2269 FAIRWAY VILLAS LN N ROOF CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
ROOF PERMIT
MUST CALL BY 4PM FOR NE)Cr DAY INSPECTION: 247-5814
30B INFORMATION:
Job ID: 15-ROOF-954
Job Type: ROOF PERMIT
Description: REROOF FL 106.74
Estimated Value: $7,150.00
Issue Date: 4/23/2015
Expiration Date: 10/20/201
PROPERTY ADDRESS:
Address: 2269 N FAIRWAY VILLAS LN
RE Number: 169398-`1090
PROPERTYOWNER:
Name: SKOCIK, COLLIN R &AMY L,
Address: 269 N FAIRWAY VILLAS LN
GENEIAL CONTRACTOR INFORMATION:
Name: LIc, Gifford Roofing
Address: 1022 N SWINDELL AVE
LAKELAND, FL 33805-4036
Phone:912-337-271'1
FEES:
BUILDING PERMIT FEE $85.75
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $89.75
PERMIT IS APPROVED ONLY 0 ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Bewh,Fl,32233
Office(904)247-5826 Fax(904)247-5945
Job Address: 1Q,-Q-9 ?i -rfttri� "I&S Permit Number:Ig-Ro�fqsq
Legal Description 30k 9 16- L"Pt"'Paircel#
F lour Alrea of Sq.Ft. 1,q
Valuation of Work S -1, Proposed Work heatedircooled �,V-'hcatcd/cooled—
Class of Work(circle one): New Addition Alteration (��C— Move Demolition pool/spa window/door
Use of existingirprormil structure(s)�ircle one): Commercial Residential
u] i
If an existing strue are,is a film sprin er system installed?(Cimie one): Yes No N/A
Florida Product proval#
nets use product approval form
For multiple p4s FLI 10(oq
Describe in detail the type of work to be performed: Q-00F "WI&494
Property Owner Information:
Narne: Coklin skocsy Address: I) 4!j 14. 4wjo44 L)4 lim Ltf
C --- vV—L �Nftlr,
ity CI)AoA Stat,E i Zip ZU-D—Phone
E-Mail or Fas:#(Optional)
Contractor Information:
Company Name: q*"Q Qua] A nt:: 1C,4W,i (YAS-t)
Address: I W, W. city state C.I Zip il-1763-
Office Phone Job Site/Contact Number Faac#
State Certification/Registration# cr-C Ixlu-n
Architect Name&Phone#
Engineer's Name&Phone W
Fee Simple Tide Holder Name and Address
Bonding Company Narne and Address
Mortgage Lender Naine and Address
Application is hereby made to obtain apermil to do I&work and installations asindicated lecraly,that nor work ew installation has cormumencedpwim to the
issuance ofapermit and that all work will bepoyarvand to meet the standards ofall laws regulating construction in thisjurrisdiction. 71jispermil becomes null
and void ifwork is not commenced within six(6)months.or irconsiruction,or%kcssided or abandonedfor aWeriod ofsag)monahs,at any time after
work is countersued I understand that separate permits must be securculfor E work,P1 ...hing Signs. �dlh,Pind; numper Reuters Hemens,
Tanks andi Conditioner;eic.
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 Yffii NOTICE OF
COMMENCEMENT.
I here 'ns6in"' "i
orre a or, 1 0
Prmsar��Of:�14
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print t4son,
Sworn to d b 'bedbefore me wom toi subscri beforq e
S'
this 1.l- D,ys.f' ,1 .2015 this2,,l]%y of 11,� 2014�1
JUANX km
Notary Public
H T,,,ER TAyLo,, N HER WAIM
CWMISSIM
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SO
EXPIRES April 23.2017 EXPIRES:Apin,
..........
NOTICE OF COMMENCEMENT
Stateof Tax Folio No.
County of C'
To Whom It May Concern:
The undersigned hereby interne,you that improvements will be made to certain real property,and in accordance with Section 713 of
the Florida Statutes,the following information is NOTICE OF COMMENCEMENT.
Legal Description ofirroperty being improved: —;Is
Address ofproperty being improved: .)'Ji L9 CA t-A
General description ofirnPreWernellts: it V V ls=.14
Owner: ('��� "rN S)� lk Add�: lj(.cj� CAjA�IA�4 LA i!I�� L r,
0,ner,s interest in site ofthe improvement:
Fee Simple Titleholder(ifothff than owner):
Name:
0
Contractor:
a- 0
Address:
Telephone No.: Fax No:
Z5
Surelty(ifany)
Amount ofBond$
Address:
Telephone No: Fax No:
z
Name and address ofany personmakinga loan fortheconstnuction oftheimprovements
z
Name: Sisow
0 1 1)
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
served: Name: G-k G'
Address: k DaL Lt. b�� 1k A-k-
Telephone No: Fax 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 Stalues. (Fill in at Owner's option)
Name:
Address:
Telephone No: Fax No:
Expiration date of Notice of Cornmenoneent(the expiration date is me(1)year from the date of recording unless a different date is
specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
S i g or d Z2 �'1-e4l,o 5 Date: -M" /r
12" &Yof Apr-.i in the Courutyoflyuval,State
to.me this
OfFlorida,hapersonallyappeared (Alllfk 4CC; K,
HEATHER TAYLOR Notary Public a Large,State ofF Duval.
C 14
My commission expires loritrof
My COMMISSION#FFOI 1230
Personally Known or
EXPIRES Aplil 23,2017 Produced Idenfifi
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APR/23/2015/THU 09:21 AM PAX No. P, 001/001
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CERTIFICATE OF LIABILITY INSURANCE 1 W2312015
THIS CPRTIPICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONS71TUTE A CONTRACT 13ETWEEN THE ISSUING INSURER(S]l, AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder In an ADDITIONTL INSURED,the policyles) must he wdomed. If SURROGATION 13 WAIVED,subject to
the terms and conditions of the policy,Certain policio may require an endorsenneft A staternent on this cardficaft does not confer rights to the
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INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MICH THM
CERTIFICATE MAY W ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN is SUBJECT TO ALL THE TERMS,
�CUUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CI.Alms.
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-RTIFICATE HOLDER CANCELLATION
CTYATLA SHOULD ANY OF THE ABOVE DESCASED y0LICIES ME CANCELLED BEFORE
WE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Atlantic Beach ACCORDANCE NTH We POLICY PROVISIONS.
Building Department
f 1.904-247-5845 IkUTHORIZED REPREIIENTATNE
800 Seminole Rd -.0
s7� , '01
Atlantic Beach,FIL 32223
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MIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
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BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sk AUMORUED
REPRESENTATIVE OR PRODUCER,AND ME CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED,the policyies)must be endorsed. If SUBROGATION IS WAIVED,subject to
DUN terms and Conditions of the policy,certain policies my require an endonsawn.m. A statement on this certificate does not Confer rights In this
ovidificat,holder In Ilau of such andomement(s).
PRODUCER OrEA'T justi-irrecerson
Assurance Agency,Ltd. FAR Me,
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One Century Centre 9==uranceagency.plogin
1750 E.Golf Road
Schaumburg IL 60173- NAM#
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666 Dundee Road,Suite 201
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COVERAGES CERTIFICATE NUMBER:802719232 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR ME POLICY PERIM
INDICATED. NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPU�T TO MICH THIS
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AUTOMOBILE LIABILITY
A-AUT0 BODLYINIURY(ft�) $
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HIREDAUTOS NON-ONNED �ERT(DAMAGE $
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MESS UAB H AGGREGATE $
DE. I I RErCNTTDN$ $
B WORKERS COMPOISATION
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ANY PRCMIETOR�ARTNER�UTNE E L EACH ACMD8NT $11"1001)
OFFICERIMEMZOR MLUDED?
(.R."".AN) ELDSEASE EAERINUOYEE $I,DDD,0DD
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Proof of Insurance
With respects to the Workers Compensation Policy,an Alternate Employer Endorsement is added,when required by written contract,in
fa�r of.-Gifford Roofing LLC,BetterStaf Inc
CERTIFICATE HOLDER dANCELLATION
SHOULD ANY OF THE MOVE DESCRIBED POLICIES BE CANCELUM BEFORE
ME EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Atlantic Reach ACCORDANCE WITH THE POLICY PROVISIONS.
800 Seminole Road
Atlantic Beach Fl-32233 AUTH RUEDREPRESENTATNE
1988-2010 ACORD CORPORATION. An rights reaer�ed.
ACORD 25(2D10/05) The ACORD name and logo am registered marks of ACORD
DBPR-GIFFORD, RICHARD ALAN; Doing Business As: GIFFORD ROOFING LLC, .,. Page I of 1
2 43 10 Filif�W015
Licensee Details
Licensee Information
Name: GIFFORD, RICHARD ALAN (Primary Name)
GIFFORD ROOFING LLC (DBA Name)
Main Address: 1022 N. SWINDELL AVE
LAKELAND Florida 33805
County: POLK
License Mailing:
LicenseLocation:
License Information
License Type: Certified Roofing Contractor
Rank: Cert Roofing
License Number: CCC1326277
Status; Current,Active
Licensure Date: 01/20/2005
Expires: 08/31/2016
Special Qualifications Qualification Effective
Construction Business 01/20/2005
Alternate Names
View Related Urenje Information
View License Complain
1940 North Monroe Street,Tallahassee FL 32399 Email: Customer contact Center Customer contact carri 850.487.1395
be State of Florida is an AA/EEO employer.Coubbabli 2007-2010 solve W Floodis.Pribmi Stagament
Under Florida qw,bri addresses a,.public mi If you do not want your email address released in response P,a public-ohoords
equest,do not send aseemoric mail to this entity,Instead,contact the shoe by phone or by traditional mail.If you have any
questions,plaose contact 850.487.1395.-Pursuart to Secured 455 275(l),Florida Statutes,effective October 1,2012,licensees
liceread order Chapter 455,1.S.most provide the Department with an email address if they have one.The emi provided may be
used for official communication with the licensee.However email addresses am public record.If you do not wish to so pply a hanconal
address,devid,provide the 0a,sourtment with an email address which can be made available to the public,prose see our chamber
m page to determine if you are affected by this change.
https://�.myfloridalicense.com/LicenseDetail.asp?SID=&id=FFE64BD I 7CEBA2139E... 4/23/2015
Polk County T�Collector Page I of I
Polk County Tax Collector
generatedon 412312015 2:47:54 PMEDT
Business TaX Renewal
Lmt Update:4/23/2015 2:47:55 PM EDT
Business Tax Renewal
Accounthiumber NewBusinessDate 1 Business Tax Receipt Year
126074 5/1412009 1 2014
Business Address Mailing Address
GIFFORD ROOFING LLC GIFFORD, RICHARD ALAN
1022 N SWINDELL AVE 1022 N SWINDELL AVE
LAKELAND FL 33805-4036 LAKELAND FL 33805-4036
Status **ACTIVE**
Occupation
CONTRACFOR ROOFING
Business Tax Fee $57.75
Date Paid Receipt ounLPaid
8/22/2014 1206308.0001 $57.7 1
http://fl-polk-business.govenim�.com/collmtmax/tab—collect mvplicV6-02.asp?PrintVie... 4/23/2015