1472 LAUREL WAY - RERF20-0210 . ):Sr•11r•-, Building Permit Application Updated 10/9/18
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, City of Atlantic Beach Building Department **ALL INFORMATION
15
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
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IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 1472 Laurel way AB FL 32233 Permit Number: R C.R.F 7( - C)Z- ICi
Legal Description 54-97 17-2S-29E . 13 HIDDEN PARADISE LOT 6 RE# 170704-0035
Valuation of Work(Replacement Cost)$ Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): DCommercial Ektesidential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes IcNo
• Will tree(s)be removed in association with proposed project? DYes(must submit separate Tree Removal Permit) INo
Describe in detail the type of work to be performed: REROOF RESIDENCE
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Florida Product Approval#FL-1012 4 . 1 r �,4�1 FL J�J f for multiple products use product approval form
Property Owner Information -D,.., vi__ 'E'
-,fie• tSAME
Name CLIFFORD BACKMANN Address
City AB State FL Zip 32233 Phone 904 514 9847
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Qualifying Agent
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Registration If E-Mail
Architect Name& Phone#
Engineer's Name& Phone#
Workers Compensation Insurer 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 YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN I ANCING, CONSULT WITH YOUR LENDER AN ORNEY BEFORE
RECORDIN OJrJR N ICE OF COMMENCEMENT.
,_,_
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(Signature of Owner or Agent) , (Signature of Contractor) 7
Signed and sworn to(or affirmed) before me this 12— day of Signed and sworn to(or a'red) bef.. mm I is 1 ?.-.day of
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(Signature of Notary `✓'� ��% n. ire of ,. )
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;«tY.e� .4,:;:'4;;,,,:;:4a••. TONI GINDLESPERGER 1.
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I ]Personally Known OR :, Commission#GG 247125 ] Personally Know ' �: 4 -.. MY COMMISSION#GG 353178
'........' ' Expires August 9,2022 4 EXPIRES:October 6,2023
p' Bonded Thru Troy fain Insurance 800-3857019 '' o`"°j Bonded Thru Notary Public Underwriters
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