760 TRITON RD •
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach, FL 32233
Office (904)247-5826 Fax (904) 247-5845 1 5 RRAK-Z653
Job Address: 76 o "T es--iv N AA I Permit Number:
Legal Description Parcel#
Floor Area of Sq.F't. Sq.Ft
Valuation of Work$ V, 300. Proposed Work heated/cooled non-heated/cooled
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structure(s)(circle one): Commercial 'esidenti,
If an existing structure,is a fire sprinkler system installed?(Circle one No N/A
Florida Product Approval#
For multiple products use product approval o rm
Describe in detail the type of work to be performed: j./�JO -,, OS t S %10
av4t:�/ el(s:s#„,• 0% s#' i s W veripei Q_(, wvt..'n/
Property Ovie ier Information:
Name:_ f r t • . / Ag Co W ei 'L Address: 7v s ,v go" 4/
City AILIP, . _ .` Statcrl/ip 122 33'hone 717 y 7/ qqe g
E-Mail or ax# Optional)
Contractor Information: CONTRACTOR EMAIL ADDRESS: /
Company Name: ', f. 4 4 c, Qualifying Agent: , Z4€ (,_ c7 iL
Address: 4/C/ 'G pry,i /t City 7rt c,C s..✓c,.,/4 State H., Zip 2 22'5
Office Phone 67 7- 4-701 Job Site/Contact Number Fax#
State Certification/Registration# c 7 2 d3 3 7
Architect Name&Phone#
Engineer's Name&Phone#
Fee Simple Title Holder Name and Address
'sBonding 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 certib,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 1
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 thisgoplication and know the same to be true and correct. All provisions of laws and ordinances governing this
type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the
provisions of any other federal,state, or local law regulating construction or the performance of construction.
r
Signature of Owner_ _ Signature of Contractor / 4 /' i,
Print Name \o r i euo c.,z Print Name •
Before me
.�..,, ON GI DLESPERG
this Day of ,20 t Be`it% r: „v' ` " •n` • "�' j'C� l 20
• 11111 .r " . _d TAN Ca 1 .l• 8,
Notary Public �" ;—
= - —
ps 0 VA 18 4@ Q Yv\4.., .o m 5 -3G--2- S'- Revised 01.26.10