Address: 88 NICOLE LN
GENERAL CONTRACTOR INFORMATION:
Name: TROPICAL ENCLOSURES BY MASTER
Address: 4411 KELNEPA DR QA SCOTT RAY NORTON
Phone: - -
PERMIT INFORMATION: PUBLIC WORKS:
Roll off container company must be on City approved list and container cannot be placed on
City Right-of-Way. (Approved: Advanced Disposal, Realco Recycling, Republic Services,
Shapell's and Waste Pro.)
Full erosion control measures must be installed and approved prior to beginning any earth
disturbing activities. Contact Public Works (247-5834) for Erosion and Sediment Control
Inspection prior to start of construction.
FEES:
ENG REV RESIDENTIAL BLD $25.00
PLAN CHECK FEES $40.00
UTIL REV RESIDENTIAL BLDG $25.00
BUILDING PERMIT FEE $80.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
CITY OF ATLANTIC BEACH
S 800 SEMINOLE ROAD
J ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
�~ r
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $174.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
2 , BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH JAN 16
800 Seminole Road,Atlantic Beach, FL 32233
Office (904)247-5826 Fax (904) 247-5845 By
Job Address: �� /� tT(�UCQ G..� . �C Permit Number: 015-5cl?IV �-
Legal Description L4 ( Ti�K losi 4e .Qe� Parcel #
For a o q.Ft. t
Valuation of Work$� w Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New <2dditio Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s) (circle one): Commercial Residential F -
If an existing structure,is a fire sprinkler system installed? (Circle one): Yes No N;/
Florida Product Approval#
OPY
For multiple products use product ap TOrm
FILE C
Describe in detail the type of work to be performed: maV2 ext' inq
OtAd CWS uc�
�' new sc.1,ePhc`asc4r1e
Propertv Owner Information:
Name: ea ( OLnd K44tL1w 4Add
ress:
City fx fn. StateIR-Zip ' 33 Phone s`4? —9$77
E-Mail or Fax#(Optional)
Contractor Information: CONTRACTOR EMAIL ADDRESS:
,V rCr�ComPanY Name � 2nCjoSG� �u
al L*fying Agent: .Sc044-xr)o P_
Address.W60 W4,66 C City -jo-y- State l Zip 7224-5
Office PhoneJob Site/Contact Number 571/-S'3// Fax# 9,99 3yp-o 31
State Certification/Registration# 5 cc t.$( (S"D 28I' 13
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 if 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 hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this
type o work will be coma..
lied with whether specified herein or not. The granting of a permit does not presume to gi e authority to violate or cancel the
arovisions of anor local law regulating construction or the performance of construction.
3i ature of .. _;e,
// Signature of Contract
Tint Name l
...... .... .. ..... ../V .............. Print Name �oPL c
3efore me Before me
his D'y of 20 this 16 Day of 20 $�
Zot y vuytKEVIN WAYNE NEWSOME t KEVI WAYNE NEWS
Qi MY COMMISSION#EE108253 °, +'! 'MY Comm1I9 SION# E108253
` AX61ed 1.26.10
EXPIRES June 30,2015 �'' EXPIRES June 30,
=;mora.••• �;le• �
(407);, 0153-°- -=klorfdalloteiYSeiilfce.CAr11 v.. _asp c .r • .c .__^--
FILE COPY .,
TIFFANY BY THE SEA HOMEOWNERS ASSOCIATION
920 3rd STREET, SUITE - �E
NEPTUNE BEACH, FLORIDA 32266
(904) 242-0666
January 13, 2015
VIA EMAIL: NEILSPERL@YAHOO.COM
VIA EMAIL: TROPICALENCLOSURES@GMAIL.COM
Neil and Kathryn Perlmutter
88 Nicole Lane
Atlantic Beach, FL 32233
Re: Lot # 1 ® Screen Enclosure Enlargement APPROVAL
Dear Mr. and Mrs. Perlmutter:
This letter will serve as approval of your request to enlarge your existing screen
enclosure per your submittal, the attached survey and drawings. It is understood that
the enclosure will match the color and contour of the existing house.
Per the Covenants and Restrictions, "no structure or other improvement or change in
the topography of the land shall be erected or made which interferes in respect with
drainage or utility easements shown on the subdivision plat."
The homeowner is responsible for obtaining necessary permitting and approvals.
Please forward a copy of the permits to this office for your file. Please note this
approval is subject to all code and legal compliance with City, County, and
State agency approvals, if necessary.
This letter will be placed in your file for future reference.
TIFFANY BY THE SEA HOMEOWNERS ASSOCIATION
Attachments: As stated
cc: Board of Directors
i
MAPO SHOWI
NG SU EY OF.
LOT 1, TIFFANY BY THE SEA, AS RECORDED IN PLAT BOOK 46, PAGES 94 AND 94A
OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLOR]&A-
3
I
NICOLE LAN E
o PARCEL "B" PRIVATE STREET 40' RIGHT-OF-WAY
,0 ,Z���� N 89'46'20"E 34.27'
\ J OHO CJ ,yD4j w (N89'47'37"E 34.36' FIELD)
U G� << FOUND 1/2" IRON FOUND 1/2" IRON
f—'0 PIPE (R 4144) PIPE (L9 3672)
t, \ W — —
z
7.5' JEA CONCRETE
p��4j O OO,OO EASEMENT DRIVE
c., Q, 00
�x
Q CLEANOUT
21.2'
39
00
ui
a :D Nva 0 o
Q a I o COVERED (n Z d Lq w
Q 3 z ENTRANCE
w
< o w 19.2 ' O Z O.4.4' G' U 0. 0 _
��
o y J 4.0 .%'
r LI LOT 2
o N o Z6 h V; 0 1.s' 1.t' W
N V
L L liJ r o 1.2'
Lr) ,. 14c' F- ,� 5.o I o -t
O r �' w F i 4' WOAD FENCEoo
4
cr
0 -, - � z
_ o z w 19:3' ?
a 0.2p O N CO
o x 1E
z �� N z
W A CONCRETE1Ytgc�
WALK
i N Z Z'
r 1.T 6' WOOD F CE 0.7'\.
FOUND 4"X4" CONCRETE
MONUMENT (NO ID)
S89'46'20"W
(S89'34'42"W 59 "
OFFICIAL
NOTES:
1, THIS IS A BOUNDARY SURVEY
2. NO BUILDING RESTRICTION '
FILE COPY
AFFIDAVIT FOR ATTACHING A NEW STRUCTURE TO AN EXISTING STRUCTURE
TO: Building Inspection Department, City of Atlantic Beach, 800 Seminole Road
Home Owner: W q; l &" KA en(,A -lav, tm to t kA
Name
9 g .0 6o li n .
Street Add ess
City. State and Zip Code
Contractor:,---S0'2' Y'1 //=J 0 tz ' -;' `
Permit Number 15;-' --5C 2 Al— l 3
As the Contractor for the proposed new structure located at the above address,I have personally viewed
with the above named home owner those portions of the existing structure on which portions of the
proposed new structure are to be attached for structural support. I am confident that the drawings and
details included with this pen-nit application depict the existing conditions of the host structure, and the
members of the existing structure upon which the new structure are to be attached are sound with no rot
or deterioration. The home owner has been advised by me that, in my best judgment based on experience
and knowledge of structural adequacy, the members of the existing structure upon which the new
structure are to be attached are sound with no rot or deterioration and will support all structural loads and
forces imposed on them. By signing below, I hereby declare that I will hold the City of Atlantic Beach
harmless and release it from any responsibility and liability for any adverse consequences or failures
resulting from this work, and further that I will not initiate, execute or enjoin any legal action against the
City of Atlantic Beach for such consequences or failures.
A copy of this document will be recorded as an official record with the Building Inspection
Department permit history so that any and all future buyers/owners of this property may be made
aware of the st s of work performed on this structure.
Signed Date / l /1 / IS'--'
Before me this _day of
In the County of Duval, State of Florida,has rersonally appeared
"SC-0 �J— Jv'5 to� ` herein by himself/herself and
Affirms all state ents a declarations herein are true and accurate. ;....
KEVIN WAYNE NEWSOfNE
MY COMMISSION#EE108253
EXPIRES June 30,2015
(4G43n 1'3 Floridallotaryservice.com
Not ublic at Ldrge, State of FL , County of Ltv ®`
Personally Known ✓Produced Identification
ID Type
F:building/affidavit for attaching a new structure to an existing structure.docx 7/21/09
J,
FILEC HOMEOWNER SUNROOM ENCLOSURE AFFIDAVIT
The purpose of tNs document is to make you aware of any limitations in the enclosure that is being permitted at your
residence. The table below, Sunroom and Screen Enclosure Requirements provides a brief description of the various
sunroom category requirements. There may restrictions on the use of your present home depending on the category.
Of Sunroom you are installing. The property owner is hereby notified that should they make changes to the sunroom
which could include, but not be limited to, addition of any form of temperature control system or removal of the
doors/windows separating the sunroom from the host structure,'the room may become non-.compliant with the
requirements as mandated by the Florida Building.Code, the Florida Model Ehergy:Code and State Statutes.
_ OWNER
6have read Ihis compl�le�form ane ,land i ani receiv+inpcategory: I Sunroorn.((I-VV) ` /� (�� �,
Printed Name v` -- � u`Y"" Address,08 lV f�.,p l`— �..h' • A' l . f 3cA,
igncd: VW-- — ate: I I
licforc me Ihis-_/_4_____day of �0 _in Cout al tate of Florida,has personally appeared
_' 4rcih "4 rein by himselr/herself and afrirms all
statements and declarations herein are true and accurate.
Q�� uu;
Notary public❑I Large,Stale of_i' _.County of tfKEVIN WAYNE NEWSOME
Personally Knownor Produced Idenlifrcat'iun❑ 3,• Y COMMISSION#EE108253
u> ryp -. ... . ....- -- ---- - - --- - --- -------- ----- --- - ---- =•„r,�---E”- 3ES June 30.2015
(407)39M153 FloddallotaryService.com
St)nroom and Screen Enclosure Requirements
Category II Ill. IV V _
Habitable Space No No No Yes Yes
Foundation Walls <200plf Walls-<200plf Walls<200plf can Walls e,200plf Walls <200plf can
can have can have` have 8"Wx12"D ftg can have have 8"Wx12"D ftg
8"Wx12"D ftg or 8"Wxl2"D ftg or or 3-1/2"slab if no 8"Wx12"D ftg
3-1/2" slab if no 3-1/2"slab if no concentrated load
concentrated concentrated >750lb
load>7501b load>750lb"
Existing exterior Relocate to Relocate to Relocate to Relocate to Relocate to
GFI Breaker exterior if exterior if exterior if enclosed exterior if exterior if enclosed
enclosed enclosed enclosed
Exit Lighting Not Required Required .Required Required Required
Interior Electric Not Required Not Required Not Required Required Required
Outlets_
Emergency Egress from Egress and Exit Egress and Exit Egress and Egress and Exit
Escape exist. structure must meet code must meet code. Exit must meet must meet code.
Openings allowed if open to code.
atmosphere and
has screen door
leading away
from residence.
Misc. Window Host structure Windows must Windows may be. Host structure Host structure
and Door windows/doors be removable fixed or windows & windows& doors
Requirements shall not 15 . Host structure. removable. Host " doors shall not may be removed.
removed. windows/doors structure windows be removed. Forced entry,air
shall not be and doors shall not Forced entry, leakage and water
removed. be removed. air leakage penetration
Forced entry, air and water requirements
leakage and water penetration apply.
penetration requirements
requirements apply.
apply..
Wind BorneNotif Required, Required, can be
.Required
Debris Opening unless built on host structure,
Not Required Not Required host structure is
Protection under an if built under
protected existing roof existing roof
Energy Sheets Not Required Not Required Not Required Required Required
TIFFANY BY THE SEA HOMEOWNERS ASSOCIATION
920 3rd STREET, SUITE B
NEPTUNE BEACH, FLORIDA 32266
(904) 242-0666
January 13, 2015
VIA EMAIL: NEILSPERL@YAHOO.COM
VIA EMAIL:TROPICALENCLOSURESC-GMAIL.COM
Neil and Kathryn Perlmutter
88 Nicole Lane
Atlantic Beach, FL 32233
Re: Lot # 1 ® Screen Enclosure Enlargement APPROVAL
Dear Mr. and Mrs. Perlmutter:
This letter will serve as approval of your request to enlarge your existing screen
enclosure per your submittal, the attached survey and drawings. It is understood that
the enclosure will match the color and contour of the existing house.
Per the Covenants and Restrictions, `ono structure or other improvement or change in
the topography of the land shall be erected or made which interferes in respect with
drainage or utility easements shown on the subdivision plat."
The homeowner is responsible for obtaining necessary permitting and approvals.
Please forward a copy of the permits to this office for your file. Please note this
approval is subject to all code and legal compliance with City, County, and
State agency approvals, if necessary.
This letter will be placed in your file for future reference.
TIFFANY BY THE SEA HOMEOWNERS ASSOCIATION
Attachments: As stated
cc: Board of Directors
Yt Lrr�+ City of Atlantic Beach APPLICATION NUMBER
(To be assigned by the Building Department.)
Building Department /� I
800 Seminole Road
i
Atlantic Beach, Florida 32233-5445 1
Phone(904) 247-5826 Fax(904)247-5845
Date routed:
E-mail: building-dept@coab.us
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
N L v ent review required Yes No
Property Address:
1� E� Planning&Zoning
Applicant: � Tre inistrator
S1, p orks
�I 1Project:PN ON-C lam'`'^ i Pu is i i ies
1 1 Z P a:H(0 VCA
Pub is
vel
\j �„r� c� S 1 Fire Services
�1 5 �.`
Review fee $ Dept Signature
Review or Receipt Date
Other Agency Review or Permit Required of Permit Verified By
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: /t ,D 6-
BUILDING v
PLANNING &ZONING Reviewed by: Date: 3 ��
TREE ADMIN. Second Review: ❑Approved as revised. ❑Deni
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY
Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date-.-
Revised
ate:Revised 07/27/10
-_.4 APPLICATION NUMBER
"s,AV
;'Ji City of Atlantic Beach T
Building Department I�. (To be assigned by the Building Department.)
800 Seminole Road J
r n Atlantic Beach, Florida 32233-5445 2015
Phone(904) 247-5826 Fax(904)247-5845 1 7i3
E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us �f
APPLICATION REVIEW AND TRACKING FORM
gC� l.Yv ent review required Yes No
Property Address:
�lcaj � lJl� yJ Planning &Zoning
Applicant: Tre inistrator
Project:Re��� SGr "Po P blic orks
P� � S'C4(0 Pubic ies
C/czn Fire Services
Review fee $ S— Dept Signature I&
Other Agency Review or Permit Required Review or Receipt Dateof Permit Verified By
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: //Z&
//,C::-
TREE ADMIN. Second Review: ❑Approved 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 07/27/10
X �
—,, City of Atlantic Beach v'. --, APPLICATION NUMBER
Building Department J � ' (To be assigned by the Building Department.)
AN-2 2015
800 Seminole Road
Atlantic Beach, Florida 32233-544
J' Phone(904)247-5826 Fax(904j 845 /
E-mail: building-dept@coab.us — `�. _ Date routed:
City web-site: http://\N"coab.us —_'
APPLICATION REVIEW AND TRACKING FORM
gC� � ,f� V� l.Yv Den, review required Yes No
Property Address: �-p
II � W� U,J aPlanning &Zoning
Applicant: Tre inistrator
P blic orks
Project: e � SGY�, ,
5'C -� 11 '' Pub is Pu 1c i i ies
c/��'� S lJ� Fire Services
Review fee $ — Dept Signat e
Review or Receipt Date
Other Agency Review or Permit Required of Permit Verified By
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
+l
Reviewing Department First Review: Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING
Reviewed by: abDate:
TREE ADMIN. Second Review: [-]Approved as revised. ❑Denied.
S Comments:
C� (T/IES
PUBLIC SAFET5 Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
rt r1,y;. City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road 15—C=►�/�
a
Atlantic Beach, Florida 32233-5445
Phone(904) 247-5826 Fax(904)247-5845 Date routed:
: i ; E-mail: building-dept@coab.us
City web-site: http://\wwcoab.us �.
APPLICATION REVIEW AND TRACKING FORM
(�C� 1��� U►�1 ent review required Yes No
Property Address:
E� �r �,J Planning &Zoning
Applicant: Tre d inistrator
P blic orks
Project: Pu is i i ies
(2-�n1 Gk P�-�-�6 S'CA(� Pubic
� �,, '/ce/ryl!� Fire Services
Review fee $ Dept Signature
Review or Receipt Date
Other Agency Review or Permit Required of Permit Verified By
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: XApproved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by:� C/ /� date: lS
TREE ADMIN. Second Review- ''---Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
Reviewed by: /`_ Date:
PUBLIC SAFETY �J
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
M A SH OWI
N G SU EY OF:
LOT 1, TIFFANY B PUBLIC RECORDSEOORDUVDIN PLAT AL COUNTY,,OFFLOR DAOK 46, PAGES 94 AND 94A
OF THE CUREN
NICOLE LAN E
PARCEL "B" PRIVATE STREET 40' RIGHT-OF-WAY
C
CV O1
.° "S N 89'46'20"E 34.27'
�� Off• w (N89'47'37"E 34.36' FIELD)
UFOUND 1/2" IRON
Q GAO ff�/�/ 7d FOUND 1/2 IRON
�V i o PIPE (R 4144)
� PIPE (L9 3672) —
h
7.5' JEA CONCRETE
O (6 0 0/ EASEMENT DRIVE 'OD
�CQ O 1 O r r
r
✓�// CLEANOUT 5
J
z,.r 3
O
w a U0 co
w a O
�QQ � vUi COVERED cf) Z < w
5 ENTRANCE Ci U 0 2' L
wr
O � 0 19.2' �'a� a ' OZ
.oa2' n LOT 2
U) h. ? I-- w Li.I
uO Z . Ni,
G �� F N O LJ 4 v Q
QU W a o 1.2'
5.0
_ M OJ
yto
4' W0iuD FENCE
Ljj r- 00
C14 3: O
CJ V U'L
Zw 19;3' Air• 10.2' \ 30 0
< U
z O X � �z
O Nm I �_ PfOPOSP� V�i ri
W z CONCRETE �9126-
r n 'D WALK
V / N
2-
CV
CV 0' '
tV
0.7' 6' WOOD FENCE
1.T 6' W:.-CD F CE \
FOUND 1/2" IRON
FOUND 4"X4" CONCRETE PIPE (LB 3672)
MONUMENT (NO ID)
S89046'20"W 59.27'
(S89.34'42"W 59 21 FIELD)
OFFICIAL RECORDS VOLUME 3459, PAGE 1066
NOTES:
1. THIS IS A BOUNDARY SURVEY. THIS SURVEY WAS MADE FOR THE BENEFIT OF
orc7oirTln�l I INFS PER PLAT. nl n DPPI IRI It. NATIONAL
PERMIT NUMBER _ _ TAX FOLIO N AMER
NOTICE OF COMMENCEMENT
FLORIDA STATUTE 713.13
J
STATE OF FLORIDA ry o
F-
CC
m �
O
EL
�U
The undersigned hereby gives notice that improvement will be made to certain real o m:5
property, and in accordance.with Chapter 713, Florida Statutes, the following informationM o
is provided in the Notice of Comanencement: EY 16� o
(O�ONJ O
1. Description of proper; : (legal description of thd.pi-operty, and "street address if available). CO 5
LO V) z
n � o
2. General description of impro ement: L✓ewt �'1G OSIAfe- k Ct�lY1�Q N o af
oA?z0
3. Owner Information: o E 00 o o w
a. Name and address: c 1t.. ��z�x c)�
L 3 Z 3 3 u �?l�o ca�E'_ 1�-+�T--
b. Interest in property: 6u,v�� ,
c. Name and address of fee simple titleholder(if other than owner):
4. Contractor(Name and address): p /��
a. Phone number: 7 i Z 35-6-:D
b. Fax
5. Surety:
a. Name and address:
b. Phone number:
c. Fax number: _
d. Amount of bond: $
6. Lender: (Name and Address)' _
a. Phone number: T
b. Fax number:
7. Persons .within the State of Florida designated by Owner upori whom notices or other
documents may be served as provided in Section 713.13(1)(a) 7., Florida Statutes: (name and
address)'
a. Phone number:
b. Fax number:
8, .In addition to himself, Owner designates
of _ to receive a copy of the Lienor's Notice as provided
in Section 713.13(1)(b), Florida Statutes.
9. Expiration date of notice of commencement (the expirali8n?date is one (1) year from the date
of recording unless a different date is specified)
S'' ature of Queer'
Print Name
Sw r tq for of d) and subscribed before me this 2 day of Ve— 20(jl by
(Name of per making statement).