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1892 SEA OATS DEMO17-0024 post-hurricane repair and cleanup permit )Jci 2_ Sect OcL.--c-,s ;;s-=���r INVOICE # '3 , n �� City of Atlantic Beach INV-2336 �;` �� 800 Seminole Road Date Due: 1/5/2018 Atlantic Beach, FL, 32233 NORMAN E CHARLES JR 612 RTE 194N ABBOTTSTOWN, PA 17301-8805 Invoice Date: 12/6/2017 Record# Record Type Fee Group Fee Description Quantity Amount DEM017-0024 DEMO BUILDING BUILDING PERMIT 0 $55.00 STATE SURCHARGES STATE DBPR SURCHARGE 0 $5.33 STATE DCA SURCHARGE 0 $3.55 WORK WITHOUT PERMIT WORK WITHOUT PERMIT 0 $300.00 $363.88 Invoice Total:$363.88 /4 /a-7_1 Pa h N� _ i r'uo 0 ,,.. oQi.7 L?t sztAdk 4's '--6e46,r) \ -----.) �` ,<) -Y\ ,cam Please send your payment to this address: Printed:Wednesday, December 06,2017 2:03 PM 1 of 1 V ri,a,`Prz.„ City of Atlantic Beach APPLICATION NUMBER JsIA Building Department (To be assigned by the Building Department.) 800 Seminole Road [E r 0 17 — 0 0 z // �r j Atlantic Beach, Florida 32233-5445 `T Phone(904)247-5826 • Fax(904)247-5845 o;t gr E-mail: building-dept@coab.us Date routed: l ( /1 Cv (( 7 City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: l 8Ci Z S :c::A 0 AT s 1<l)( De artment review required Yes No ,�.11uildinq) Applicant: ER v P R V Planning &Zoning Tree Administrator Project: I N Gi24 0 0._ D c © Public Works Public Utilities Public Safety Fire Services Review fee $ Dept Signature Other Agency Review or Permit Required Review or Receipt Date of Permit Vo-ified By Florida Dept. of Environmental Protection Florida Dept. of Transportation St. Johns River Water Manan Army Corps of F Division of Hote 'NC"— Division of Alcoh Other: ( " 0 Reviewing Department First Re' ['Not applicable (Circle one.) Commen BUILDING PLANNING &ZONING `o. k Date: TREE ADMIN. c„, Second Revit0- CJ Q L]Denied. ['Not applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. ❑Not applicable Comments: Reviewed by: Date: Revised 05/19/2017 Nov 16 17, 12:26p Nisa's Tags&Title 717 259 9944 p.2 3 . U ©/ vC • Building Permit Application City of Atlantic Beach 800 Seminole Road,Atlantic Beach, FL 32233 /}-)0 d" [� Phone:(904)247-5826 Fax:(904)247-5845 Job Address: (I 1 _cam cxx-`3 140q„r,i:k‘ fl 3)-a3SPermlt Number: 't F��1 l - C dZ Legal Description REM Valuation of Work(Replacement Cost)$ heated/Cooled SF Non-Heated/Cooled • Class of Work(Ord'one): New Addition Alteration Repair Move Demo i Pool Window/Door • Use of existing/proposed structures)(Circle one): Commercial Resi4e boli • If an existing structure,is a fire sprinkler system Installed?(Circle one): Yes 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:WC:Ckoor iY,iktricki+cisN diiiLV ) ��C Ill i .,1� , C�1( 1 1 i �L 5�i .y A Florida Product Approval# for multiple products use product approval form Provertv Owner Information Name: 1t°.b ?1£ Elt1Yff'CA-.1 Address: 1`3ti a Salo ('. 5 1:48, City 4Ht - ( Ark State Fl•.-. Zip 3:3x33 Phone -7 I`"j-1-1L5-83 E-Mail fly,I6 d Ckc ,e1..41.-1 Owner or Agent(If Agent,Power of Attorney or Agency Letter Required) Coktrsctor kiformatlpn Name of Company: _ e.4 )( Qualifying Agent: Address .1`I r-rri.,r9 .I to City Dc,;;-re State M4 Zip o c o Office Phone 's_S`')J`S lob Site/Contact Number State Certifiwdan/Reglstration# Erre i•,,♦ . ,,,s E-Mail Architect Name&Phone ti Engineer's Name&Phone# Workers CompensationI,l-,�-r• Xe— }g' -i _.#7, 4_4, Exempt/Insure lease Employees/Expiration Data 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 alt 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. 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. ' .kd'I-.;4;...C.'-\-, '-(,det- - I/ -LA {Signature of Owner or Aaent including contractor) ,--" it _i 4/2ii /,0&- , -:'' ') -')z)??(""(4/11.__JA (Signature of Contractor) Signed and sworn to(or affirmed)before me this jk_tay of Sig ed and sworn to(or affibefore me is day •1 N6-V , `/_�I ,by !De , �.1 cc _ al(7, by 440 - it': LATA rad Colv.e :1' . ,:w ,.r, 11NS'Y rANiA - Ill.""- 41:41- *4' r . NO • AL SEAL i . ,yl, • Micky L.Spears,Notary Public I t 11 p h Known Abbottstown Boro,Adams County 1 441437115904.8., • i I )weed laentifkation My'comrnissiol expires February.03,20181 Personally Known OR rr i )produced Identification ;i; �� ` Type klentt3lcatian: PA-. r i�C<< L ' Type of Identification: "''iiii� if�r`' aDQ4 � a��� Nov 16 17, 12:26p Nisa's Tags&Title 717 259 9944 p.1 Nisa's Tags 544 WEST KING STREET(ROUTE 30),ABBO 'SHOWN,PENNSYLVANIA 17301-9101 PHONE/ FAX: (717) 259-9944 E-MAIL: NISA3@COMCAST.NET Fax To ( Company or Organization ): Date Faxed: 71a1) / / 2a17 Attention ( Contact Person ): Sender's Name: /6/2#1 C//Che rrzej; )4616/7-.-L (' ' 1./b1-772 Cnn To ( Fax Number): Sender's Contact Phone Number: 99 t-7/ / Subject or Topic of Fax: Number of Pages Faxed: 46/A1,4-"2 A----1V// AThis cover page plus / attached pages /*S7-70 (0,Cri (T Requested Action(s): ❑ Urgent ❑ Please comment n Please sign ❑ Please reply ❑ Sent as requested ❑ For review 8 /or action Comments: Tags & Title, Gifts & Collectibles , Notary