1065 Little Cypress Key - Permit Application BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road, Atlantic Beach,FL 32233
1 fiG 5 Office (904)247-5826 Fax(904)247-5845
.lob A.ddress:� _� � Permit Number:
Legal Description.g06n 1129-29 oajakk Iw Pe c�elu
F oor rea n t.
q. ''- �me_ q. t
Valuation of Work S Q� Proposed Work heated/cooled D /�5o non-heated/cooled
Mas:. (ofWurA.(circle ate): New Addition Aitemliun Repai Move Demolition pool/spa window/door
Use ol'existing/proposed structure(s)((circle one): Commercial Restden
It an existing structure,is a fire apron er aXstem installed?(Circle one): es No /A
Florida Product Approval # �ln(9�U 3o
For multiple products use prat approval form 1
Describe in detail the type of work to be performed:4sX cirF ha e&TE — 11Rr -51N (yam QA0IR.Y1Wa1Y T)
(hnls, �fu,_�,,sast3.._IJAIIw ,YtF�O - C�na�at,,.T�na.�.��1¢e1tl.�
i'rn n•rly Cr btfurmation:
am<. /s ` Addre�: D
i., SlateZip Phone
I-. Mml m Fa,N 4(optional)
Contractor Information:
Company Name i YI C1h1lS, I'Cfll>F7VIQ a i lin Agent: 0-t"Q-t'�� IA�'•0,�.(-MO
Address: City t. rrZip�sl)
Office Phon Job Site/Contact NumberQ. Fax#
State Cenifi atiott/R gistration# �� � 0 Ino ,
Architect Name& Phone#
Pe _
gineor s Name& Phone# __ .. -_-.
Pec Simple -Title Holder Name and Address
i3ondutg Company Name and Address
'vkotgage Louder Name and Address ...__ --.--- -----
applimlwa is hereby,node to obtain operant to do the work and isstallatiom w indicated. I cert that no work or installation has commencedprior to
issunnre ata permit and that all work will beperformed to meet the standards ofa//laws regulating construction in this jurisdiction. This permit becomes
.m,d x>id J work it oat enmmrneed within siz(6)months. ar ijcanstrue[ian ar work is sus nded or abandonedfor a period afsiu//6)months at any time c
work i.r commenced. I undecvand/hat separate permits must be secured for ElectNca Work,PWmbing,Signs, Wells, Poois, Fumacrs, Boilers, Neat
Tanks and Air Conditiones,etc
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS
FO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING CONSULT WITH
YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT.
ti r 11I," r s l a i i rxanined rho gjj,haafion and know rhe same io be true and m ct. all p I isi rr of 11111" t 'di...mc rang
A I I r/li.d w ifh u hUher ,wcr/ •d here r ur nnl. TM1e A anlrng nj'a pvr rl darx not "at irr r<a r u u.�udur n.rr
n; o,uy11 "1 nml orlaalawiegulati comimeon or the pe,f..rmanr.r ofcunvrru.nnn.
/ uU
Signature of Owner _ Signature of Contract's
rr11ww // -- //•• //[/ t r
Print Name . .'✓f.e/�Le_-ffl/Ir4 Print Name . .... .. .. . ... ..........P..h vL-t_L...........
Sworn to and subscribed re me Sworn and subscribed b fo me 20�"/
this Da of .200 this Day of
--'00 WON. — tietlles_.---.___ .---___-----
n;ugl'nhli,. NoIVE
UBLIC ARYPIIBLICNOTARY F'FLORISTATE OF FLORIDA TE OFFLORIDA RevisedD1.26.10
Conmg FF235532 m#FF235532
Exp!ras 5/281:079 m 5/28/2019