33 Lewis RERF20-0158 Revised>fF 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
-t�asst IS REQUIRED.
*^Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: �3 L e r yPermit Number:
Legal Description( ' �i" r� '�t'IYIStI RE#`�
Valuation of Work (Replacement Cost) $'_46r Heated/Cooled SF Non- Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial 'tesidential PO
• If an existing structure, is a fire sprinkler system installed?: ❑Yes ❑No
Will trees be removed in association with proposedproject? ❑Yes must submit separate Tree Removal Permit ❑No
Describe in detail the type of work to be performed:
Florida Product Approval # for multiple products use product approval form
Property Owner Information
Name b e ( Address Z
City -\ K c cc State rtr Zip :a:Z Phone
E -Mail
Owner or Agent (if Agent, Power of Attorney or Agency Letter Required)
Contractor Information /
Name of Company h ! 4 Qualifying Agent Q�,,Ir d
Address , 0 "�- City 7—\& State _ L Zip Z 2 q L
Office Phone 4 4 o Job Site Conta t Number GIG' t7YT7`'T C
State Certification/Registration # E-Mail_Qd,41tp Ile n L.,C��'1
Architect Name & Phone # (G -C i S (L4 7-o io
Engineer's Name & Phone #
Workers Compensation Insurer _ OR ExemptExpiration 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 OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
Signature o 'Owner or Agent) Signature Contractor)
Signed and sworn to (or affirmed) before me thts day of SS" n�e�d�a�n�dj sworn to (or affirme before me this (D' _ day of
Signature of Nota/y) „�
(Signature of Notary)
Personally Known OR �] Personally Known OR
[ ] Produced Identification (] Produced Identification
Type of Identification: _ Type of Identification: _