1671 FRANCIS AVE - RESO20-0037 - SHELTER FOR JORDAN PARK Building Permit Application Updated 10/9/18
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City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address:
b 4,1d/ o Permit Number:Aft I�L c> zc )-- vQ 37
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Legal Description /V 5T �66t rt ',Obi:. eII a'1 Lo'{7 ��k� C{ SMS{�7 S46i{it,;v„ RE# i 7 22•51 —4/
Valuation of Work(Replacement Cost)$ oOp =^ Heated/Cooled SF — d Non-Heated/Cooled
• Class of Work: LJNew ❑Addition DAlteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): latommercial ❑Residential
• 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) Zfrlo
Describe in detail the type of work to be performed: i / 1
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name Ca i3 Address
City State Zip Phone
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company /74 Li, f2c4t4 8.4-11 Qualifying Agent C/t it/z; j,jt°!!
Address 147 �a ost � City !T .til, State �-,y Zip 32 233
Office Phone /14 S7'3/ Job Site Contact Number
State Certification/Registration# z8e, (Pi 2_31n E-Mail I eon 5 li'G •.r g 6•orGs r)46,1-0
Architect Name&Phone# NINA
Engineer's Name&Phone# Sd$0 c.ngmr+Cle
Workers Compensation Insurer v V 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 FINANCING, CONSULT WITH YOUR LENDER OR AN A % RNEY : FORE
R ORDING O R NOT CE OFC MMENCEMENT.
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(Signature of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this day of Signed and sworn to(or affirmed)before me this `/'qday of
by be gibe' , 20X ,by C/ytViiS
(Signature of Notary) Si:na ur- of t
KYLE mATTHEW HURRAY
s+F : Notary Public•State of Florida
[ ]Personally Known OR [YQ'Personally Known OR , Commission#GG 981383
[ I Produced Identification [ ]Produced Identification of n. My Comm.Expires Apr 23,2024
Type of Identification: Type of Identification: Bonded through National Notary Assn.