763 ATLANTIC BLVD - COMM20-0036 , o .,v Building Permit Application ' _) ) ) Li Updated 10/9/18
n City of Atlantic Beach Building Department **ALL INFORMATION
. 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Ott p� IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 1103 akd-tc MiC. Blvd. kk B MI_ BEACH 3223Permit Number:( _-01Y\ \a) - 003 Cj
Legal Description 3$ * 2S E. .4q 'B DE CAS e..0 y F6 tZ.S2.EQ.Gal-rt RE# Ili tp 53- 000S
PTRECt7012 IjA . ici Z
Valuation of Work(Replacement Cost) $ `-'�,000.0 0 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: New Addition EAlteration krtepair ❑Move ❑Demo EPool ❑Window/Door
• Use of existing/proposed structure(s): k'C`ommercial EResidential 7
• If an existing structure, is a fire sprinkler system installed?: ❑Yes Al
• Will tree(s) be removed in association with proposed project? EYes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed:
X'a
/ /a -c= ciw4 //
Florida Product Approval # for multiple products use product approval form
Property Owner Information
Name Lt 2_ SOGrclyva l k. LAC- Address PO $Ok 3304L43
City }1.4-Ian 1-►C 2)eCtCh State FL Zip 32233 Phone (Aoki 241 1151
E-Mail ENtOW t 0ES @ Pe.--rG.)Cox .C..OIM
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company `j-L'1eS CANISIIIIS_}(pn Qualifying Agent DCA r c.,1l Sml* i
Address?O 60( 3341130 City Mt P Cath State FL Zip 223 3
Office Phone 904 5115 910 Job Site Contact Number `-`•-•'' 3-1")---,/,-P-7 3
State Certification/Registration# ¢ G/L�.'G('9 E-Mail'D A a.REIT 4131 LQ g�1t$OVTN.Nel
Architect Name & Phone# �/1
Engineer's Name& Phone# er _ 3, , - 03 C
Workers Compensation Insurer o DL✓'l OR Exempt ❑ 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 YO • PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OB ' " IN ANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
REC1: iI;L�r YOUR NOTICE OF COMMENCEMENT. ( ,�; ��
y , COMMENCEMENT., -B
(Signature of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed) before me this q day of Signed and sworn to(or affirmed) before me this 4 day of
CY46C51 , 20 by Y OC- Db•e.G , ZA by l S
Tr
si nat of Notar (Signature Notary)
:p% BETHANY SALCAN
1..'``.. :% BETHANY
• 1. BETHANY SALCAN�/ r� FAY COMMISSION#GG 317919 �'�'�'' ��';
/1\1 Personally Known 0 i'"• * EXPIRES:May 11,2023 personally Known OR -'.; !� c. MY
Cit 317919
�Ii ! ?• c
Produced Identificati i foii.;; ' Produced Identification `;�;���o;�
[ Bonded ThN',k:iar,vubiic underwriters I ) ;Fo.�.oP: EXPIRES:May 11,2023
Type of Identification: Type of Identification: Bonded Mu • ,t_ ers
NOTICE OF COMMENCEMENT
Permit No. 11 t. 3• D—S
Parcel ID/Tax Folio No. _
l& u 1-MDS3•�O5
State of Florida,County of Duval
THE UNDERSIGNED hereby give notice that the improvement will he made to certain real property in accordance with
Chapter 713,Florida Statutes,the following information is provided in this Notice of Commencement.
I. Description of property(legal description of property and address if available): 763 A4.Ian}te- 81va.
14\IrniCe SCh cls 32233 . 8- 2s-296, 492 $D__ cs,s-van Ni FE it.2ErL G�pr� . PT
2. General Description of improvements: RKO Of(Z 19990
___Dia4Lulat1
-
3. Owner Information:
a)Name and Address: 41 2.. Bo rdVLfaIlL_Ing.
b)Interest in property:
c)Name and address of simple titleholder(if other than owner):
4. Contractor Information:
a)Name and Address: JL - \•I`111 . -IllI f i •O :0) 330130 • ►C e / e`(-
b)Phone Number:gO4. 54S-9 10"1 32.2-i3
`. Surety Information:
a)Name and.address: )
I))Phone Number. /At
c)Amount of Bond:S
6. Lender Information:
a)Name and Address: t\1 )4 \t
b)Phone Number. [
Person within the State of Florida designated by owner upon whom notices or other documents may be served as
provided by 713.13(1)(a)7.Florida Statutes:
at Name and Address:
b)Phone Numbers of Desienated Person:
8. In addition to himselfherself.Owner designates 1.1\ of to receive a
copy of the Lienor's Notice as provided in Section 713.13(1)(b),Florida Statutes.
a I Name and Address:
b) Phone Number of person or entity designated by owner:
9. Expiration date of Notice of Commencement(the expiration date may not be before the completion of construction
and final payment to the contractor,but will be one(1)year from the date of recording unless a different date is
specified:
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE
NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART 1,
SECTION 713.13, FLORIDA STATUTES, AND CAN 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 COMMENCING WORK OR RECORDING
YOUR NOTICE OF COMMENCEMENT.
Under penalty of pert , I declare that I have read the foregoing notice of commencement and that the facts stated
therein are t t es y knowledge and belief.
Signature of Owner or Owner's Authorized Officer/Director/Partner/Manager Signatory's Printed Name&Title/Otlice
The foregoing instrument was acknowledged before me this _y day of a- i1+(_ , 202
by*z Vi 10 ___._. ah -�' _ tier 1U2 boardwatu_I4\c ..
(Name u Pawn) ('Iy1w o Aut wnty,i.e.Officer/Attonsey) (Nuuie til Party Instrument was Executed cur)
` ttEiWllfr>;ALCJJI ., LA Ck xi�.1`k
m, 160J1741y NOT RY Pl I,I( . •I'I:,OI' FLORIDA
MIRf8:wy11,2023 Print Name: --uC 1 /, y�
���I�NN+1 eadw rm Keary Pubic lkn.r.,w. 1]Q 1�Yhl� — —— —
4,j'ersunally Known
Doc#2020220545.OR BK 19399 Page 915 ldentilicatiurfl'ype:
Number Pages 1 -----------
Recorded 10/O62020 12 49 PM,
RONNIE FUSSELL CLERK CIRCUIT COURT DUVAL
COUNTY Revised 1/18/18
RECORDING $1000