660 MAIN ST RESO21-0009 SIGNED APPLICATION -c--- r Building Permit Application Updated l0/9/18
J'
City of Atlantic Beach Building Department **ALL INFORMATION
�' 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
,-,°iS1�' IS REQUIRED.
(�Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: Vt� OIL 0 Mn J'-k-l(-t.-e - At)QY iG fseMal f/Permit Number:
Legal Description 4Tc,4.NiTc. 1:38-Acal 5ec N 5 30 fr Col 3, Al !0 FTCG>y s/4 '4# 17d q/c-07So
Valuation of Work(Replacement Cost)$ 2200 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial ,esidential
• 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) /No
scribe in detail the type of work to beerformed:
ravers mil L,e, \hc1-me� ih -h-e bolckyord fa creche c pct-h-o.
Florida Product Approval# for multiple products use product approval form
Property Owner Information I-
Name M;cha-e\ l r11-eSS-eY1k,.ISen Address (I a0 Nom Sire-et
City / c AWN C f.e()1G1n State C1.- Zip 3 22 3 3 Phone (2 a 4 2L-3'0 12
E-Mail NI f-1-a)0 0 11 @ evil • C0eV]
Owner or Agent(If Agent, Power bof Attorney or Agency Letter Required)
Contractor Informati n
Name of Company fed,5 •PiA ve 1 s S/I C . Qualifying Agent Gtol Noe, ,.,u)
Address 1-$05 .50uf'ik.s.de .B)vei. City.JAeK5o+` }e State FL Zip 3zZIb
Office Phone cl 0y s51 O(, e Job Site Contact Number
State Certification/Registration# r 2,000 00 4I Zgl) E-mail Reda/ T rc us qn .�,
356 ,a;I• co .
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer Ei51 b gsgal OR Exempt❑ Expiration Date C, I ill Z0 Z2
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. $OTICE: In addition to the requirements of this
permit,there may be additional restrictions applicaa'6TTiTs'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 ATTOR EY BEFORE /'l
REC 0 RDING YOUR OTICE 0 '1 M E CEMENT. $4 0 ea
li / . /../ -4, .„. .ei. — e Ma "
ignature of Owner or Agent) (Si• I tractor)
c-
i e and sworn to(or a ed)before me this•-�� day of • n d and sworn to(or aff'rm-:)be ore me this 5—..y of n
ZoZ t , "y M ►C4 ciQ,( K. hie., . e�b 70Z( ,b 'elk ' vl ACoz:s :
'S e_.'\_.- 1.1111111.1101
1_•Miall ►7.41!!141_
i:natuj..Q otary)
- .� cJJCC
,-V— TONI GINDLESPERGER i;sy,?u .,, TON(GINDL RGER
.°" .:' MY COMMISSION#GG 353178
°• GG 353178 • •`•'
2` ,► jgerlbfi�(+ifQ� ( ]Personally Known OR �.��•o` EXPIRES:October 6,2023
" . oduE VaPtlkirP'20 3 [ ]Produced Identification 1)--",,f,'d2 Q Bonded ThruNotary Public Underwriters
.OF,:pe 8.6' [4..5i.":fi Public time Type of Identification: