59 Forrestal Cir RES20-0144 Replace WindowsOWNER:ADDRESS:CITY:STATE:ZIP:
PETTERSSON HANS
NICOLAS 59 S FORRESTAL CIR ATLANTIC BEACH FL 32233
COMPANY:ADDRESS:CITY:STATE:ZIP:
Anderson Installations, LLC 3278 BYRON RD GREEN COVE
SPRINGS FL 32043
TYPE OF
CONSTRUCTION:
REAL ESTATE
NUMBER:ZONING:BUILDING USE
GROUP:SUBDIVISION:
171736 0000 ATLANTIC BEACH VILLA
# 01
JOB ADDRESS:PERMIT TYPE:DESCRIPTION: VALUE OF WORK:
59 FORRESTAL CIR RESIDENTIAL
WINDOWS/DOORS replace windows $9425.00
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
BUILDING PERMIT 455-0000-322-1000 0 $100.00
BUILDING PLAN CHECK 455-0000-322-1001 0 $50.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.25
LIST OF CONDITIONS
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
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.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY 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 FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLORIDA BUILDING
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
1 of 2Issued Date: 6/17/2020
PERMIT NUMBER
RES20-0144
ISSUED: 6/17/2020
EXPIRES: 12/14/2020
RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $154.25
2 of 2Issued Date: 6/17/2020
PERMIT NUMBER
RES20-0144
ISSUED: 6/17/2020
EXPIRES: 12/14/2020
RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
DESCRIPTION ACCOUNT QTY PAID
PermitTRAK $158.50
RES20-0144 Address: 59 FORRESTAL CIR APN: 171736 0000 $158.50
BUILDING $100.00
BUILDING PERMIT 455-0000-322-1000 0 $100.00
BUILDING PLAN REVIEW $50.00
BUILDING PLAN CHECK 455-0000-322-1001 0 $50.00
STATE SURCHARGES $8.50
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.25
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.25
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL FEES PAID BY RECEIPT: R12116 $158.50
Printed: Wednesday, June 17, 2020 10:09 AM
Date Paid: Tuesday, June 16, 2020
Paid By: Anderson Installations, LLC
Pay Method: CREDIT CARD 5
1 of 1
Cashier: CT
Cash Register Receipt
City of Atlantic Beach
Receipt Number
R12116
Building Permit Application Updated 10/9/18
....... }'~I City of Atlantic Beach Building Department
800 Seminole Road, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us
**ALlINFORMATION
HIGHLIGHTED IN GRAY
IS REQUIRED.
Job Address: 59 Forrestal Cir. S. Atlantic Beach , Florida 32233 Permit Number: ___________ _
Legal Description 30-5617·2S-29E ATLANTIC BEACH VIllA UNIT 1 LOT8 BLK 1 RE# 171736·0000
Valuation of Work (Replac ement Cost) $..:9'-'.4"'2,,5 . .:.00=---____ Heated/Cooled SF _____ Non-Heated/Cooled, _____ _
• Class 01 Work: D New D Addition D Alteration D Repair DMove D Demo D Pool iZlWindow/Door
• Use of existing/proposed structure(s): D Commercial \ZIResidential
• If an existing structur e, is a fire sprinkler system installed?: DYes i2lNo
• Will tree 5 be removed in association with ro \ZI No
De scribe in detail the type of work to b e p erformed:
12 Replacement windows size for size
Florida Product Approval #_5_1_7_9-4 __________________ lor multiple products use product approval form
Property Owner Information
Name H ans Nicolas Petiersson
City Atlantic Beach
Address 59 Forresta l Ci f . S.
State Florida Zip 32233 Phon e_8_17_-ll_1_B-_0_0_7_6 ________ _
E-Mail_-:-_-::-:-:-_-::-__ ::-:c-:-__ -:-_---,-,-_::--:--::-,-_________________ _
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required) ____________________ _
Contractor Information
Name of Company Anderson Inst allation s. LLC Qual ifying Agent ..cG"'reg=An..:..cd.:.ers=on-'--=--,-, __ --:=-;::-___ _
Address 3278 Byron Road City Green Cove Springs State Florida ZiP..c.3_204'-'-3 ___ _
Office Phone .:9.:.04-.:..:.95::;5-:..5::;8::3.:.0 __ -,.".-,-,.,-..,.-____ Job Site Contact Number ..:9.:.04-.:..2::;3:.:3-:..7,,8"'20=---___________ _
State Certification/Regist ration # CRC-1331537 E-M ail si d@andersoninsta lla tions.com
Architect Name & Phon e # ___________________________________ _
Engineer's Name & Phone # _.,--::-_.,..,-__ --::-__________________ .,-:-:-::==:-___ _
Workers Compensation In surer NorGuard In su rance Company OR Exempt 0 Expiration Dat e .:0,;,1/,,0,,3/.:.20::;2:::1 ____ _
Application is hereby made to obtain a permit to do th e work and installations as indicated. I certify that no work or installation has
comme nc ed prior to the issuance of a permit and that all work will be performed to meet the stan dards of all the laws reg ulating
construction in this jurisdiction. I understand that a se parate permit must be sec ured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILER S, HEATERS, TANKS, and AIR CONDITIONERS, etc. NOTICE : In addition to the requirements of this
permit, there may be additional restriction s 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
applicab le law s 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 LEND R OR AN ATTO
RE I G Y NOTICE OF COMMENCEMENT.
Signed and sworn to (or affirmed) before me this ft day of
~ • Z DZ Q ~~-:.:.
--=~~~~;;t;;!~~~~;;;~~~W~ ~ = "' •. lp.... (Sjgnatu~~ ~~ Nota'lLEXANDER oRANTES
"~'~"~'" JO~EPHF.SANTORA "' ... ,.'~ .. fM15~" (!J,A:~ M~;p~~~~;~~~:~~.~;9 [ .rson.lly Known OR ~~<?: ~;;:o~..,: 19E.!
'<~~'~:f,~~~" Bonded Thru Notary Public Ullderwme reduced Iden tification 1'') OF .\.Q<f. BQnOe4 ThN BuQ;tltNotlWy
[ ] Personally Known OR
[xl Produced Identificatio,.
Type of Identification: -,"--,'L...=-~~-'-,'f'-..,...L""""'-f-"""""----Type of Identification : fk ~V~/ ( iU/'g?
PRODUCT APPROVAL INFORMATION SHEET FOR THE CITY OF ATLANTIC BEACH, FLORIDA (*REQUIRED)
*Project Address: 59 Forrestal Cir. S. Atlantic Beach , Florida 32233
*Owner/Project Name: Hans Petterson / window replacement
Permit #: __________ _
As required by Florida Statute 553 .842 and Florida Administrative Code Rule 96-72 , please provide the information and product approval number(s) for
the building components listed below as applicable to the building construction project for the permit number listed above. You should contact your
product supplie r if you do not know the product approval number for any of the applicable listed products . Information regarding statewide product
approval may be obtained at: www.fl ori dab ui ld ing.org .
Category/Subcategory Manufacturer Product Description Limitation of Use State # Local #
A. E><TERIOR DOORS
1. Swinging
2 . Sliding
3. Sectional
4. Ga rage Roll-Up
5. Automatic
6 . Other
6. WINDOWS
1 . Single hung
2. Horizontal slider Simonton Vinyl window 5179 .4
3. Casement
4 . Doubl e hung Simonton Vinyl window 5167.1
5. Fixed
6. Awning
7. Pass-through
8. Projected
9 . Mullion
10. Wind breaker
11. Dual act ion
12. Other
---------- ---------------
Page 1 of 4 Update d 10/17/18
In add ition to completing the above list of manufacturers, product description and State approval number for the products used on this project, the
Contractor shall maintain on the job site and available to the Inspector, a legib le copy of each manufacturer's printed specifications and installation
instructions along with this Product Approval Sheet.
I certify that this product approval list is true and correct to the best of my knowledge. I further certify that use of different components other than the
ones listed in this document must be approved by the Building Official.
.Contractor Name (Print Name): Greg Anderson ·Contractor Signature: _~.,,-~...!(k,-,-_~ ___________ _
"Company Name : Anderson Installations, LLC
"Mailing Address: 3278 Byron Road
"City: Green Cove Springs .State: Florida .Zip Code : 32043 ~---
"Telephone Number: (904) 233-7820 .E-mail Address: sid@andersoninstallations.com
Cell Phone Number: Fa x Number : ________________________ _
Pa ge 4 of 4 Updated 10/17/18
5, ~(fN-IvrJ )/71/-/
REv. • RtVIS10NS EVISEO SY-O ... TE:
MODE! QfSIGNA]ON' Simonton Horizontal Slider Series 07-09 / 07-10 / 07-20 107-75 Vlnyl Window NO P.E. SEAL REQUIRED
INSTALLATION SUPPORTED
BY AAMA TEST REPOR TS
7 I ADDEO NOTE 10. T.o.O. 01/011/12
MAXIMUM DVERA!! NOM I NAL SIZE ' See Size Chart ~ UPDATED NOTES AND C.W.OUTS. T.O.D. 03/20/14
DESIGN PRESSURE BA TlNG ·
USAS! f CONfiGU RATIONS-
GENERAl DESCRIPTION-
See SIze Chart
xx, OX, or XO
The head, sill, and side jambs are extruded evc. The well thickness
through which the anchor screw penetrates Is 0 minimum of O.070~.
SIU CONE CAULK
SEE N01!S 13 &; 14 ~j SJlICONE CAULK
_ &E NOrtS 1.3 &: '4
2X WOOD SUCK
l 1/S' MAX. SH IM
~tTI
9 ADOEo MIN. EDGE DISTANCE TO NOTES "'" OI5!II5{1S
1Q ,,~~._~ ~ .. " CHART -A and "'" 12/13/16
I I I ADDED SlZEjDP20 TO SIZ E CHART. "'" 10/16/16
SILICONE CAULK EB .~
[
~ , 1 ,..~.,,~
? +-II--~.w.l SIUCONE CAULK
I-SEE ~'5~~~J c~u~ __ SEE NOTES lJ 6: 14
~x WOOD BUCK
IB ~ 2 1/2" MIN . WOOD
SCREW WITH I.M" MIN.
EMBEDMENT IN TO WOOC
MIN . EDGE 015T., SEE NOTES
SEE NOTES lJ 6: 1-4
1/8" MAX. SHIt.!
-.;;x;-
~ 2X WOCO BUCK ~1:.<",, ___ ::::O,.j PECORA 696
SILICONE CAULK
I
g
:'
x x
@ If If
<l
tT\ SilL tT\ JAMB
\V \.l./
NOTES:
1. Thi s Installation has been eva luat ed fo r use In locations adhering to the Florida Building Code and whe re pressure requirements as determined
by ASCE 7 Minimum Design Loads for Buildings and Other Structures do not exceed the design pressure ratings herein, for use outside the
H.V.H.Z.
2. All Interior and exterior perimeter surfaces of the window must be caulked.
3. Anchors shall be speCifi ed and spaced as shown Anc hor embedment to base material sha ll be beyond wall dressing or stucco and Into wood.
4. The respons ibility for selection of Simonton products to meet any app licable local laws, build ing codes, ordinances, or other safety
requirements rests so lely with the architect, building owner, or contractor.
5. Sh im s are optional. Maximum shim stack Is 1/8".
6. Wood bucks (by others) must be engineered and anchored properly to t ran sfer loads to the structure. Wood bucks shall be spruce -Pi ne-Fir.
Wood minimum specific gravity = 0.42 pSi.
7. Wood screws must be at least Grade 5 for untls with a des ign pressure < 50 PSF, and at least Grade 8 for units with a design pressure
rating 2: 50 PSF.
8. When used In areas requiring Impact protection, t his product REQUIRES the use of approved Impact res istant shutters or other external
protection. f----------.W' t.4AX. OVERALL WlOTH----------i
SIZE CHART
OVERALL SIZE
DP RATING W.~~H H~O~
72" 63"
7S" 72" ±20 PSF
,," 65"
7S" 63" t ±25 PSF
73" 5'" ±50 PSF
63" 48 M I ±55 PSF
9. Flashing should be applied using the ASTM E 2112 method appropriate for the opening Into which the window Is being Insta ll ed.
10. Insta llation screws must be at leas t 3/4" from the edge of the wood .
11. This product comp li es with ASTM E 1300.
12. Designation "X" and "0" stand for the following: X: Operable Panel -0: Fixed Panel.
13.Use 100% pure sUicone cau lk compliant with AAMA 800 Sect io n 1 • Sealant Specifications for use with Architectural Fenestration Products.
14. Use a backe r rod on all joints >3/4" deep an d/or w ider than 1/4". Finished caulk Joint should be a minimum of 3/8" deep.
~ "n'm.Ann IIIATERIAl.:
~\~~:~:~:~'f'I:-t~~~~.~"~~"·{~::~~i~r~tTt~n~~Et0:e:!~· En",'~;~"':,.' ~'~~~'R"fr'U","",~'I--------I
cndlUcn thot II II ncl 10 bl dl l el" .. d, ,eproduc.d In whel. CI""'_._R' ~ Pao;.~~,';' o~'~ °f:)Jc"nCIl~ ~\~h.,th~0~"~~On7:u~~~::, or ",.""0,, ------j •• o:o'"""',' -----I
wlthoul It I conllnl. ~. r .. vletlon dcoel nel Umlt the recipient'_ right. 10 ulll,. ~Iormcllon contolned kI Ihl e
doeum ... ! \f!hleh I. property obteTned from onoth., lou,e •.
FlLE: FU ~l7g .•
;URF'~CE AREA:
1514 TREATMENT:
OI",,,,,,lonol Toilloncn
lin in" Oth" .. T8t Sp,<;lll.d
Oecimals ""nglu
/~SIMONTON· :.:F ArnNo137' 11;' ~w I 1'1 D () ... S t'~~ JL1Al~' __ ._
I Cochrane A,-cnue T.D.O . I 06/10/08
Penlllooro. WV26415 !CHECKEO. A'~:
SCALE: ~ EET: ~PPR D SY: OA TE:
.Xi.03 F1T 11ell
.xx;xi ~og~ O· 30 ",I~. SE~~O\1 / 01-1D / 07-20 I 07-1~ HORIZONTAL SlIDER
TITLE:
2X SUCK INST ..... L ... nON
S'; N-.,.~ +0 N 5/P.\
NO P.E. SEAL REQU IRE D • FI('I1S1ONS: REY1sro BY DATE:
MQQEI IlE:iiIGt;jA]Q~' Simonton Double Hung Series 07-09 I 07-10 / 07-20 Vin)1 Window INSTALLATION SUPPOR T ED 12 ADDEO NOiE 11. W.O. 01(10/12
MA~!M!lM Q~BAII t:JQMI~AI SIZE' See Size Chart BY AAMA TEST REPORTS 13 UPOATED SIttS ~ER NEW TESTlNG. T.O.O. 08/10/12
CESIGti EBESS~lBE BA]t:H;i:' See Size Chart 1. UPDA.TED SiltS PER NEW TESTlNG. T.D.O. O~/20/1J
1$ ADDEO 1oIIN. EDGE OIST .. NOTES, "'" 0&/20/1'
USABI e: CONfiGURATIONS-X
X 11 ADDED NOT£S 12 " 13 -AMAA &00 "'" oe/18/11
f.[t::IEBAI CE:SCBlenQt:j' The head, sill, ond side jambs ore extruded PVC. The woll thickness
through which the anchor screw penetrates Is 0 m inimum of 0.070·,
Ej SILICONE CAULK
S/UCONE >< 2X BUCK 2X BUCK ..... .-----=r CAULK ~/ II'" "AX SH'M
-ff ~ p.;; :-----$lUCONE CAULK
~-<l J 1/4-~ MAX. SHIM ,8 X 2 1/2" MIN. WOOO
~ SCREW 'MTH 1.!5" ~IN~ "-~;: EMBED~ENT INTO WOOO
8ii ~IN. EDGE DIST, SEE NOTES ~~ ,.....-: 1/4" ~AX. SHII~
ffi HEAD '/--SILICONE CAULK
SIUCONE CAULK---'-....L.
~ IT\ S I ~;3~~/ 9 V' "'-" ><J CD JAMB ,
w 2X SUCK
~ CD SILL ~
~ ~
0
~ NOTES:
• 1. This Installation has been evalua ted for use In locations adhering to the Florida Building Codes and where pressure requirements 8S determined by ASCE 7 Minimum
. ' Design Loads for Buildings and Other Structuras do not exceed the design pressure ratings herein , for use outs ide Ihe H.V.H.Z .
2, AU exterior perimeter suriaces of the window must be caUlked. Interior caulk ing Is optiona l unless noted otherwise.
3, Anchors shall be 8S specified and spaced as shown . Anchorembedmenl to base ma teria l shall be beyond wal dressing or stucco and Into wood,
4, The responsibility for se lection of Simonton products to meet any appl icable local laws, building codes, ordinances , or other safety requirements rests solel y with the
architect, building owner, or contractor,
5, Shims alll optional. Max, shim slacK Is 114M.
E8 6, Wood bocks (by others) must be engineered and anchored property to transfer loads 10 the structure.
ff ~ 7. When used In areas requiring Impact protection this product REQUIRES the use of approved impact resistant shutters or other external protection, -j: 8. Flashing shou ld be applied using the ASTM E 2112 methodology appropriate for the opening Into which the window Is being installed.
9. Insta ll ation screws must be at least 3/4' from the edge of the wood.
10, In stalla ti on screws may be placed In the Interior or exterior track of the Jamb. Screws shou ld be flush with the vinyl.
L"W" MAX. OVERALL 'R~"' "'D",-J
11, Glazing shall comp ly with AS TM E 1300.
12. Use 100% pure si li cone caulk comp liant with AAMA BOB Section 5· Sea lant Specifications for use with Architectural Fenestration Products, Make sUle surfaces are
complete ly free from aU old cau lk, damaged wood, wood fibers, grease, 011 dirt, rust, mo ld or sim il ar contaminants. Vacuum and clean opening surfaces completely, A
fu ll y primed surface Is recommended, bu t not requ ired, Cleaning of all surfaces shou ld be done the same day of which the silicone cau lk is to app li ed, Fo r more details
visit Simonton,com.
SIZE CHART 13, Cau lk application: recommended air and surface temperatures et the time of application are to be between 40 and 90 degrees F. Insure all contect surfaces are clean
OVERALl.. SIZE and dry Including the new wlndow(s), Use a backer rod on ell Joints >3/4' deep andlor wider than 1/4", Finished caulk Joint shou ld be a minimum of 3/8" deep and
,,!~H I H~,~T OP RATING make full contact with both the new window and structura l open ing surfeces. SIlicone ca ul k should be forced Into jo int or compressed 10 assure lull contact on both
surfaces end to expel any air pockets. ,,' so" ±25 PSF"
5'" B'" B : IN0067' r 16' tlI5q QS!IRE SHIfUfNT ".,,"." (I)~l ~p~rc~r'f 36' "" Thle document Ie Ih. Pf"l' .. ty "I Slmonlon """<10,.,, whh;h ~, ""'~ DIm"",long\ TeI_oncu ~R~~.f· OA;i~/06 ... tol'l. 011 .... oprt.tory one! clh. right. to II ..... I>jecl molt .... 1I1l1111 QUI.udll :sa,,11It1i .. " .. " Th la cIocum .. t Ia ~ to the r,q.ltnt on th, '''IIr,..-.I ~" . I Cod ..... Avenue ","",-CI<w !:IV': DAI~: ,r "" ±50 PSf ~jruon tl'ool It II not to bt dlKlcled. 'eproductd In whort or Pt M.bo.o. WV 26415
port, nor uMd In con).neUon wllfo tht daIgn. monuroct .... t or ~~ .. ~~ Dedmols AnQln
5'-,," ''Poll' 01 good, lot' anyon. olt.. \I'oon SImonton 'Modow. ~-: FIT i~T~r 1 F'PR 0 !:IY: ,
wltllout III con .... l. Th ll r.,trlctlon doH nol lim it the .X ± .OJ "" ,.-±65 PSf recipient', "'lot, to ulll~. InfonnoUan contained h this F"'~-~ ~~'''"' ,XX ± .01 0' JO min. 07-(KI I 07-10 107-20 OOOBLr HWG d_ .... t ""ld'I It prep.,!y obtohtd rrom onottwor _ct. , .XXX i: .oms
"'~,
Fll(: lNOOII7 2X BUCK INSTALLAlIOti
NOTICE OF COMMENCEMENT
(PREPARE IN DUPLICATE)
Permit No. -""7,-:-;----------
State of ___ FI_on_·d_a _________ _
Tax Folio No. _----.=:;-___________ _
Coun~of ____ D_u_va_I _____________ _
To whom it may concern:
The undersigned hereby Informs y o u that Improveme nts will be made to certain real property, and in
accordance with S ection 713 of the Florida Statutes, the following Information Is stated in this NOTICE OF
COMMENCEMENT.
Legal description of prope~ being improved: 30-56 17-25-29E ATLANTIC BEACH VILLA UNIT 1 LOT 8 BLK 1
Addtess of property being improved: 59 Forrestal Cir. S, Atlantic Beach, Florida 32233
General description of improvements: _R_e-'p'-l_a_c_e_ffi_e_n_t _WID_·_d_o_w_s _______________ _
Owner Hans Nicolas Pettersson
Address 59 Forrestai Cif. S. Atlantic Beach. Florida 32233
Owner's in terest in site of the improvement _l_O_O_o_lt. ________________________ _
Fee Simple Titleholder (if other than owner) ________________________ _
Name ________________________________________ _
Address ___________________________________ _
Contractor Anders o n Installations
Address 3278 Byron Road Green Cove Spri ngs, Florida 32043
PhoneNo._4_07_~_~_1_0_33 ___________ FaxNo. ________________ _
Surety (if any) ___________________________________ _
Address ______________________ ,Amountofbond$. _________ _
Phone No. ________________ FaxNo. ________________ _
Name and address of any person making a loan for the construction of the improvements.
Name ________________________________________________ _
Address _____________________________________ ___
Phone No . _____________________ Fax No. _________________ _
Name of person within the State of Florida. other than himself. designated by owner upon w hom notices or other
documents may be served :
Name ________________________________________ _
Address _______________________________________ ___
Phone No. _________________ Fax No. _________________ _
In addition to hims@lf. own@r d@sign"te" the follow ing parson to receive .. copy of the Lienor's Notice ,,,, provided in
Section 713.06 (2) (b), F lorida Statutes . (Fill in at Owner's option).
Name ________________________________________ _
Address ______________________________________ ___
Phone No. ______________ Fax No. ____________________ _
Expiration date of Notice of Commencement (the expiration date is one (1) year from the date of recording unless a
different date is specified): --------------".""'""-:::o-::A:------------------
THIS SPACE FOR RECORDER'S USE ONLY OWNER
""'~';;"" ... :)i~"~i;... JOSEPH F. SANTORA
i.j > MY CO MMISSION # GG 290939
,~; .// EXPIRES: February 18, 2023
... ~r .. ,· Bonded Thru Notary Public Underwriters
Public at Large. State of unty 01 ____ _
ommiuion o'iplrQJ:.~ _________________ _
ersonally Known ~
Produced Identlflcatlon 1"L /;) L ? y IJ /iR/(,44 (' -rJ 7 ~
or