380 12TH ST - ACC20-0025 �rCity of Atlantic Beach W APPLICATION NUMBER
. ) 0
Building Department (To be assigned by the Building Department.)
800 Seminole Road Q
Atlantic Beach, Florida 32233-5445 / 'C 2O-0025
Phone (904)247-5826 • Fax(904)247-5845
E-mail: building-dept@coab.us Date routed: 5-13-20
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 0 0 12+k C�T,ee+ Department review required Yes No
0�h�� Building
Applicant: Planning &Zoning
Tree Administrator
Project: AGO Paye D��v�t�ay ublic Works
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
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:
BUILDING
PLANNING &ZONING f---/
Reviewed by ('j �� d4 �� Date:
TREE ADMIN. Second Review: (Denied. ❑Not applicable
nApproved as revised.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied. ['Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
o\ Building Permit Application Updated 1W9/18
y, City of Atlantic Beach Building Department **ALL INFORMATION
\ HIGHLIGHTED IN GRAY
\,dor! 800 Seminole Road, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: C, 1 1 - Permit Number: ACC 20 - O C 25
Legal Description Z7 \� L5- lk_ ,1) •'S?'lv �c%�`r`. Vn`� I L-Ok-�
p Cc r E(� �C D nI(1. tva 3;.: RE## 1. 1 \`y2(Z —CLCD
Valuation of Work(Replacement Cost) $ q\.Q Heated/Cooled SF NJ )FZc Non-Heated/Cooled Iv//It
• Class of Work: ❑New Eyaadition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool EWindow/Door
• Use of existing/proposed structure(s): ❑Commercial l'esidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes Q610
• Will tree(s)be removed In association with proposed project? ❑Yes(must submit separate Tree Removal Permit) IA/Vo
Describe in detail the type of work to be performed:
rN-Cir‘O'\ SPCA,S
Florida Product Approval# �% /A for multiple products use product approval form
Property Owner Information
Name Ve A-t'- 2- Pro \ \\G`'- Address 12 � ":SkThr to-
City A-'t'\Cw -- C_ (2)£'G"C A-`, State tel— Zip ,3L2-3? Phone 47-A
E-Mail (-AtY\iAre---‘),fpvc\\G\� @C\ - O\ \ • CCCc"•
Owner or Agent f Agent, Power o Attorney or Agency Letter Required)
Contractor Information
Name of Company S.R . l_[7(\Cl►,Tr'C Qualifying Agent "7(7,1e\- l ne elreS_
Address k1.0 1 rt - C) Wei\`'e--a City(YCP\C tE (my'V._ State lC--L. Zip 37 01-3
Office Phone Clc4 2t.p4 r+'� Job Site Contact Number C 4- -4t
State Certification/Registration#C(t C(.115C'14)01/4E-Mail \\C-Ii--c, ( ' os\OC\C�
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer Z •4 c --'.[+,sC c-. r I P1 J% dG•OR Exempt❑ Expiration Date(ti3 0(4, Z'
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
RECORDING YO Ail 0 E COMMENCEMENT.
M a (Signat• of owne Oo 2 e ) ignature < • ractor)
Y
Signed and sworn to(or affirmed)before me this day of Signed and sworn o(or • med)before me this 11 I day of
,by (Y �UL� ,by
. i / '/.-
(Signature of Notary) (S • ature of Notary)
. \+
ozoz'siger:S3NIdX3
[ ]Personally Known OR { rsonally Known OR 616z00NNOISSIYVYVoD Cl4
[ 1 Produced Identification ( 1 Produced IdentificationA HL210NNOSNHOI V0�13219 "m.. d
Type of Identification: _ Type of Identification: /'
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JOB COPY
Approved By Permit Desk
Building Department
City of Atlantic Beach, FL
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