2337 SEMINOLE RD BUILDING PERMIT APPLICATION
J CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904) 247-5845
lob Addegss• n w Permit Number:
.egal Descrtt�on q ^ 16"tWC.L ,9
g P
oor Area o q. t. q• t
Valuation of Wor Proposed Work heated/cooled non-heated/cooled
� i t_-OAT lass of Work(circle one): New Addition Alteratio Repair Move Demolition poo pa window/door
Jse of existing/proposed structure(s) (circle one): Commercial Residential
I an existing structure,is a fire sprinkler system installed? (Circle one): o N/A
lorida Product Approval #
For multiple products use product approval form
Describe in detail the type of work to be performed:R G Pq A-1zc-L i a_ L�+A Vzr' S O t1
?roperty Owner Information:
Vame: L%x L%L Tcr ddress.1Z C rn trio L2 Ra
-itytA'i' State�i SSS Phone 04 '4*[1—G 2JIM
Mail or Fax# (Optional) !a1
,,ontractor Information:
3ompany Name: _' C- Qualifying Agent4_ t'(t S e-_r t,%b,6 S
Address: City a. State��Zi
office Phon - Job Site/Contact Numb-{ sl l _
State Certification/Registration# G pGS S�r��I `'?'D byf 6-iZ L' y.�tC
Architect Name& Phone#
Engineer's Name&Phone#
Fee Simple Title Holder Name and Address
Bonding Company Name and Address
Mortgage Lender Name and Address
4pplication 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
.ssuance 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
2nd void if work is not commenced within six(6)months, or if construction or work is suspended or abandoned far aperiod of six(6)months at any time after
,vork 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.
there 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 certify
will be complied with whether speci ted herein or not. The granting of a permit does not presume to give authority to violate or cancel the
7rovisions of any other federal,state, or local law regulating construction or the performance of construction.
Signature of Owner ' Signature of Contractor
Print Name Print..................................... Print Name (," �1,'C,.If ..5...........�.r..1�.n...`p....S...........................
Sworn to and subscribed before me Sworn t 01r.Etl 20
this Day of 20 this
- m Upkel Doe 16,2016
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Notary Public ... ,Y MY COMMISSION t FF w60otary C%„OF f � t I�1011>r MMI
a EXPIRES:March 28,2018 Revised 61.26.10
Bonded Thru Notary PuWic Underwriters
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