2191 FAIRWAY VILLAS LN - ROOF f------
ci: fly�tCITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
J
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
'-'40Ji)
ROOF PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-ROOF-1676
Job Type: ROOF PERMIT
Description: RE ROOF - SHINGLES
Estimated Value: $4,500.00
Issue Date: 7/26/2016
Expiration Date: 1/22/2017
PROPERTY ADDRESS:
Address: 2191 S FAIRWAY VILLAS LN
RE Number: 169398-1064
PROPERTY OWNER:
Name: HUMPHREYS, PATRICK
Address: 2191 S FAIRWAY VILLAS LN
GENERAL CONTRACTOR INFORMATION:
Name: RON RUSSELL ROOFING INC
Address: 4419 HUDNALL RD QA RONALD WAYNE RUSSELL
Phone: - -
FEES:
BUILDING PERMIT FEE $72.50
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $76.50
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
•
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach,FL 32233
Office(904)247-5826 Fax(904)247-5845 n`ROOF - I / SO
Job Address: 2111 Fk away \J 1\ S Permit Number:
Legal Description 31-ZZ O - 2 3 -zq L,111 Parcel#
Floor Area of Sq.Ft. Sq•Ff
Valuation of Work$ 9,56 0 .0 O Proposed Work heated/cooled 4/- non-heated/cooled_/0 SD _
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structures)(circle one): Commercial
installed?an existing structure,is a fire sprinkler system (Circle one): Yes c.z.9 N/A
Florida Product Approval# /a 12 y• /0
For multiple products use product approval form
Describe in detail the type of work to be performed: (2t.-V bcA•rr-• - E r`K� eX%sire.,
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Property Owner Information:
Name: ,\a S.. Vroeerk-iis LLQ- Address: 2`1`to`t Moss Citn.�k Gn
City it ore %)t $u c�. State f Zip 3�pfdr Phone 9oY- (c'7- SZ &3
l -Mail Fax#(Optional)
Contractor Information:
Company Name: P-0.4 gt4ss.ct( R..crv� 11;44_ Qualifying Agent: guisiee
St tet 1F+— Zip 32t-e"t
Address:` i c191`1 Pk,elv 'R I City J�x
Office Phone 70-/- -2/9 /90'1 Job Site/Contact Number Gov- Sr 'S 3 Fax#
State Certification/Registration# 4.c G 13 -1'1 $y
Architect Name&Phone# t.//A
Engineer's Name&Phone# Jv/b
Fee Simple Title Holder Name and Address tJ/A
Bonding Company Name and Address N/A
Mortgage Lender Name and Address N
Application is hereby made to obtain a permit to do the work and installations as indicated. I 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 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 abandonedfora period of six(6)months at any time
after work is commenced. 1 understand that separate permits must be secured for Electrical Work, Plumbing, Sins, Wells, Pools, Furnaces, Hollers.
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
C
I hereby certify that I have read and examined this fpplipation 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 an,v other federal,state,or local taw regulating construction or the performance of construction.
_ of Contractor ,E
Signature of�caner 51 --)1i •
Pri•tNames 20., 12.Est‘.\
Print Name i J 411'S`v
wo to an,subscribed
Sworn to and subscribed before me
before me this 23 Day of-1•0-/
this�Day of____M ,
,20 1(p 20 /6,
in d-----1 --- -
;),, r" Notary Public
No 1 Public
• Ryan Resnick Eyrick
,��Iiiiiirfi� Revised 01.26.10 / , NOTARY PUBLIC
••it. MONS I1 =STATF OF FLORIDA
�� Q...••"' F i. Comm#FF945229
��. NOTAgy c/O0'
Expires 12/20/2019
MY Comm,Expires
January 6,2019
No.FF 187613
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