765 Plaza RES20-0232 Permit PacketOWNER:ADDRESS:CITY:STATE:ZIP:
FORNEY RALPH J 765 PLAZA ATLANTIC BEACH FL 32233-3907
COMPANY:ADDRESS:CITY:STATE:ZIP:
RAM JACK 14403 Main St Jacksonville FL 32218
TYPE OF
CONSTRUCTION:
REAL ESTATE
NUMBER:ZONING:BUILDING USE
GROUP:SUBDIVISION:
171119 0000 ROYAL PALMS UNIT 01
JOB ADDRESS:PERMIT TYPE:DESCRIPTION: VALUE OF WORK:
765 PLAZA RESIDENTIAL ALTERATION
RESIDENTIAL
foundation repair - injecting
polyurethane for void fill $3200.00
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
BUILDING PERMIT 455-0000-322-1000 0 $70.00
BUILDING PLAN CHECK 455-0000-322-1001 0 $35.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $109.00
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: 9/10/2020
PERMIT NUMBER
RES20-0232
ISSUED: 9/10/2020
EXPIRES: 3/9/2021
RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
2 of 2Issued Date: 9/10/2020
PERMIT NUMBER
RES20-0232
ISSUED: 9/10/2020
EXPIRES: 3/9/2021
RESIDENTIAL PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
DESCRIPTION ACCOUNT QTY PAID
PermitTRAK $109.00
RES20-0232 Address: 765 PLAZA APN: 171119 0000 $109.00
BUILDING $70.00
BUILDING PERMIT 455-0000-322-1000 0 $70.00
BUILDING PLAN REVIEW $35.00
BUILDING PLAN CHECK 455-0000-322-1001 0 $35.00
STATE SURCHARGES $4.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL FEES PAID BY RECEIPT: R13173 $109.00
Printed: Thursday, September 10, 2020 1:56 PM
Date Paid: Thursday, September 10, 2020
Paid By: RAM JACK
Pay Method: CREDIT CARD 360773594
1 of 1
Cashier: CG
Cash Register Receipt
City of Atlantic Beach
Receipt Number
R13173
Ts 'r, Building Permit Application
City of Atlantic Beach
800 Seminole Road,Atlantic Beach, FL 32233Oily
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:
tnje'i-\.' ' LY&dnzin2 Coi" V Oi,ck C1 ll.
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.
It, 4i V 6-1('-:'
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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