87 4TH ST W - BLDG PERMIT BUILDING PERMIT APPLICATION
��'(Pe--' CTY OF ATLANTIC BEACH FILE COPY
6\ 800 SeIminole Road, Atlantic Beach, FL 32233
S Office (904) 247-5826 Fax (904) 247-5845
Job Address: �7 9 Stye-e,k W _5+ Permit Number: I(€)--DPL)(-, ,9'1X)
Legal Description Parcel#
Floor Area of Sq.F't. Sq.Ft
Valuation of Work$ ;CO,000 Proposed Work heated/cooled Q5( non-heated/cooled 7 LI
x4-0
Class of Work(circle one): 4110 Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structures) (circle one): Commercial es entia ZS I (pO O
If an existing structure,is a fire sprinkler system installed? (Circle one): es No �` 2 9 /l
Florida Product Approval # See Pri u„c' pro vu\ S'�;e etc
't
For multiple products use product approval form 2--,53.1/4(�.t
Describe in detail the
type of work to be performed: New ie-5) e evl,t \ d►-,,(y DIn,ej ),v,
N v�' Cori r t/,,c.- .-'r1 PCS /-lat t 5
Property Owner Information:
Name: Piet D U 6ppii ) LL,C. Address: ?ICS k"^ r'- r' r x,00
City 140MCA-V. StaterL Zip 33035 Phone 7 G 119-13i"
E-Mail or Fax#(Optional) —Pli,-- 3'-tc- 134 V' Foqe
Contractor Information: /� yy��
Company Name: 13L&.(1. 1,� (Aa l).r„ k 120S,�(Q Sol/a-St-QualifyingAgent: k v,n tz, matt
Address:(x.,610 3 8p (3(.4,WC(' City Jam State h- Zip 3aakA4
Office Phone qsz-t-135--t30) Job Site/Contact Number/5c-L- 35-3.30.7 Fax#
State Certification/Registration# 6fs055c/
Architect Name& Phone# ,
Engineer's Name&Phone# Maxi•;r. '&y,reef,i t L1_C 10 -4 7a-ti-tSq
Fee Simple Title Holder Name and Address
Bonding 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 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 abandoned for aperiod of six(6)months at any time after
work is commenced. I understand that separate permits must be secured for Electrical!Fork, Plumbing,Signs, Wells, Pools, urnaces, Boilers, Healers,
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.
I herebycertify that l have read and examined this a plication and know the same to be true and correct. All provisions of laws and ordin' ces governing this
type of ork will be complied with whether specified herein or not. The granting of a permit does not presume to give authority t• iolate or cancel the
provisions of any other federal,state, or local law regulating construction or the performance of construction.
4fr.400.1°'°!°°......--
•
Signature of Owner Signature of Contractor
Print Name f�o,+r,t ebe" Print Name Ke✓i r) R. Mart)n
Sworn to and subscribed before me Sworn to and subscribed ,efore me
this 3,6 Day of e pkv P , 20 IC-a this c1174of - . - Q' 20
Notary Pub!' N ary Public
Revised 01.26.10
AtEks, C►x1eti,A Kuschd __