1820 Ocean Grove. RES21-0003 Corrected.Building App 2-3-21 (2 of 7)_1,�•, - f, � vvv vr.at�t�tVo�.. ■�vYv� e --a `iVt.a,:4 v�.,.Vir, �� � i J64JJ
` Phone: (904) 247-5825 Email: Building -Dept coab.us _ - _ -
Job Address: ��,.,.��� ` tt rY ,�j � �- Permit Number. 0
Legal Description �,ttlyt'l73{i't° t�at1T tLA Z LaT?—g
RE#
Valuation of Work (Replacement Cost) $ Head/filed SF Non- Heated/Cooled
)(NewClass of Work: CIAddition ClAlteration ❑Repair ❑Move ❑Demo 0Pool DWlndow/Door
Use of existing/proposed structure(s): ❑Commercial OResidential
• If an existing structure, is a fresprinkler system installed?- Oyes CNo �
•
Will tr &1 m y i i i ah gEM=dr' ?Oyes m mi Tr R [ P r i N
Describe in detail the type of work to be performed: New ' S'r'r't�
Florida Product Approval # for multiple products use prod
uct approval form
me V1
Gatyy .Q Address ;14.1D (a / MLUS'i`Y P2't
E -Mail Q
State _ZpPtf(� Phone
s T
Owner or Agent (If ent, Power of Attorney or Agency Letter Required) _
Contractor Information
Name of Company Qualify
Addres Cly
Office Phone Job Site Contact
State Certification/Registration # /.5Q IUQ E -Mail ]
Architect Name & Phone #
Engineer's Name & Phone #44t. / pall r
Agent �!
State rp_ 3L�gZ
Workers Compensation Insurer G 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. 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 maybe 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 FINAN G, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING "
TICE OF COMMENCEMENT.
re of Owner or bent) (Signature of Contractor)
Sign#d a d sworn to (or affirmed) before me this 2 Z day of
by C V
L,olc�
Notary Public (Signature of Notary)
State of Florida
Comm# HH037833
n2024
Nilroduced Identification
Type of identification: _ l� I . (�) )r't U P V i C l' i!3
SII ed and sworn to (or affirmed) before me this day of
F7 6 , 7,'W . by
g ib or Florida
Ava J Buder
W cWMj3si 024 007279
personally Known ORppExoms 09111
ji j Produced Identification
Type of Identification: —