472 Royal Palms Dr RES20-0131 2 of 5 permitBuilding 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: kJ-z.. t2tqa \ l'tt.,\ros Dr Permit Number: _______ _
L.egatOescrl~tlon 2> H lR n-2.5-Zq e RiP of N Qf EO! \ttl YtJ.\IYIS REn n itS I \ -0000
\A n 11" ~ f'< l..Ot I U' IN . .-\!: II
Valuation of Work (Replacement Cost) $ \.eZ.64-' Heated/Cooled SF Non-Heated/Cooled ____ _
• Class of Work:' New DAddltion DAlteration DRepair DMove DDemo DPool t>(Wlndow/Door
• Use of existing/proposed structure(s): [lCommercial fZjResldentlal
• If an existing structure, is a fire sprinkler system installed?: gx. Yes ONo
• Will tree s be r 0 ed i ssoc'ation with ro No
Describe In detail the type of work to be performed:
..flJ{" 5\U
Florida Product Approval " __________________ for mUltiple products use product approval form
Property Owner Information
~i~;e£~&«t!,gtt!ili State
Address 1l2. enlJal til Oms Df"
'F/... Zip 2;Z.;Z.-??3 Phone g04-. 9'62' Q 10lo
E-Mail ___ =-:--_:-_-:-_________ -:--c:-. _________________ _
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required) -"nl"'a'--________________ _
Contractor Information
ANdadmreesOsf 5~!,an!~~~~:? ',\ OL Qualifying Agent (ts\ \ f, K'.o-eh l.eAC = If___ _ _K _e City dQc.¥soY\\1ilU State ft-Zip '3 Z-2Xl
Office Phone Cia· . Job Site Contact Number .!to1=: 11M· 6'22&2
State Certification/Registration n C0G05!o 163 E-Mail C (M ("b\1M 1:J@C!lIiaau;pcrtYl i tti 01' CorY)
Architect Name & Phone n ________________ 0 ________________ _
Engineer's Name & Phone # _______________________________ _
Workers Compensation Insurer _____________ . OR Exempt 0 Expiration Date ______ _
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 ail the foregoing Information is accurate and that ail 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
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECO )Q OUR NOTICE OF COMMENCEMENT. /d-U" C /(o-ebe
. ature of OWner or Agent) (Signature of Contractor)
Signed and sworn to (or affirmed) before me this I C( day of
~ s: rn
" ~ ); and sworn to (or affirmed) before me this L day of
MC0j ;uOZ ~~~~;n'~---o~~~T-----:--~ rn ~ ~ -OiJ)AI
~ ~ 0 to 0 en 5-z m otary)
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N":c [)<;.Personally Known OR .0 g :s
[ J Produced Identification 2 ~ ~
Type of Identification: ---------------t:....:o~;o:2l>:J
{ ] Personally ~:~:"';;;;;;;;;;;;;;:;;;~~;;;;;;;;;;;;H
)4Produced Identification
Type of Identification: ___ -.lp~L"'-________ _