332 4th St FNCE20-0134 f BUflding Permit Application Updated 10/9/18
�t " City of Atlantic Beach Building Department **ALL INFORMATION
vi HIGHLIGHTED IN GRAY
\u:lur y 800 Seminole Road, Atlantic Beach, FL 32233
Phone: _ IS REQUIRED.
(904) 247-5826 Email: Building Dept COab.uS �_ NGC z c - I � 1_
Job Address: Permit Number:
AA /
Legal Description _ 44 :/J —Cjj 0` RE#
r /
Valuation of Work(Replacem t Cost)$ 04 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New DAddition DAlteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door1"c-e—
• Use of existing/proposed structure(s): OCommercial ❑Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree s be removed in association with •ro•osed •ro'ect?Oyes must submit se.arate Tree Removal Permit ONo
Describe in detail the type of work to be performed: / re A C
,4_ d -
Florida Product Approval# / for mul ple prod cts use prod Ict approval form
Property Owner Information (L
Name Kel/-e---' rj/1A--0d n Address 83,1 U/` d// eel '
City 1r I ' I I State F7. Zip 3�a 3 3 Phone A1¢7Q -V6t. - 'dj,
E-Mail I a_le k-lo i�iv, e /"G to,/G%. Ciyv
Owner or Agent(If Agent, Power of Attorney or Agencyt(etter Required)
Contractor Information
Name of Company ?
V 'It/errrn4-) f'-ei'- C.- Qualifying Agent L>,Irc& S1 1 v er►�a.r1
Address 1 D9$ (30 SK C4- City ZQCKsGCIU i I I C, State P 1 Zip 322-OJ
Office Phone to`4l?,00 $2 Job Site Contact Number
State Certification/Registration# il2 1 -4 'IZ3 E-Mail I n fO ® S\ I verrynari cence,5 . C GM
Architect Name&Phone# f
Engineer's Name&Phone#
Workers Compensation Insurer FI on do. Ca 4-r t S' OR Exempt 0 Expiration Date 10 12021
Application is hereby made to obtain a permit to do the work and installations as indicated.I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the st4ndards of all the laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE: In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county,and
there may be additional permits required from other governmental entities such as water management districts,state agencies,or
federal agencies.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEM , ,
if, . . 1 . iL _ _ r
/ ( ign.ture of Owner or Agent) / ail.-
of Contractor)
Signed and sworn to(or .ffirm: ..)befor- m• I • .. day of Signed and sworn to(or affirmed)before me this S day of
OV ,ZO2 c7 ,,y i/ L,f .A ' 1/ i_. OOve(Y1 ZG7r by Ly nd.�- SI u•er rw--n
,�iM1110/i I ` ��= _
i�
ei patu�. �, i ►v..,
ignature o N• .
.Ir Notary Public State of Florida
[ ]Personally Known OR o`� q`, TONT GINDLESnally'nown OR T Deana Garcia
S':' u. •" MY COMMISSION(i 9 c?e$d I I-ntification
[ ]Produced Identificat' '„i ,,N, d' My Commission GG 294446
'1 a.• ^`�o, EXPIRES:Ccto ,op Expires 09/25/2021
Type of Identification: 1enti ation:
7(,A«:.; Bonded Thru NotaryPublic Underaiters