1749 Seminole Rd RES20-0097 permit submittalY;11,
Building Permit Application 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 Fax: (904) 247-5845 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: Permit Number:
r1 1-r yj
Legal Description 20 -;)0 OW-,- 0{012. (/1- i R E # /6 963 9 62 ov
Valuation of Work (Replacement Cost) $ ' SI �f 3 Heated/Cooled SF Non- Heated/Cooled
• Class of Work: Q]New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool indow/Door
• Use of existing/proposed structure(s): ®Eommercial t-
If
entia
• an existing structure, is a fire sprinkler system installed?s N
• Will tree(s) be removed in association with or000sed oroiect-Q!res (must submit separate Tree Removal Permi�l l�'3
Describe in detail the type of work to be performed:
(`e.PIaC2 %, �/tnLW> -1- 3 bwrS )(24
Florida Product Approval #
for multiple products use product approval form
Property Owner Information
Name it *. 14.!�,L:r Address 1-7!t9 _QM ,% (2
City , State Ft zip M-13 Phone
E -Mail
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required) n/a
Contractor Information
Name of Company PPA U,, -(-_NO (S Qualifying Agent J ame> P CUIL•n(
Address 3 Sb S F_ t -(IL( I.v City L9its I-rtou L State 1�'t zip 3
Office Phone _'7 00 Job Site Contact Number
State Certification/Registration # C 60`l 7/ a E -Mail JaMe 5 R9W�O.w` {�w s1,QQ �� Q�ih �i ov C,� �►,
Architect Name & Phone #
Engineer's Name & Phone #
Workers Compensation Insurer �SA, —Irl OR Exempt ❑ Expiration Date / Z:0::
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 FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDG YOUNOTI OF COMMENCEMENT.
X
(Signature of Owner Agent) (Signature of Contractor)
Z"'A
Signed before this/� day
Signed and sworn to (or affirmed) before
nip this day of
and sworn to (or affirmed)
me of
byJ tin 1
r"_`j'
,ACL• ao� , by
�e)MZS
IN A WRIGHT
i n u eofN t r
•.
�4- ?Mary Public State o` FloriCa
;,::;�?»; ; TIMOTHY R. O'MALt-EY
�F
[ ]Personally Known OR 'Fort~;:`
Commission k GG 719590
My Comm. Expires May 20, 202
onall Known OR
�= MY COMMISSION # OG 117135
�= EXPIRES: Au gust 7, 2021
Produced Identification Banded through National Notary Assr
produced Identification
.;�; ;°' Bonded Thru Notary Public Undenxriters
Type of Identification:
Type of Identification:
Doc # 2020065593, OR BK 19147 Page 335, Number Pages: 1,
Recorded 03/20/2020 10:22 AM, RONNIE FUSSELL CLERK CIRCUIT COURT DWAL COUNTY
RECORDING $10.00
Permit Number
Parcel ID Number
NOTICE OF COMMENCEMENT
State of Florfdb.,
{,
County of
The undersigned hereby gives notice that the imprcvement(s) will be made to certain real property, and in accordance with
Chapter 713, Mrida Statutes, the following Information is provided In this Notice of Commencement.
L Description
Legal
2. General description of Improvementts)
S.
of the p(operty, and street address If available)
6,A-4 7
4. Fee Simple Title Holder (if Qlher than owner shown above)
Address Phone & Fax Number
S. Contractor
Name 1DAAA MM=ws & Dom Phone & Fax Number
Address 35e wstee Road1i.�Ji
6. Surety {if any) Longwood. FL 32750
Name WA Phone & Fax Number
AddressNIA
7. Lender (If any)
Name WA Phone & Fax Number
AddressWA
8. Persons with the State of Florida designated by Owner upon who notices or other documents may be served as
proved by 713,13(i) (a) 7, FloridaStatute
Name Phone &Fax Number
Address
9. In addition to himself or herself, Owner designates the following to receive a copy of the Uenor's Notice as provided in
713.13(1) (b), Florida Statutes. \
Name l 1 Phone & Fax Number
Address
10, Expiration date of Notice of Commencement (the expiration date Is one year from the date of recording unless a
different date is specified:
WARNINGTOOWNBt: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF
COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART 1, SECTION 713.13, FLORIDA
STATUTES, AND CAN 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 FINRNCING, SULT YOUR LENDER AN ATTORNEY BEFORE COMMENGNO W K OR RE RDING YO R NOTICE
OF OM6AENCEME _-
Slgnafixeo0 +n otOwnds mnh Iced aH'r OL.am(Partnar/rdanaaer PrineN J �M�\
Sworn to (or alffrrned) and wbscribed before me this��day of NU 20�– py , r r 311
I
�� �]L� (type of authority, e.g. ofOcer, trustee, attorney In fact) or �r� a e of pay on t �+
behalf of whom Instrument was executed. _personalty knos�n to me or –_j==V sduced
as Identificatio
KEVIN A WRIGHT
•'� :'tt3' ?�.
�?�•��'' Notary h.•bI1C • Store o! Florida
of Noury �'� y (Seal) ommission a GG t19596
My Comm. Exoitls May 20. 2022
N.—(P,Intl B.nded through National Notary ASM
Verification pursuant to Section 92525, Florida Statutes. Under penalties of perjury, i ddec/l`a�r/'e) t I have read the tore ng and
that the facts stated are true to the best of my knowledge and belief.
atoryy atural Person Slgni (in Hna }Abovo
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