1629 BEACH AVE RES21-0078 .,`S '-`' Building Permit Application Updated 10/9/18
tit 'irt-rit? City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
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IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
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Job Address: '1/4161 �,( �i !�(ryPermit Number: � �SZ
Legal Description /5-/00ct -:LS -,1yl.:. ) 'M-)c.',dc etc.),A v,)1t- Ne' i'f'' RE# / 6C! 60(3.-ead0
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Valuation of Work(Replacement Cost)$ 0U"`Q' Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition Alteration ❑Repair ❑Move ❑Demo ❑Pool ( /indow/Door
• Use of existing/proposed structure(s): ❑Commercial Ofre sidential
• 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) C1No
Describe in detail the type of work to be performed: 6c15e !'oar Get ejUf
Florida Product Approval# 0 1- 9 o'$gAl for multiple products use product approval form
Propert Owner Information
Name /�i r f/' t(W . it - Address &:-. �G
2 y /3r C /4./(,City 4th 4// A LZ'/.Ch State FL Zip 3ZZ33 Phone a2,02.• • r,,• .- / (
E-Mail a--tip SD040 e 7/4/4,/ e'014^
Owner or Agent(If Agent, Power o Mtorney or Agency Letter Required)_
Contractor Information
Name of Company r'r 0- 64•i3-4- 6wa,e 4pe� Qualifying Agent IA CVpt L`kro ;/}t`
Address L/.V 1--- ---AOf— t4L/ ✓✓ City a.tv State p r Zip .32.)J6
Office Phone 7t1.k/—LI .41 Job Site Contact Number
State Certification/Registration# E-Mail re G•r./e ,r v CfO 1. (c.rt
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt zr Expiration Date 6Ii,/.2-2,
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 OBT A I' FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECO. 4 NG/ I TICE OF COMMENCEMENT.
S' nature of Owner or Agent) (Signature of Contractor)
•
' ed and�-,w,o n to(or affi me.)before me thi day of 1 gned an sworn to(or affi•m d)before m- this_ day of
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ieP llt , TONI GINDLESPERGER
`m' '�- • COMMISSION
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F ••••P; �slg� Il�Atc�v6 3 [ ]Personally Known OR i/r• " :•. TON(GINDLESPERGER
P`O•' ,', MY COMMISSION#GG 353178
• _.d_'_T.I.;-. uhlit ID L [ ]Produced Identification iv; •Iti is
�> tlters �) a '4`.= EXPIRES:October 6,2023
Type of Identi ica I. . Type of Identification: .1.(6:.•bP
.r�• -„•- � 'ers
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