1482 Marsh View Ct RES20-0013 Replace Windows RESIDENTIAL PERMIT PERMIT NUMBER
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800 SEMINOLE ROAD CITY OF ATLANTIC BEACH RES20-0013
\V ISSUED: 1/23/2020
\
~�`__,;1� EXPIRES: 7/21/2020
ATLANTIC BEACH. FL 32233
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLORIDA BUILDING
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
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.
JOB ADDRESS: PERMIT TYPE: i DESCRIPTION: I VALUE OF WORK:
1482 MARSH VIEW CT RESIDENTIAL WINDOWS/DOORS replace windows $21216.00
TYPE OF I REAL ESTATE ZONING: BUILDING USE SUBDIVISION:
CONSTRUCTION: NUMBER: GROUP:
170704 0110 HIDDEN PARADISE
COMPANY: ADDRESS: I CITY: STATE: ZIP:
Coastal Green Energy
Solutions 6710 Benjamin Road Suite 200 Tampa FI 33634
OWNER: ADDRESS: CITY: STATE: ZIP:
1
SELLERS DAVID J 1482 MARSH VIEW CT ATLANTIC BEACH FL 32233
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT
IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
LIST OF CONDITIONS
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
.... .
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
BUILDING PERMIT 455-0000-322-1000 0 $160.00
BUILDING PLAN CHECK 455-0000-322-1001 0 $80.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $3.60
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.40
TOTAL: $246.00
Issued Date: 1/23/2020 1 of 2
- %'S'`'.N. RESIDENTIAL PERMIT PERMIT NUMBER
z_ CITY OF ATLANTIC BEACH RES20-0013
,� v 800 SEMINOLE ROAD ISSUED: 1/23/2020
.:U;; 9% EXPIRES: 7/21/2020
ATLANTIC BEACH. FL 32233 I
Issued Date: 1/23/2020 2 of 2
rS�-1Y,-, City of Atlantic Beach APPLICATION NUMBER
/j -ft;,; Building Department (To be assigned by the Building Department.)
r 800 Seminole Road (� Sc O-0013
j Atlantic Beach, Florida 32233-5445 1�
\ Phone(904)247-5826 • Fax(904)247-5845
\'`Rlq �J
Email: building dept@coab.us Date routed: ( 11, leoa-1�
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: (LI % (7` SV) \i49-‘) LA-• D- • . -nt review required Yes No
CZ
� �, n c�` Briding
Applicant: Dc i. \ ('i(Q;Q(� {1 Jc�It4tya,\ - arming &Zoning
`' C Tree Administrator
Project: L fk Qt-L On!t n (,10,-i) J Public Works
Public Utilities
Public Safety
Fire Services
Review fee $ Dept SignatureD w0-i_
dour a7
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept.of TransportationC
Q
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Approved. Denied. ❑Not applicable
(Circle one.) Comments:
BUILD G\
PLANNING &ZONING -/6 .-a
Reviewed by: Date: 0
TREE ADMIN. Second Review: ['Approved as revised. ['Denied. ❑Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ['Approved as revised. ['Denied. I 'Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
rik. - Building Permit Application OFFICE
COPY Updated 10/9/18
J'
City of Atlantic Beach Building Department **ALL INFORMATION
{iamprv 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
on�� IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: \ A ( c.Xic.''1 \1 \@V� C\ A\\p,l�\\�Y ' :i,t,\\ \_ `F�`ermit Number: RES(&Q " o 0(3
Legal Description V"\'c\---\ ' aC,-:.,"‘ L -k .Z\ \-\\C\C.\e.x YU(C(\\\L \ \ Z\ RE# \1p1 OA 0\\O
Valuation of Work(Replacement Cost)$ Z\,2\ 9 Heated/Cooled SF Non Heated/Cooledi '')I
u c i
'
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool 'D (ndow/Door 11 I
• Use of existing/proposed structure(s): ❑Commercial ❑Residential l
J JAN 1 4 2020 1iLill
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No ) +
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed:\]`(\(\du`N \e \4(_Q\'\eNO-\ �\Z� (u�._-� \? __\)_\.1.\.,(\ �wS)-
R.A \y,, \1 c.)1-1A,\11.'x"-1,1, t\yS2. .\, \-1"t')S'.\, \-I�SS, �_
Florida Product Approval#\fit C)\(yi'Q.) c4 '\ C\\\O \N\C_V-\&e L\ for multiple products use product approval form
Property Owner Information
Name %\k\6 l._\,\ C\-\wk C� V.\\e_\ Address \\AY, - lam(.\\( \iAv\QW CIN
City ,A- ()-`(l3\\ ,C,(,‘.(.\r State c.\,-- Zip LI-29) Phone CWL\- VYC.-a` 2ScL\v
E-Mail S\\s \\v,\AN0 A'R�N
gent
Owner Aif Agent, Power of Attorney or Agency Letter Required) Q\j(.(O\ --'\\ \\
Contractor Information 1
Name of Company CtoC\ \U.\(3 ke `l\e'(C S\i\U\\U•(\S -Qualifying Agent �ebeS.0 Ca \,CA\
Address`U \\C� '\ : <h\1\\'C1 t -2aj City \u,.\(-(\�CJ\ State L Zip
Office Phone j.\ - \L- (SIC)1L-\ Job Site Contact Number V
State Certification/Registration#ClrL 1 'lc\ E-MailWik1'\\\11`l\C, CbO\\C.\\C)c 'Y\' _1('\e'(Gy-VUC i
t
Architect Name& Phone# Z
Engineer's Name&Phone# Z
Workers Compensation Insurer WC 2'0 a 000000 OR Exempt 0 Expiration Date I illikalZ• ' 52
• 1-
Application is hereby made to obtain a permit to do the work and installations as indicated.I certify that no work or install*Ib a4 p
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all the laws regOttii'§ 6 V
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SI?JSt.) 0 o c
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE:In addition to the requiremenoFthil 0 x
permit,there may be additional restrictions applicable to this property that may be found in the public records of this coun p Q
there may be additional permits required from other governmental entities such as water management districts,state agertie ricin- (n
federal agencies. CC
0 UJ
W
OWNER'S AFFIDAVIT:I certify that all the foregoing information is accurate and that all work will be done in compliance withVll� c W
applicable laws regulating construction and zoning. Q a IX 03
W
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MT V w CA w w
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INT11D °C uJ
Ili TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER +R AN ATTORNEY BEFORE cc
RECORDING YOUR NOTICE OF COMMENCEMENT. 1
—J2 LQ,eA-& maU-jAP \ 11
(Signature of Owner or Agent)
, ignature of Contractor)
Signed and sworn to(or affir d)before_ me this 1 day of Signed and sworn to(or affirmed)before me this`' -day of
.1. � O , by Y7�C�d M,)31 ..)aYwav\-k• , a O by 1-
ignaturc---777-3 . T.
wig Notary Public State of Florida
i9 Rachel Ann Rozier �+�'+� Notary Public State of Florida
[Personally Known OR Rachel Ann Rozier
�A� My Commission GG 319764 ,Personally Known OR � • My Commission GG 319784
[ 1 Produced Identificati. 'iia*d� Expires 04/04/2023 [ 1 Produced Identification ��a,!/ Expires 04/04/2023
Type of Identification: _ Type of Identification:
Sketch of Residence
OFFICE COPY
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Lender: Green Sky Notes
Terms: L 0 I 3 — t u S - 5-U 0%,
HOA
Class/Design Pressure in PSF 40(7.68) Wind Velocity in MPH 129
OFFICE COPY CoastalGreen e Energy
Solutions
CDavid Sellers
Cust.Name
Tara Sellers
1 —1J �/� Phone Number 904-352-9325
FOial d✓I
C..) ( 7 ) 0 Phone Number 904-382-4275C
Cont.Date 9/26/2019
�J r 1482 Marsh View Ct
� (�(/C%� rl� M 13tveti?
�yy �� Address Atlantic Beach,FL 32233
/ Iii
A\ County Duval
1< Sales Rep: Bob Shepherd
C Phone Number 904-885-2590
1a [� Frame Type Block / Wood
�. `1�` 5n�)�,/ F`' O Exterior Siding
t11�! YB 2005
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Lead Test Y/N NO
Lead Results Y/N
Qr'4J 4 Bucking Req i
Ff ? ht—
'I
. $k1 TA Color .UGrids
I .* m Frosted
�p 7 Impact Qty.
L N-r Non-Impact Qty
f Window Shields Qty.
Door Shields Qty.
Cust.!nit
Customer agrees to the above
Nr jRoom n 3 uW 7/ H CStyle l Series OBS I Temp Screen�reGrids Add'I Options
1 - 1 'f S &V 7 4) 70 �� J ,il ! 2 p r ... .1...: .~' ~ r' 11- i.
2 KIT 6 N 3 S (09 /8 c44-sE i / 1 )( F711 ' I 0.0 . f— ,
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Customer Signat re: � Z Date: to . 1 ` Measured By: 4 I,- -
Do you live in a flo o Yes or No (Please circle one) Date: 1
OFFICE COPY
FORMS
FLORIDA BUILDING CODE, ENERGY CONSERVATION 1
Residential Building Thermal Envelope Approach I
FORM R402-2017 Climate Zone ❑ I
Scope:Compliance with Section R401.2(1)of the Florida Building Code,Energy Conservation,shall be demonstrated by the use of Form I
R402 for single-and multiple-family residences of three stories or less in height,additions to existing residential buildings,alterations, I
renovations and building systems in existing buildings,as applicable.To comply,a building must meet or exceed all of the energy efficiency '
requirements on Table R402A and all applicable mandatory requirements summarized in Table R4028 of this form.If a building does not
comply with this method,or by the UA Alternative method,it may still comply under Section R405 of the Florida Building Code, Energy I
Conservation. \‘..k \-`I / I
PROJECT NAME yQ-A\..'«-'a `�- C?,�L\`V"&.CA BUILDER:L�CS., J�CS`C��•'�(�'�(Q- L�. V\--\:\\�s
AND ADDRESS: ` -\`CN\‘\(-VQI1LC�l, ' �PLZ�3 Q, \ 1.�\Y� \�
OWNER: '/� T PERMITTING OFFI E:
)o.-'&\& U�� \ ,y4,C:. \-0t-ks JURISDICTION NUMBER:
PERMIT NUMBER: I
General Instructions: I
1.Fill in all the applicable spaces of the'To Be Installed"column on Table R402A with the information requested.All'To Be Installed"values must be
equal to or more efficient than the required levels. I
2.Complete page 1 based on the"To Be Installed"column information. I
3.Read the requirements of Table R402B and check each box to indicate your intent to comply with all applicable items. '
4.Read,sign and date the"Prepared By"certification statement at the bottom of page 1.The owner or owner's agent must also sign and date the form.
1. New construction,addition,or existing building 1. I
2. Single-family detached or multiple-family attached 2. '
3. If multiple-family,number of units covered by this submission 3.
4. Is this a worst case?(yes/no) 4. - I
5. Conditioned floor area(sq.ft.) 5. I
6. Windows,type and area
a) U-factor. 6a.k)
V r?•)Z!Q'8%}UolCiA410a:1l I
b) Solar Heat Gain Coefficient(SHGC) 66.t�+?.- 0,,NC 0. 1 -�0. 'P
c) Area Sc. I
7. Skylights
a) U-factor. 7a. I
b) Solar Heat Gain Coefficient(SHGC) 7b.
8. Floor type,area or perimeter,and insulation:
a) Slab-on=grade(A-value) Ba. I
b) Wood,raised(R-value) 86•
c) Wood,common(R-value) Sc.
d) Concrete,raised(A-value) ed.
e) Concrete,common(A-value) Be. I
9. Wall type and insulation: I
a) Exterior: 1. Wood frame(Insulation R-value) gal.
2.. Masonry(Insulation A-value) 9a2 I
b) Adjacent: 1. Wood frame(Insulation R-value) 9h1. I
2. Masonry(Insulation R-value) 9b2. I
10. Ceiling type and insulation
a) Attic(Insulation R-value) 10a. I
b) Single assembly(Insulation R-value) 106. I
11. Air distribution system:
a) Duct location,insulation 11a. I
b) AHU location 11h. I
c) Total duct leakage.Test report attached. 11c. cfm/100 s.f. Yes❑ No 0 I
12. Cooling system: a)type 12a.
-
b)efficiency 12b. I
13. Heating system: a)type 13a. I
b)efficiency 13b.
14. HVAC sizing calculation:attached 14. Yes 0 No 0 I
15. Water heating system: a)type 15a. I
b)efficiency 156. I
I hereby certify that the plans and specifications covered by this form are Review of plans and specifications covered by this form indicate
in compliance w h he Florida Building Code,Energy C ns ation. compliance with the Florida Building Code,Energy Conservation.Before
PREPARED BY: SG.�1` i Date��U/IOW construction is complete,this building will be inspected for compliance in I
I hereby certify that this building is in compliance with the Florida Building accordance with Section 553.90 I
Code,Energy Co a ation. CODE OFFICIAL:
OWNER/AGENT 1 1'V Dater Date: f' /6 `d 0 1
FLORIDA BUILDING CODE-ENERGY CONSERVATION,6th EDITION(2017) R-55
FORMS OFFICE COPY
I TABLE R402A
' BUILDING COMPONENT PRESCRIPTIVE REQUIREMENTS' INSTALLED VALUES
Climate Zone 1 Climate Zone 2
I Windows LIFactor=NR U-Factor=0.40z U-Factor=k1 ,0..Sii l0(ISA.1U m OtL1
' SHGC=0.25 SHGC=0.25 SHGC=0\'L�O<\ \ 0, l (I IVi,O t
Skylights U-factor=0.75 U-factor=0.65 U-factor=
' SHGC=0.30 SHGC=0.30 SHGC=
1 Doors:Exterior door U-factor=NR U-factor=0.403 U-factor=
Floors: NR
Slab-on-Grade NR
1 Over unconditioned spaces' R-13 R-13 R-Value=
' Walls':Ext.and Adj.
Frame R-13 R-13 R-Value=
Mass
Insulation on wall Interior R-4 R-6 R-Value=
Insulation on wall exterior R-3 R-4 R-Value=
' Ceilings' R=30 R=38 R-Value=
Air infiltration Blower door test is,required on the building envelope to verify leakage_<1 ACH; Total leakage=ACH
test report provided to code official. Test re ort attached?
•
Yes DI No❑
' Air distribution system':
Air handling unit Not allowed In attic Location:
' Duct R-value R-value>_R-8(supply in attics)or>_R-6(all other duct locations) R-Value=
Air leakage':
Duct test Postconstruction test Total leakage<_4 cfm/100 0, Total leakage= efrn/10Ds.f.
Rough-in test Total leakage<_4 cfm/100 s.f.(air handler Installed) Test report Attached? Yes 0 No❑
Total leakage<_3 cfm/100 s.f.(air handler not Installed) Location:
Ducts in conditioned space Test not required if all ducts and AHU are in conditioned space
Air conditioning system: Minimum federal standard required by NAECA`:
' Central system<_65,000 Btu/h SEER 14.0 SEER=
Room unit or PTAC EER[from Table C403.2.3(3)] EER=
' Other. See Tables C403.2.3(1)-(11)
Heating system: Minimum federal standard required by NAECA°:
Heat pump<_65,000 Btu/11 HSPF 8.2 HSPF=
1 Gas furnace,non-weatherized AFUE BO% AFUE=
Oil furnace,non-weatherized AFUE 83% AFUE=
Other.
1 Water heating system(storage type): Minimum federal standard required by NAECAB:
Electric1 40 gal:EF=0.92 Gallons=
50 gal:EF=0.90 EF=
' Gas fired° 40 gal:EF=0.59 Gallons=
' 50 gal:EF=0.5B EF=
' Other(describe): •
1 NR=No requirement
' (1)Each component present in the As Proposed home most meet or exceed each of the applicable performance criteria in order to comply with this code using
this method.
I (2)For impact rated fenestration complying with Section R301.2.12 of the Florida Building Code,Residential or Section 1609.1.2 of the Florida wilding Code,
' Building, the maximum U-factor shall be 0.65 in Climate Zone 2. An area-weighted average of U-factor and SHGC shall be accepted to meet the
requirements, or up to 15 square feet of glazed fenestration area are exempted from the U-factor and SHGC requirement based on Sections R402.3.1,
' R402.3.2 and R402.3.3.
' (3)One side-hinged opaque door assembly up to 24 square feet is exempted from this U-factor requirement.
(4)R-values are for insulation material only as applied in accordance with manufacturer's installation instructions.For mass walls,the"interior of wall"
I requirement must be met except if at least 50 percent of the insulation required for the"exterior of wall"is installed exterior of,or integral to,the wall.
I (5)Ducts&AEU installed"substantially leak free"per Section R4033.2.Test required by either individuals as defined in Section 553.993(5)or(7),Florida
Statutes,or individuals licensed as set forth in Section 4-89.105(3)(f),(g)or(i),Florida Statutes.The total leakage test is not required for ducts and air
' handlers located entirely within the building thermal envelope. '
' (6)Nfinimum efficiencies are those set by the National Appliance Energy Conservation Act of 1987 for typical residential equipment and are subject to NAECA
rules and regulations.For other types of equipment, see Tables C4D3.2.3(1-11) of the Commercial Provisions of the Florida Building Code, Energy
1 Conservation.
' (7)For other electric storage volumes,minimum EF=0.97-(0.00132*volume).
(8)For other natural gas storage volumes,minimum EF=0.67-(0.0019*volume).
R-56 FLORIDA BUILDING CODE—ENERGY CONSERVATION,6th EDITION(2017)
OFF ICE COPY
FORMS
•
TABLE R402B MANDATORY REQUIREMENTS
Component Section Summary of Requirement(s) Check
Air leakage R402.4 To be caulked,gasketed,weatherstripped or otherwise sealed per Table R402.4.1.1.Recessed lighting:IC-rated as
having<2.0 cfm tested to ASTM E 283.
Windows and doors:0.3 cfm/sq.ft.(swinging doors:0.5 cfm/sf)when tested to NFRC 400 or
AAMA/WDMA/CSA 101/1.S.2/A440.
Fireplaces:Tight-fitting flue dampers&outdoor combustion air.
Programmable R403.1.2 A programmable thermostat is required for the primary heating or cooling system.
thermostat �
R403.3.2 Ducts shall be tested as per Section R403.3.2 by either individuals as defined in Section 553.993(5)or(7),Florida
Air distribution system R403.3.4 Statutes,or individuals licensed as set forth in Section 489.105(3)(f),(g)or(i),Florida Statutes.Air handling units
are not allowed In attics. '
Water heaters R403.5 Comply with efficiencies in Table C404.2.Hot water pipes insulated to>_R-3 to kitchen outlets,other cases. '
Circulating systems to have an automatic or accessible manual OFF switch.Heat trap required for vertical pipe
risers.
Swimming pools&spas R403.10 Spas and heated pools must have vapor-retardant covers or a liquid cover or other means proven to reduce heat
loss except if 70%of heat from site-recovered energy.Off/timer switch required.Gas heaters minimum thermal
efficiency is 82%.Heat pump pool heaters minimum COP is 4.0.
Cooling/heating R403.7 Sizing calculation performed&attached.Special occasion cooling or heating capacity requires separate system or
equipment variable capacity system.
Lighting equipment R404.1 At least 75%of permanently installed lighting fixtures shall be high-efficacy lamps.
•
•
•
•
FLORIDA BUILDING CODE—ENERGY CONSERVATION,6th EDITION(2017) R-57
STATEWIDE PRODUCT APPROVAL SUBMITTAL
0 Revision Date: 5/24/04
\‘'1/4 \"�a( V W�L\ � 3� � v',4\�.x\.6 i sc. <�,5�...\G;�AIr S�\�-1 xc:�i
Application/Perm : Building : A \ �1 \( ?GCA1�C�. wner:_\\�.(S Contractor: ,A
Lc.:;N7 (,�
LLI Openings: Sliding Glass Doors,Exterior Swing Doors, Overhead Doors, Fixed Glass, Windows, Mullions, Skylights
C) **Pressure Product Approval Product Model#or Glass Attachment Approval Expiration
*Qty D T Manufacturer Category Number/Seq#. Name Series Type/Size Method Entity Date
a CO 'SQ• '" y41/4,;:\eh"s°`'' \rk,riVCA, V`12 . 'y,\. U\5 A•(v 0y QN 6,\S \_,,, . 14 v
3 � �v SSS\�-tihS .\. \,1/4.\ ,,,,,,,...,
�i� a„� \'1 t 3'L.'\ \� ,��\o, S\ Vi.\G :•,it3La c .i
\9 ; Sc_ UNCv vv\\,NWrS \-1Zc :\ V\\ 'LS. .Z' LAL:.
t Wit S\rC” \ra`0 ,\ 1-1 .3' Y' , \,L\\o.\\-\`- ll:2-0 �.� ..2*L;
I hereby designate and authorize the agent and/or qualifier listed below to act on my behalf as the agent
in the processing of this application for the permit and to furnish on request supplemental information
in support of this application. In addition, I authorize the below-listed agent to bind me to perform any
requirement which may be necessary to procure the permit or authorization.
Printed Name of Qualifier/Certified Contractor: u\. \ C - CK_
Signature of Qualifier/Certified Contractor. A•,►=
Date: \ I \ si 11_41-0
Printed Name of Authorized Agent: Ke-V_LCJ\ V.-A\ V.:)..\
Signature of Authorized Agent: —Ni1-mA A 0} G4)
Date: ‘ \ fLO Z 0
Printed Name of Owner: 1 Gy()` (.:?.`C\6 \--)O'\\C\ 6\e,t
"CA-5--. llll �
Signature of Owner(Mk I QJ" /,�
Date: / - / / -
Job Address:
\‘---\M \c cChA\�\,A C A\\cAr\\\ W Ck(.)>�\_,... L 2._- 3
Owner Name:\ OA U (� \ \'(\V\(� �C\�e'cc Phone Number:Clb�-\-��L C���-��
Mailing Address:\'-\L \-)\(AQ\\1•\ \N ��1 City:A \ \\ -•\N State: U..
Zip.271-2-
The foregoing instrument was acknowledged before me this 1`'I day of ,20 2)in the
State of Florida, County of-0vV� t �x
Signature of Notary •ublic ------ -
[ ] Personally Known OR [X Produced Identificat'on Type of Identification: $b-�
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