1 W 1ST ST VET PARK (2) City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
.�- cam - 3
800 Seminole Road
Atlantic Beach, Florida 32233-5445
Phone(904) 247-5826 - Fax(904)247-5845
E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address:
ASr �� De artment review required Yes No
r• b r in
Applicant: .J Tree Administrator
Project: f'(/ //�/�w 0� ublic Works
u Utili ie
/J i �/ Public Safety
�`-� 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: ❑Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING&ZONING Reviewed by: Date:
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
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax(904) 247-5845
Job Address: -lt►i (A 1n`10#r,-k- �U I- s�s j Permit Number:
Legal Description Sg ck )4, 19" 12rg
J� 1-3 Parcel# 1 -2` 0?
Floor Area o . qct
Valuation of Work p. Proposed Work d/cooled non-heated/cooled
Class of Work(circle one): New ditio Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s)(circle one): Commercial Residential Ic)fes ��'�
If an existing structure,is a fire sprinkler system installed? (Circle one): Yes No
Florida Product Approval#
For multiple products use product approva orm l ,�
Describe in detail the type of work to be performed: rJ C4_Z NAI^^Ci
0-11, Q-)V-C lam w►.. �. �w-3 s�v'V�� Ir�YY.�,�rlc,-Q ' 1 �C
Property Owner Information:
Name: C 4 (/-. (Address: ► S +" D�'//�'f✓z Lam£
City Stats�L Zip`Phone Q - 19 - 5
E-Mail or Fax#(Optional)
Contractor Information: CONTRACTOR EMAIL ADDRESS:
Company Name: � `'►
a. Cu QualiWng AE-C4
nt:
Address: I�� S , ek 1 Z City a'F - State 1-4- Zip—;22 ro
Office Phone Job Site/Contact Number Fax#
State Certification/Registration#
Architect Name&Phone# � /a-
Engineer's Name&Phone#
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and Address w "
Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 thisjurisdiction. This permit becomes null
menced within six and work void
mmenced.not
I understand that separate permimonthsts muor st be secured for Electrical Work,Plums ng,Sigconstruction or work is su-gpended or ns,or aWeUs�P olsxFurnnces,Boilers,months at tHeaime t 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 BEFR ERRETCORDING YOUR NOTICE OF
I hereb 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 ojYwspecified will be complied with whether speied herein or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of any other federal,s or local law regulating construction or the performance of construction.
Signature of Owner Signature of Contractor 51
r. o✓ Print Name 5....�1........ .. `.. ......................................................................
Print N ea./G....4..A.5................................................................................. '
Beffor Before m _
20
this - Da off/ this ► Day of
o ry Public State of Florida — NG V.SCARBOROUGH
t ommission FF OL18990 b s +' �
Nota ui
Not c Y ;r IRES March f4,2019
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