310 7th St ROOF BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach, FL 32233
Office (904)247-5826 Fax (904) 247-5845
Job Address: 3 kb ` t�aht�c- ���� + ---Permit Number:
Legal Descri tion LQ - t Parcel#
g p oor rea o q. t. ' sq.Ft
Valuation of Work$ obO - ` Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New Addition Alteration Repair emolition pool/spa window/door
Use of existing/proposed structure(s)((circle one): Commercial Resi
If an existing structure,is a fire s inkier system installed? (Circle one . es N/A
Florida Product Approval#LO 2�-
For multiple products use product approval form rr �oS
Describe in detail the type of work to be performed:l'DOT �Q D�.l 1 5 -3 3 S �f C- ,
' -� ,� ` /I1or e f+ ih ,P moo/ �v�►�/� // b�
�to 1Q�p(� l�'/Or`tz�g o?D/O Exis�•re) Gt(cl�n GAP-chla fPr [ eue 1 1
Property Owner Information: ��Pia t,�n — ge�7O X11) _ l�
Name: 1 Address: J -1 ! s r
City State ip XJ 3 3 I'�one
E-Mail or Fax#(Optiona) v
Contractor Information: '(
Company Name: �Vl Quali mg Agent:�1 a�/IS ��(J,,UG�'1'rP� J��I�CompaAddresny
Ci aC SOY1V1 State _Zip
Office Phone 0 - Job Site Contact NumberWA_ 3 I � Fax# - 9 (V-1!4t0(Q -W40
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
work or
commenced
rior
issuance
the
licationis a permit hereby nd that obtainll wd[betpedbrmed tot to do the omeet the stanrk and dardsof all laws as rregulatinicated I g nnsstruction in thiis jurisdic'on.his perat mit bectime omesonull
and work void
�mmenced.ct 1commenced within six understand that separate permitsmtufrt be secutred for Electrical Workion or work is , Plumbing,Sior gns,or aWells�Poolsxl�u)aceslsBoilers,Heaters,
tis,
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
BEFORE RECORDING YOOBTAIN UR NOTICEF CONSULT H
YOUR LENDER OR AN ATTORNEY
type work w that I have read and examin,
will be complied with whethertpeci tehis dlhertein or and
The granting of permitw the same to be true does cnot prt. All esumeito givons e a autholaws rity to i violatenances orcancel this
provisions of any other federal,state, or local law regulating construction or the performance of construction.
Signature of Owner f Signature of Contractor
sR L G Print Name � 5........ ............................................
PrintName J.... f.M......... ........................................ .............
...... �.�..
Sworn to and subscr'bed before me Sworn to and subscribed before me 20 l S—
this a of 20 this Da of
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;:;.► �e ., r« Publi _ No r Public-State F rida
ANKE B DEAS6R N y � p• JU�.1b
Notary ub n =• °'. :o; M C Ex fres u 0
3�! MY COMMISSION#FF085842 "� o,��a
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'+o.,.�'` EXPIRES January 23,2018
(407)398.0153 FloridallotaryService.com