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871 OCEAN BLVD - RES20-0080 Coquina Repair City of Atlantic Beach APPLICATION NUMBER Building Department (To be assigned by the Building Department.) .„,, 800 Seminole Road e. Atlantic Beach, Florida 32233-5445 E z-c OOg 0 Phone(904)247-5826 • Fax(904)247-5845 71 ? E-mail: building-dept@coab.us Date routed: 3 City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: d'7 ( C�al� 1, 1_11..0 review required Ye/ No 1 mg Applicant: 1 V\,11- L. CO Q L 24A C tanning &Zoning 1 Tree Administrator Project: CLQ — 2 Public Works C h l ti /� C Public Utilities K`�G2 c©2 p7 DEA/NN AC, Public Safety Fire Services Review fee $ Dept Signature Review or Receipt Other Agency Review or Permit Required Date of Permit Verified By /1� Florida Dept.of Environmental Protection t/— \ . Florida Dept.of Transportation o�• X 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. / riDenied ❑Not applicable (Circle one.) Comments: C i Qg r1-1 ec,1 Ec nra £i Q BUILDINe PLANNING &ZONING Reviewed by: Date: 471—/—� TREE ADMIN. Second Review: Approved as revised. Denied. INot applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: I 'Approved as revised. Denied. Not applicable Comments: Reviewed by: Date: Revised 05/19/2017 UI- I- ICE COPY Building Permit Application Approved By Permit Desk Updated 10/9/18 r .�_ City of Atlantic Beach Building Department CityBuilding Department of Atlantic Beach, F **ALL INFORMATION A. // 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY 01:),- IS REQUIRED. Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address: 1 i O(. rtln PI.i cl 14-16,4-K_' BP� ��� Permit Number: 1-- S z�- UU J0 Legal Description —499 f f i V 2S' 24 f' . O RE# 102 36 -CO20 Valuation of Work(Replacement Cost)$ ,c00,.).03 Heated/Cooled SF Non-Heated/Cooled • Class of Work: ❑New ❑Addition ❑Alteration Xlepair//❑Move ❑Demo ❑Pool /D6OPY • Use of existing/proposed structure(s): ❑Commercial tesidenti I • If an existing structure,is a fire sprinkler system installed?: ❑Yes"INo • Will tree(s) be removed in association with proposed project? FlYes(must submit separate Tree Removal Permit)/<to Describe in detail the type of work to be performed: /'v J) n� K ‘041rWcaTu2 Q Rv� a-1•- c C—xT€1:21 �C. Florida Product Approval# for multiple products use product approval form Property Ow r Informatio I r Name LG t1N1C(J in(rROlu hC( Address 411 a e 8I'�/Q • 4-i4o.fiL Vr'GC.h 1 L ?22?? City . , 1 t _ State � Zip -3 2131 Phone .U) 2117 (lb gt-/ E-Mail ' - 1) kle( 4 G uo to in Owner or Agent(If A:ent, Power of Attorney or Agency Letter Required) Contractor Information I 1I Name of Company M�Al C(; U�lt1rJ f rdII art fre/1 Qualifying Agent \\I1tt(a -i SOI,, J Address i3ci S C'(toCCSS e It t ve City I- OW.State Zip - Office Phone 90 140.yLi�bp i� Job Site Contact Nu ber State Certification/Registration# ....VIOL IL-WI II- E-Mail 01 ( V1 IMi • l'' Architect Name& Phone# 1/4; 4 Engineer's Name&Phone# (\)II\ • Workers Compensation Insurer OR Exemp Expiration Date_ 1 Application is herebymade to obtain apermit to do the work and installations as indicated. I certifythat no work or insta i h N I. PP �� �Z � commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all the laws regia gL O S. construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, O H WELLS,POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirems8tPs2 H permit,there may be additional restrictions applicable to this property that may be found in the public records of this couJydnE O Q g there may be additional permits required from other governmental entities such as water management districts,state agcip,ei "'in G federal agencies. C I Q CC Z OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance MO)U - U) applicable laws regulating construction and zoning. f C Q H Z WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT M1ibt115 ¢ � ppOwwCC m RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO Y UR 'RO,'ERT F •U lr\ EN ,,, 5 o TO OBTA of FINA CING, CONSULT WITH YOUR LENDER O � •R ' %- ORE w V co cc ¢ w RECOR I�G YOUR T E OF COMM NCEMENT. / w w cc (Signatur of Owner or Agent) (Signature of Contractor) Signed and sworn to(or affirmed) •efore me this I) day of Zeird sw¢¢¢J���l_�n�/ry�Jr�or affirmed)before met is l6 /iff►,, MATTHEW DA ..n•Ati-1> E, I ,r/ .!nature of Notary) tipQ� A� Notary Public,State of Florid(Si: ature of Notary) Z Commission#GG 909094 c )iriii My comm.expires Oct 28,2023 [ ]Personally Known OR • [ ]Produced Identification [.1 duced Identificati �ry�,Q(c I„- ,�0 Type of Identification: Type of Identification: V" " '1 �lW�`�-+ • �v�lckn� Vet- \ JOB COpy Document Name: State of Florida Jurat Notary Certificate STATE OF FLORIDA COUNTY OF QU UQ\ Sworn to (or affirmed) and subscribed by personally appearing before me by physical presence this tk day of CIQrOn , 20 Zee , by, Gp n .\e cmlc1 k PC- . (Signature of notary public) VOek$Q, (Name of notary public) My commission expires:OC1 D/ Official Seal Personally known OR T(( ' Produced identification Type of identification produced: t-" V0 I� PAOLA FANO_ p°e 6 Notary Pubic.State of Florida e,, Commission#GG 38797 •'' My comm.expires Oct.18,2020 rrmemeerrrrser 05-74-0432NSB 02-2020