670 Plaza - Permit Application OFFK� Building Permit Application Updated 12/8/17
City of Atlantic Beach
800 Seminole Road,Atlantic Beach,FL 32233
/7 Phone:19041247-5826 Fax:1904)247-5845 qp,
Job Address:�7 PICtz,, 1�cq . Permit Number: AQQ1 8 ' b60�
Legal Description REg
GL-
Valuation of Work(Replacement Cost)$ =Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Addition Alteration Repair Move D mo Poo Window/Door
• Use of existing/proposed structure(s)(Clyde one): Commercial 0exient.aF3
• If an existing structure,is afire sprinkler system installed?(Clyde one!7s No N/A
• 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:Re a VCIIL aeel I .rx5'kxll 1 �dr< ovtr an,\ Tf."e.f e{-
P•.t lk V , ra }tIL MARrINI m pMI•
Florida Product Approval g 1 for multiple products use product approval form
Prgpertv Owner Information pp I�
Name: k5rp�3\ Address: 670 0147, 'b
city H� he Pgo�l_ State FL Zip aaa33 Phone W_ /_4 -6_`Aa
O Mail r Agent
SntPowlQMrsu, C9yyf
Owner or Agent(If Agent,Power fAttorney or Agency Letter Required)
Contractor lnfortnatlon 'I
Name of Company: C . qualifying Agent: �YtQ.'IMQ-Y1 2M 'ei I/
Address 51 •lla COI City _t6P11S0rh1I1C State Zipo'! /
Office Phone 0 — a — b Job Site/Contact Number (9COr 110-1 - IB
State Certification/Registrationg E-Mail COY Ott . C
Architect Name&Phone If
Engineer's Name&Phone
Workers Compensation
Exempt/Insurer/Lease Employees/Expiration Date
Application is hereby made to obtain a permit to do the work and installations as indicated.I certify that no work or instal lation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all the laws regulationg
construction in this jurisdiction.I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS,and AIR CONDITIONERS,etc.NOTICE:In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county,and
there may be additional permits required from other governmental entities such as water management districts,state agencies,or
federal agencies.
OWNER'S AFFIDAVIT:I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
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.n
(Signature ofO er or Agent) Signatulfeof Contractor)
(includin ontractor) ���..��yy��
Sped and sworn to(or affirmed)before me this J3J—day of Sied and sworn to(or affirmed)before me this i�day of
7 �by by
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