1671 W Park Terr RES19-0156 Homeowner Authorization City of Atlantic Beach APPLICATION NUMBER
Js �� Building Department (To be assigned by the Building Department.)
800 Seminole Road
L-Sla-O 116
j r� Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845
E-mail: building-dept@coab.us Date routed: t
City web-site: hftp://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: �Yl�� � 'rL✓� -+�Ir. nt review required Yes No
Building
Applicant: ��. L Planning &Zoning
Tree Administrator
Project: �, ns'�[I �j�(/ d a�.� Public Works
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature C(L
Other Agency Review or Permit Required Review or Receipt Dateof Permit Verified ByFlorida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Water Management DistrictArmy Corps of EngineersDivision of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: T rApproved. ❑Denied. []Not applicable
(Circle one.) Comments: /], _� h d Y-aq 4 1� t e 1 I r r P edird -f yo v,-,,BUILDIN /'1 V '�'�`c
1'1 v rI 8 b w PA-t V_ p
PLA G &ZONING Reviewed by: Date. 26 �20/
TREE ADMIN. Denied. ❑Not applicable
PUBLIC WORKS __ n
PUBLIC UTILITIES
PUBLIC SAFETY Date:
FIRE SERVICES Cc/ Denied. ❑Not applicable
Date:
Revised 05/19/2017
F( U&
Building Permit Application OFFICE COPY Updated 10/9/18
_ City of Atlantic Beach Building Department "ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.LlS IS REQUIRED.
Job Address: I��1 Ipo- l e rra
cc- \1"i-e- Permit Number:_ Q c-S I C(^ c)(51(0
_S � ��Legal Description og - ' aCCI4E#
LA n---1 Cu-- I5 L-K- t
Valuation of Work(Replacement Cost
MoD. c,,!) Heated/Cooled SF ayyy Non- Heated/Cooled (-.o C,Q—
• Class of Work: NNew ❑Addition ❑Alteration ❑Repai` RMEIVEDrr❑Move ❑Demo ❑Pool ❑Wi• Use of existing/proposed structure(s): ❑Commercial tlpResidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes ❑No
• Will trees be removed in association with proposed romect? ❑Yes must submit separate Tree Re= er i
Describe in detail the type of work to be performed:
ln5h 1Ia,hoo ok
Florida Product Approval# _ for multiple prodlj itps@�y � � � �L
Property Owner Information
Name Jleso" Address 1lD-1 I [fix/k e✓✓acs wpSt
City A+IarI h L l C Lh Staters Zip 3 3_� Phone
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company po V rd Hocr-e r Qualifying Agent
Address �1,0 S_ -)7_tb(rr3a(,L-,_,2 pIaCd,- CityJ(rlCK-1yOn 4 1 L. _ State C-1—Zip
Office Phone 0011 Q(3 fj Job Site Contact Number
State Certification/Registration# LK(_ 13; C 3Sei E-Mail I CC tYI
Architect Name& Phone#
Engineer's Name& Phone#
Workers Compensation Insurer `)n S(A Kcar ler r Cy- �OR Exempt ❑ Expiration Date
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 the laws regulating
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 FINANCINGfP. NSULT WITH YOUR LENDER OR AN ATTO NEY BEFORE
RECORDING YOUR I 50 MMENCEMENT.
ture caner or Agent) ( ' ature of Contractor)
Signed and sworn to(or affirmed)before me this 2U day of Signed and sworn to(or affirmed) before me this O day of
by �1
Ov v �J ICI
agSVgnr,
of Notab 1Gry) 0(signatur4 of Notary)
+Py TIFFANY HORNBAKER �; / ;" �y<<;. TIFFANY HORNSAKER
personally Known OR MY COMMISSION#GG 030650 Personally Known OR ,, MY COMMISSION#GG 030650
[ ]Produced Identification `:FP;r EXPIRES:Sep tembar 15,2020 ]Produced Identification / EXPIRES:September 15,2020
Bondetl Thru Notary Public UndeFoOters Borxied Thru Notary Public Under+rners
Type of Identification: 11 rype of Identification:_