1960 BEACH AVE - RES20-0075ft j• , City of Atlantic Beach APPLICATION NUMBER
o„ Building Department To be assigned by the Building Department.)
800 Seminole Road
I--ES.o 0075AtlanticBeach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845
011 t.)? E-mail: building-dept@coab.us Date routed: 3 Z17)
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address:
IC) (D E.-C--AN4 RVG, Department review required Ye No
wilding-
Applicant: EL i Y E CTh - L ma PTarin ng &Zoning
Tree Administrator
Project: e_c_c RE-PA t 2 Public Works
Public 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:
APPLICATION STATUS
Reviewing Department First Review: F4Proved. Denied. Not applicable
Circle one.) Comments: NO c; cop,7I 0.1 f pka 1 ,v,. y t.{d r iLc la--r
Bl. fri Q u n- o v ,r-f
PLANNING &ZONING
Reviewed by: V Date: 3l74/2C)
TREE ADMIN.
Second Review: Approved as revised. Denied. Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by:Date:
FIRE SERVICES Third Review: Approved as revised. Denied. Not applicable
Comments:
Reviewed by:Date:
Revised 05/19/2017
t' '.'".,, Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Departmend 0B COPY **
ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Oif19-
IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
ES op-
754
Job Address: I 9 (. 0 (3 e 6,-LI...6,-LI... c Permit Number: ' ZC)
Legal Description 09 -25-29e • II PT C-V 1 La k- 3 ODIC ]S690 -2335 RE# Hogs'2S.-ooCO
Valuation of Work(Replacement Cost)$ 5 03 0, 0 0 Heated/Cooled SF Non-Heated/Cooled
Class of Work: New DAddition Alteration Rfepair Move Demo Pool Window/Door
Use of existing/proposed structure(s): OCommercial E i(eesidential
If an existing structure,is a fire sprinkler system installed?: Yes EI'h'lo
Will tree(s) be removed in association with proposed project? Yes(must submit separate Tree Removal Permit) 1T31 o
Describe in detail the type of work to be performed: c -h.p.c_ , ..) Y c to, •
Florida Product Approval# IU I A- for multiple products use product approval form
Property Owner Information
Name 7;, •,. r~ 0. r `, A.--(\ r...- (—r r;^ Address 060 r3e -c I.. Svc
City 1k-1-t.. , --i( l e c L State r L Zip 3 )-)-1 I Phone 70 LI- G 6i - 6 k-1 ,a .z
E-Mail T1-6,rr-,. @ Sand i,,(„
r-“"., (c;•'.
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
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Name of Company l;t,1t CvsJ-•.^ (to„„c. 4- 12.•..a,-esti.. t,4QualifyingAgent l7w.,es A- 16e (ley U
Address .)-3 6`{ e e*--1,, 0 r- City 7K 14s+N.J,1 I c State r----L Zip 3.2, to U)
Office Phone 6I U 4-(v y(, - 4' I k- Job Site Contact Number 9u y-( VG -k-1 k K
J
I I 4 Z
State Certification/Registration#(..-..66_,- ( 2 (o O )•- E-Mail T(e C a AS i-r u-c -I;o,. 6 t{ yt).-ti u o , cpi ZZ (
Architect Name&Phone# ti W 0 VjH
Engineer's Name&Phone# U ® p n a
Workers Compensation Insurer S{-+ N.),-A Z,.,c Co ^c- OR Exempt Expiration Date 101 I ) a r3 4 U C
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or instatlit sz
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all the laws rel R a
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, G
FN-
CO 4WELLS,POOLS, FURNACES,BOILERS,HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirem®ts'fg)iVj
permit,there may be additional restrictions applicable to this property that may be found in the public records of this coehttirtif W >:
there may be additional permits required from other governmental entities such as water management districts,state a cis,mrtr m
federal agencies. RECEIVE FY— w p w
C !
i • ... E
N W
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in com li nc h all jz W
applicable laws regulating construction and zoning. i,'?, MAR 1 1 2020 W
cc
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT AY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER ORA ATTORNEY BEFO
RECORDINIR COMMENCEMENT.
Signature of Owne or Agent)
drivvi af
Signature of Contractor
cMc=1andbeforeornto(ora' d) m• this `
9
u'( day of , . • and orn to(ora -d)before me hi day of
TONI GINDLESPERyP.
V Ply:••,••
h-'%•*: MY COMMISSION#GG 353178
4- EXPIRES:Octo r 6,2023 j Fersonall Known ORF''. .'.,,,;l]]y,I4 Y TONT GINDLESPERGERiUnderrniters
Produced Identification =*: •;* MY COMMISSION#GG 353178
Type of Identification: Type of Identification: 7r'.'7,o`•; EXPI• •e. .-
Bonded Thru Notary Publk Underwriters