1633 Sea Oats Dr FNCE20-0030 Public Works Review City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
,,,,
800 Seminole Road �j�cE 20-003o
• '„ Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845
,-Lort19� E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: I (0 33 SO Oc drive Department review required Yes No
Building
Applicant: $►9 -Seirvy s gvIci 115 Planning &Zoning
pp Tree Administrator
Project: V\C Ci Public Works
b1 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:
APP CATION STATUS
Reviewing Department First Review: air Approved. ❑Denied. ❑Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING 4.20-20
Reviewed b • // Date:
TREE ADMIN. Second Review: ❑Approved as revised. (Denied. [—Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: I !Approved as revised. ❑Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revised 05/1912017
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�'�� /r�- Building Permit Application Updated 10/9/18
... :... :, City of Atlantic Beach Building Department **ALL INFORMATION
1
800 Seminole Road, Atlantic Beach FL 32233 HIGHLIGHTED IN GRAY
::,.,.;r,P'•-' , IS REQUIRED.
Phone: (904) 247-5826 Email: iiilditii,.:L)e: i tt>t
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Job Address: i ��� : � KFC-I•�� Y'-L- Permif Number:
Legal Description RE#
Valuation of Work(Replacement Cost)$ 2 200 •C)C' Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ONew ❑Addition ❑Alteration 'iRepair ❑Move ODemo OPool ❑Window/Door
• Use of existing/proposed structure(s): OCommercial ` 1Residentlal
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s)be removed in association with proposed project? OYes(must submit separate Tree Removal Permit) ONo
Descr,j e In detail the type of work to be performed:
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Florida Product Approval# for multiple products use product approval form
Property Owner Information '
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Name '' \/ f�dt2.i n
Uig �t1)/p,�:N ive fill. Address I L 31; r(—�} CAI- p2
City A-c4-fi.11 k L I OA-CA JHA State Zip "S 7_'2-- -; ' Phone 9v-{ 2.41 -C L 6515.5 -1 a's
E-Mail 90 11001 O' 1 {,COvvIcASt' l\�="C, 1-L
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor information I t
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Name ofCom any 0av't 1-c.k..1 -111(16 ,4 04 1.'��1 �z�i�Qualif 1g Agent
Address I / t O l?)ii.ActF PA Vcl. S iiP. .- H t City ,14(..1)__c O rl V Li le. state ='i,4, zip 72 2 cr
Office Phone 9(t►- - it/to 9_52.`( Job Site Contact Number CI(7)1'-ii'7 -"- -!--;.2.K
State Certification/Registration# E-Mail
Architect Name&Phone ti
Engineer's Name&Phone#
Workers Compensation Insurer _OR Exempt n 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 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 OBTAI FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECO tTIC F OM ENCEMEN ::'r
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(Signature of Own or Agent) (Signature of Contractor)
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A Signed and sworn to( a lr adl before me this day of Signed and sworn to(or affirmed before me this L day of
f y (';-...i t. :-),_.:?,-, `l. yi rt;r if11_; , ,r, t'..t /jr �1/ Z�La ,by Flamm y1�L5
tore o Nott
it' e�., AP�lY'T h10RENG Notary Public State or Florida
_ Notary Public-State of Florida > Christian Retana
?w i �o' Commission r OG 304875 ' OW'yii, My Commission GG 227200
My Comm .nExpires Jun 9,2023Ex ire
I 1 Personally Known OR . Bonded through National Nota Assn, [ ]Personally Known ORof P s 06i11/2022
,(L-)Produced Identification ... Produced Ident{ficatlot
Type of identification: i�'. ype of Identification: I 17
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