541 Beach Ave RES20-0095 window flashing repair permit applicationJob Address: { tl t fifa, P llv tPvE Permit Number:
updoted 10/9/18
*,*ALL INFORMATION
HlGHLIGHTED IN GRAY
15 REQUIRED.
Valuation of Work (Replacement Cost) S $ a.,3oo Heated/Cooled SF
d L'4illi L
RE# l7Ot5i- olo,r
Non- Heated/Cooled--
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Legal Descriptio n 5 -(rr it 't\ " 2,1( ,Lio hrt tu;'L 8l A. tt: ti;p
o Classof Work: trNew lAddition trAlteration E(epair DMove nDemo DPool nWindow/Door
o Use of existing/proposed structure(s): ECommercial E/6sidential
o lf an existing structure, is a fire sprinkler system installed?: DYes {*o
a
Florida Product Approval H lv/A
Propertv Owner lnformation
Name Pi:b,2\ '=:i'l:. lrtt Address f 'l I
City /IrLA,vr," 13 fAL q State rjl Zip Phsns tlt:tl, l-LL. j7lIle
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Owner or Agent (lf Power of Attorney or Agency Letter Required)
Contractor lnformation
{t ts
Name of Company
Address f '.i
.,i 1-iutl{vliio'-Qualifyi ng Agent Joffltl tl. /ur,r/l ctk
C State !" L Zip ,eelj
Office Phone .'.,'j Job Site Contact Number
State Certification/Regist ffi'- E-Mai
Architect Name & Phone # |
I J*'.f ''s.1 ,aLi a.r ri4c. (.er1t
Engineer's Name & Phone #
WorkersCompensationlnsurer (;,,'u'tl'r.r^.,;, ORExemptn ExpirationOarc lt./,7:i'c
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,andAIRCONDITIONERS,etc. NOTICE: lnadditiontotherequirementsofthis
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 othergovernmental 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 !N YOUR PAYING TWICE FOR IMPROVEMENTS TO PROPERTY. IF YOU INTEND
TO OBTAIN FI NCING, CONSULT WITH YOUR LENDER O RNEY BEFORE
RECORDING R NOTICE OF COMMENCEMENT.
(Signature of Owner or Agent)(Signature of Contractor)
Sigr
N
ned and sworn to (or affirmk42 ozo
before e is/t aav or rmed)before me this 24 day of
OS
(Signature (Signature ota rv)
lfiersonally Known oR [ ] Personally Known OR
lylProduced ldentificatlon[ ] Produced I
,<
Type of ldentificationbt* Efliz
KAREIIFASCIAI..^
Commisinl0G 11631E
Lidod Ttrr Iry F& hxrrnc. l0$st$?t1l
XAREH FASCIAXA
ComrnBson # 6G t463,t8
londod llrt loy Fah hnneoce 900.3E$l0te
Type of ldentification:
by
44tt- t>t
Building Permit Application
City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL32233
Phone: (904) 247 -5826 Email: Buildins-Dept@coab.us
for multiple products use product approval form
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Describeindetail thetypeof worktobeperformed:l:f .'-t t- - /-'.t^'
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