1785 BEACH AVE RES21-0049 42'1-/: Updated 10/9/18
Building Permit Application
City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
''t9~ IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: f7 3 �o c'ie• Permit Number: F G-J Z ' o 1 1
Legal Description 16-lel CR-25-290.25510 14444 &Q 3 OM;# Alin /d 38 RE# OM"6161
Valuation of Work(Replacement Cost)$ 993.00 Heated/Cooled SF Non-Heated/Cooled _
• Class of Work: ONew ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo OPool t�Window/Door
• Use of existing/proposed structure(s): ❑Commercial Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes LtK0
• Will tree(s)be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Permit) B31(o
Describe in detail the type of work to be performed: ]Pep/ace 3 mare ex;s1-iit er•1er+or dear 1,3* 3 aew i►Mpad.z pered
P64 I kw- E oars.
Florida Product Approval# fL 15213.1. for multiple products use product approval form
Property Owner Information
Name 19A4& tI) Lte►r//d Address MC &ad' de-
City hilisPc. 8ez A State fL Zip 32233 Phone 0Q00 66-7304
E-Mail L.,$/Jle 0 ke#sex* NA'
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information //��
Name of Company M •6•54,144‘ T"c' Qualifying Agent I+/bel #66-
Address
G6Address Et it &Ax,ior ( ke A . City SurksottvdlL State Ft Zip 5ZZ4 _
Office Phone 000 31 -7053 Job Site Contact Number Moil) 231-7653 —
State Certification/Registration# C6C /26 3o/9 E-Mail Wei&cow+r+c-05akeo co»,
Architect Name&Phone#
Engineer's Name& Phone#
Workers Compensation Insurer OR Exempt/Expiration Date Dy- 07- ZO2/
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
TOBTAIN FINANCING, CONSULT YOUR LENDER OR AN ATTORNEY BEFORE
RECO DING YO R NO - OF COMMENCEMENT.
RECO
(14/9(14 1 di --'-r
(Signature Owner or Agent) (Signature of Contractor)
Si and sworn to(or affirmed)before m- his 0 day of Signed and sworn to(or affirmed)before me this day of
le n, p, ' o'' • . -ic,'ICI'CAC. 4 a 't �� Ll \ by 1\k‘\- r.i. r
}'i,� ( -
.gnatu •o :ot. '' r (Signature of'Notary)
I ° MICHAEL LANGLEY I
( )Personally Know R;,;nYp TONI GINDLESPERGER [ ]personally Known OR =� ,�,';,'_
[ ]Produced Identif :;fin, .: MY COMMISSION fE GG 353178 [Produced Identification ��! c MY COMMISSION r GG 292845
Type of Identificatio ••• ' ' Type of Identification: 'V( I ;; ,\i'"5 t PIKES:January 21,2023
EXPIRES:October 6,2023
"Sri;,^, P � ..-•- --_
oF F,°' Bonded Thru Notary Public Underwriters
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