765 Plaza Permit App Ts 'r, Building Permit Application
;� City of Atlantic Beach
800 Seminole Road,Atlantic Beach, FL 32233
Oily r Phone: (904) 247-5826 Fax: (904) 247-5845
Job Address: '7 ? caLc. A-}\avtt\c .becc..v- FL 3.a33 Permit Number:
Legal Description 3n-kno a,-ZS- ••tC 91c44.1 e.(inas L1n1i- 1.a1�.�.11K\ RE#
Valuation of Work(Replacement Cost)$3,at u.co Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Addition Ite ation Repair Move Demo Pool Window/Door
• Use of existing/proposed structure(s) (Circle one): Commercial Residential
• If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No N/A
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe 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
Name: cLQ l+r Corti FOrn Address: '1b5 tq`lc, A-1\culkccFL 3aa3
City State Zip Phone S13. 5.8•to3).a
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company:{ a'SGCt.< Qualifying Agent: aot-k 61142.,LADwnk
Address (4UD3NI Mc...,'tn%-t City T Cci SMVi\\t State FL zip 3a1•Q
Office Phone 901-1-S 0.3edI Job Site/Contact Number .ci o4-St70 3b51
State Certification/Registration#CG,c1S 1B`ta.�o E-Mail FCPeVINA� $V'c kcicc,On\c,C),/,•,
Architect Name&Phone# SCt.L,.Q C\ncG-f4,IY Z L.*11.33
Engineer's Name&Phone#
Workers Compensation _
Exempt/Insurer/Lease Employees/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 regulationg
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.
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.
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(Signature of Owner or Agent incl ing Contractor) (Signature of Contractor)
Si:01.1lld/yyyfirn to(or affirmed)before me this 1:2) day of Signed and sworn to(or affirmed)before me this Iii day of
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