1927 SELVA MARINA DR RES21-0053 Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department4k,:w
"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: 6iT3'7 StLUA 11114,24NA- 1OK. Permit Number:k -S Z.,1 - IDC) 5 E
Legal Description 3'7— 40 Ug— J "oQ`jE, <5. 2_,N)/1- /VI&11U74- RE# i rl Q0O— o S8
-32.0 v UNIT w `
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Valuation of Work(Replacement Cost)$ 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 ylResidential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes po
• Will tree(s)be removed in association with proposed project?❑Yes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed: H-ActSZ AND 6 JSS 1-')Ar-Et?-0 t F 0 LL RE
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name b.A i)'AS '1-V-f T}k'1 LA-1J6 Address I T...-7 � .1.-J174 04A1iJ4 62_ ,
City A--rIAN1-[tC. 13 _.> a State Zip 32-2, Phone ci614--toOfd- yQ17
E-Mail D1/.....1_A--f'I‘ 1 a6 ,'01A-1,L.. COWN-
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
Contractor Information -
Name of Company Qt24:7'e5U 11-01=42--5 O f D 2 Qualifying Agent 71--0 15 0-CDS--- ---C
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Address 11 L 5 OA-k % )P&8 ,PR,- City /A,CK� ¶lLI-tState L Zip 32-ZZ-
Office Phone 4'04* - 3Q,6 00'1 A Job Site Contact Number
State Certification/Registration#CGI \ 1€3.[ [4--. E-Mail suf L-i e-5 099- ),G11/4-4,1"-(L -CO 4I .
Architect Name&Phone it
Engineer's Name&Phone if
Workers Compensation Insurer 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 YQUR PROPERTY. IF YOU INTEND
TO OBTAIN_EIt ANCING, CONSULT WITH YOUR LENDER OR 41 ATT0 • :EFORE
RECORDING YO U R N TI E OF MENCEMENT. ,-- ( =,
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1- Signatur o ner or A (Signa*.f Con actor)
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Sgned and sworn to(or affirmed)before me thi r-¢' day of iii: ed.and sworn to(or affirmed)before me tt � day of
Lej 2U�( ,by tLnni . -. c�' 7`0V
�1byI _ �� nSl '
h'P'4%'0.P1 AW- EER/ �ERROBERTSON (Signature Notary)
MY COMMISSION#HH 009325
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P `-:;, `P EXPIRES:June 11,2024 ( ersonally Known OR
[ ] ersonally Known O'; ''.,FOF,q Bonded Thru Notary Public Underwriters rrProduced Identificati Produced Identificatiorr��_�•, LS 5� l��
Type of Identification: (-,vcr ;Ge,,,jQ Type of Identification: \(tel
"* VICKI KAY KRONS
=.: enr u ':,-
.Commission#GG 216132
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'-,;.fir..�:' Expires May 9,2022
.'''"°P Bonded Thru Troy Fain Insurance 800-385-7019
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