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763 Atlantic Blvd COMM20-0012 1 of 26 permit applicationBuilding Permit Application o..!o...J 'JJ City of Atlantic Beach Building Department 8 00 Semi nol e Road , A t la ntic Beach , FL 32233 Phone : (904 ) 24 7-5 8 26 Email : Building-Dept@coab.us Updated 10/9/18 ""ALL INFORMATION HIGHLIGHTED IN GRAY IS REQUIRED . Job Address : 763 ATlANTIC BLVD Permit Number: ___________ _ Lega l Description 3&-25-29E .49 B OE CASTRO Y FERRER GRANT PT RECD OIR 189!JO.1982 RE# 177653-0005 Valuation of Work (Replacement Cost) $._90-'._000 ______ He at e d/Cooled SF _____ Non-Heated/Cooled ____ _ " Cla ss of Work : D New D Addition !!!Alteration DRepair D Move D Demo D Pool D W i ndow/Door • Use of existing/proposed structure(s): !!!Commercial DR esidential " If an existing structure, is a fi r e sprinkler system installed?: D Yes !II! No " Will treelsl be removed in association with orooosed oro 'ect? D Yes Imust su b mit seDarate Tree Removal Permit} D Na De scri be in detai l the typ e of work to be performed : Tenant Buildout -Curaleaf-includes Bldg , Mech , Elect , Plumb Florida Product Approval # ___________________ for multiple products u se product approval form Property Owner Information Name 412 BOARDWAlK Addre ss P a BOX 33046 City ATLANTIC BEACH . State FL Zip .:..3223=3'-____ Phone 904-894-8620 E-Ma il ehlonldes@gmarl,oom Owner or Agent (If Ag e nt, Power of A ttorney or Agency Letter Required) ___________________ _ Contractor Informati on Nam e of Company _T_BD _______________ Qualifying Agent _______________ _ Address City State ___ Zip _____ _ Office Phone 786.200.2807 Job Site Contact Number -,786::::.2.::00=.2.::60::.7 ____________ _ State Certification/Registration # -,--,--:-:==~ ___ E_MailBRIAN @EZP ERMITSIN C.COM Architect Name & Phone # _R"-ya_"_Rad.,--e,_, _386.,..,.-;.'5..,7_.050....,.,.':-;-__________________________ _ Engineer's Nam e & Phone # .:..R",ya.::".:..Ra:::"",""::.· .:..386=.'::.57..::.0"'50:::''-__________________________ _ Workers Compensation In surer OR Exempt 0 Expiration Date _______ _ Appl ication i s hereby made to obtain a permit to do the work and installa tions as indicated . I certify that no work or installation has commenced prior to the issuance of a permit an d that all work will be performed to meet the standards of all the laws regulating construction in this jurisdiction. I understand that a se parate permit must be secu r ed for ELECTRICAL WORK , PLUMBING, SIGNS, WELLS, POOLS, FURNACES , BOILERS, HEATERS , TANKS , and AIR CONDITIONERS, etc. NOTICE : In addition to the requ i rements of thi s permit, there may be additional restrictions applicable to this property that may be found in the public records of thi s 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 informati on is accurate and that all work will b e done in compliance with all appli ca ble la ws regulating const r uction and zoning. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY G TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND G, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE NOnCE OF COMMENCEM ENT. ture of Owner or Agent) r'l, Sig ned and sworn to (or affirmed) before me th is h a ay of f.<i)\ ~ \ ;~ :::,~b~y ~C~h;f~"S~;~f6~e~:>~-~ e-;;to;)O '~ STEFANI SERNA ~Pers onally Know n 0 f"iJ \ Stale of Flor i da -Nola rv Publ i c ( I Produced Identifica ~ *= Commission II GG 235032 -;'::"~ ... "d:~~ My Commission Expires Type of Id entificatio n: t\;~"~'~"iiiiiiiiiiii~~~~~~~j, (Signature of Contractor) Signed and sworn to (or affirmed) before me this __ day of ______ -J ____ -J,by __________________ __ (Sign atur e of Notary) [ I Personally Known OR [ ) Produced Identifica tio n Type of Iden tificatio n: _____________ _