567 SELVA LAKES CIR DWAY20-0049 Building Permit Application Updated 10/9/18
HIGHLIGHTED IN GRAY
Cityof Atlantic Beach Building Department **ALL INFORMATION
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' :. 800 Seminole Road, Atlantic Beach, FL 32233 HIIS REQUIRED.
Phone: (904) 24T5826 Email: Building-Dept@coab.us
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�w Pt/Address: G I I, x 1� Permit Number:
�' 9 ^ 11 I-1-75-?A E `x,1MC�1rSU0,4--7 Lvf 65 RE# 1720.0 -5..3w76-5..3w76� Legal Description
Valuation of Work(Replacement Cost)$ 115 7 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New DAddition ,14A-Iteration ❑Repair ❑Move ❑Demo OPool ❑Window/Door
• Use of existing/proposed structure(s): OCommercial 9sidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s)be removed in association with proposed project?❑Yes(must submit separate Tree Removal Permit) 21117-0
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Describe in detail the type of work to/belperformed: Q ) ( r rcervi-r2\O(a(e, ID CI 1`6tAiG� °t' W /lnn1 v/&il4PAV-(5 . (6/15- Nt oit ii gib'0.
Florida Product Approval# r for multiple products use product approval form
Property Owner Information �/_ �n,l t/�n /101/4
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Name 00,n n ,07,(n Address (Q �''//ll
City iL LAN,< State f L Zip 3 7,1.3 Phone lifiA7S7 g0 4•-6 bl.q— /-24 3
E-Mail r`d 7,41- -- l ar^.u.Sf. r\44-
Owner
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Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
Contractor Information
Name of Co pany X #f7 I , [, QualifyingAgent kd girlie
Address a t�� t City A. 8• State Zip 372
73
Office Phone (911 r 371- 7 Zz6. Job Site Contact Nuri/ber )�. 1 377 INTr
State Certification/Registration# E-Mail 7 of - Ke,f*> /"n r . Cv9r+s,
Architect Name&Phone#
Engineer's Name&Phone# f
Workers Compensation Insure54-S4' OR Exempt LiExpiration 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 FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOT CE OF COMMENCEMENT. / ._ .,1„.,--
(Signature of wner r Agent) /
(Signature of Contractor)
affirmed)Signed and sworn to(or before me this 3D day of
Signed d sworn to(or affirmed)before a this 19 day of g 'b tiZ QTT I
Cbl-r)bcr, ZOZD ,by So ,, ,n �� 004Lkbt-f, a ) t� t (--
Mk k=-- (Signature of Notary)
;i"':. JENNIFER JOHNSTON q g • - • 'ota ry)
"� MY COMMISSION 9 NH 057579 '
.- i= EXPIRES:October 27,2024 onally Known OR u"" '4t JENNIFER JOHNSTON
�!a► ?' •• ''� 1 *mem [ I Produced identification ;.? MY COMMISSION 0 NH 057579
ktober.2T,.202
` ' n Type of Identification: �' •o= 4
Type of Identifications F�- l'AI Li S `�LLnSC .fft o,: Bonded TlruWary Pao Ude s
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