465 Inland Way Transfer ApplicationBuilding Permit Application Updated 10/9/18
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_ City of Atlantic Beach Building Department **ALL INFORMATION
V 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address:F" L 33
�7ic B1Aj Per
mit Number:�7 Y v i e vS IeIAI�
Legal Description _Cy' I (r. IIn t' %C- � N I� H LK U P i T C RE# 1(C<1(a 3
Valuation of Work (Replacement Cost) $ S rf ImeC.064,.S Heated/Cooled SF r� Non- Heated/Cooled
• Class of Work:lNew ❑Addition E7Alteration ❑Repair ❑Move ❑Demo f]Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial l�.Residential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes M qo
Describe in detail the type of work to be performed:
U�� uoor C.CA�ntN�c. I ILCC[,�ti.
Florida Product Approval #
Property Owner Information
Name A L\`f
City A" f C 1;�
r
��� Address
State Zip
for multiple products use product approval form
Phone v4"�
E -Mail I Y1+�' ice-', iih Lttf�ij_C J►�?
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company WW1 soaoL Qualifying Agent)t I �� v► L���I� �t
Address v MVLJ City+, cilk,MAt_ a State ( L Zip ZZS�
Office Phone 1 U Lf �Jl I b r1 Job Site Contact Number c� 1D` �t
State Certification/Registration # GAG 12 tit -{L ti- E -Mail .S;4Ce-915-TZ a 1TV4,1 I C't)Ykn
Architect Name &Phone # c `> , �� � &,-1 ..
Engineer's Name & Phone # f 9 i►14 - , U _ iD
Workers Compensation Insurer OR Exempt Expiration Date 2P Z&O
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 my 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
BEFORE
RECO 71
R NOTICE- OF COMfV�LENCEMENT.
(Signature of Owner or Agent)
Signed and sworn to (or affirmed) before me this
by
(Signature of Notary)
()Personally Known OR
[)Produced Identification
Type of Identification: ,_
(Signature
day of Signed and sworn to (or affirmed) before me this
by
[)Personally Known OR
[ ]Produced Identification
Type of Identification: —
(Signature of Notary)