1580 BEACH AVE - DEMO 4
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- " L1ti ILDING PERMIT APPLICATION
�� 41. k CITY OF ATLANTIC BEACH
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��12jr 800 Seminole Road,Atlantic Beach FL 32233 OCT 7411::
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Office: (904)247-5826 • Fax: (904)247-5845
Job Address: /58O BEAU-1 Ave Permit Num.er:
Legal Description lo-11 1c0 -a 521E MALI:aLay 1.0110 '61)1RE# )-4 IA 75 -oaao bio X10.-3,3c
Valuation of Work(Replacement Cost) $ /00Q 0 Heated/Cooled SF Non-Heated/Cooled
° Class of Work(Circle one): New Addition Alteration Repair Move (Demo Pool Window/Door
° Use of existing/proposed structure(s) (Circle one): Commercial Residential
o If an existing structure, is a fire sprinkler system installed?(Circle one): Yes No N/A
o Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work to be performed: �•--16 *Be- — fV1t ibezhsvni t,-p, OMAT -
1SEk, Ukany ¢Cn+-1. e.e \TL.rpt a)ESt fill. it.e..30 a DAMS. -tone-1 cttsrt.-v—c--F-- -W-
5t1)%,- (. 4- 14•Vb'4'31 Lt. •vE-l• ��les.4"1 5l 01%. G - gape› t ts-vtRAL-1-0 -1-'l-6 4 t- CtDE,-d oQo DI Y,*-
Florida Product Approval#_ for multiple products use product approval form
Property Owner Information
Name: t\ E.. MAeC 4 Address: (o 604,.. ..., -h...
City Ctx. ct'. -r i State 6H Zip LI 5G M Phone /- 5/3- 3 i q-aa 5 y
E-Mail ?MAzc \ e m5E-7-- ET
Owner or Agent (If Agent,Power of Attorney or Agency Letter Required)
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.
Contractor Information:
Name of Company: 1.-VRJ `lult.ue25 Qualifying Agent: C AZL \46z
Address: I L?/5 51 3c,l• l- Pc 417 City Iu . State Zip 4., 3.1711Co
Office Phone 964- Job Site/Contact Number q611-,26i-3317
State Certification/Registration# GGC CY5R ? E-Mail mpl@ 1-1oQ.,.. .t.AE3_S-CA,--t
Architect Name &Phone#
Engineer's Name &Phone# 1_cx., '-Po--R� -d 46.. C.- 4/644--?4,,,) -640 3
Worker's Compensation
Exempt / Insurer / Lease Employees / Expiration Date
Application is hereby made to obtain a permit to do the work and installations as indicated. I certi&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, rs,Heaters,Tanks andlk
Air Condition s,etc.
Signature of Property Owner: Signature of Contractor:
Before me .1iN
I this 3e' Day of CDei-oe t.. Before me this 3`N Day of Oct, 3Ers�
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�;•••k¢ PATRICK RICH *9.......Q0 PATRICK RICH
Notary Publ. at-*41,=. * MY COMMISSION t FF 054075 Notary Public: MY COMMISSION#FF054075
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o, ep r RPIRE�:September 15 2017
ergo,o Bonded TAN Budget Nobry Services vi44.0i noo°e Bonded Thru Budget Notary Services
I hereby 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 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
peifonnance of construction.
Rev. 3/14/16
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