1939 FRANCIS AVE FNCE20-0139 ;%''w, Building Permit Application Updated 10/9/18
a4 City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904)x247-5826nEmail: Building-Dept@coab.us REQUIRED.
JobAddress: I 139 Er QhCiS 4Ve. Permit Number, l— 1\1)(1.E, l'_C) - C,'I .�9
Legal Description Pe nne(S Lo-E a, , i o.(o PT Lo-f- ( RE# 1 -c230,4 - 000d
Valuation of Work(Replacement Cost)$ /5-0 0 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: fa‘v ❑Addition ❑Alteration ❑Repair [Wove ❑Demo OPool OWindow/Door
• Use of existing/proposed structure(s): OCommercial NKe//'sidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s)be removed in association with proposed protect?❑Yes(must submit separate Tree Removal Permit) ONo
Describe in detail the type of work to be performed: l U Eci -1¢A Ge a 6 9 Crti E $
Florida Product Approval# for multiple products use product approval form
Property Owner Information _ �/ ! / �// G�
Name v., nail-45 l�- /-�l1SYom` Address / 38 Se-Iva /'(of/Loct - . f Ad
City 1471. ad-, State Fl Zip a Phone 9,0 4'- 7//n -,rAc17-
E-Mail a-A r6 /Q 60 (5 cOo 1.GOsy\
Owner or Agent(tf Agent,Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company A l'M i.t/OVI G( F-,tc C 6D. Qualifying Agent a 0 N IV1, i 1"c r ,
Address 31g II f a//, 't nd '- ci --4-4.V,-.4- , state $ ) Zip •7� /0
,20
Office Phone `1 D - i�- p - gUPS 3 3•-A Job Site Contact Number 6?/34-1- 11
State Certification/Registration# l E-Mail G 1-141/( (P 1)r - c--)-r,-,-.,5.--re-,cc .e-c..-i
Architect Name&Phone# /(J ,9:.-
Engineer's
Engineer's Name&Phone# 4/I h
Workers Compensation Insurer `.- OR Exempt o 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 NOME:In addition to the requirements of this
permit,there may be additional restrictions appicable 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 agendes,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 toning_
WARNING TO OWNER:YOUR FAILURE TO RECORD A k s— OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEME. TO OUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING,CONSULT WITH YOUR LE DER OR •N NEY BEFORE
REC• •DING YOUR N N. •FA MENCEMENT.
-'`.ice
(Signature of• :•-• or : rt)
cc,,, H E (Signature of Contractor)
c., "'N2I
• i 3 "•'r •and sworn to(or- )bgforee me this • Signed and sworn to(or affirmed)before me this .7 day of
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ROBERTHALL-!•e`•' ofldentificati• I • ` . MY C319�i`SE'••?`14GG353178 iNotary Public Ste ofFlorda�_, I Type of Identification: eL,,,inission0t154695
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REVISIONS
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