2247 BEACHCOMBER TR RES21-0163 • 0=j ''- . . Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
:? ,
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
�r��ssperIS REQUIRED.
Phone: (904) 247-5826 Email: .,._,,, i,;., ,. -_,,L coab.us
Job Address: 7„uo- O raw Aiwa Nui fi- 33-3) ermitNumber: 1RESZ ( 'C) ( (c, 3
q Legal Descr�ipt��on X74 I ' V-/ C9'&72,1';,796. d9 t 37�?S--e#�l f z:,3-0/6,e--/
Valuation` ofiNV+n R acerae t Cost)$ , oa� Heated/Cooled SF Non-Heated/Cooled
• Class of Work: (=New ❑Addition ❑Alteration ❑Repai`rl ❑Move ❑Demo ❑Pool ,D�Window/Door
• Use of existing/proposed structure(s): ❑Commercial �IResidential
• If an existing structure,is a fire sprinkler system installed?:' ❑Yes )(No
• Will tree(s)be removed in association with pro�7osed roiect? ❑Yes(must submit seaarat ree Rem val Permit) o
Describe in detail the type of work to be performed:✓ vete:,
t c ,pa,„14r ei "4OW c'E'
/OW 1%4—' A.)- u-4= 0 P/1 4,\A- iWU( 4-4(ro .(5
Florida Product Aroval# • TJ X for multiple products use product approval form
Property Owner Information /
Name CIA141 P!t- a> 61442-64 Address 7444 t41t- Md' ''1Qkfl fe l- batZri` it. 3 ii5 3
City tra4 itl- PjVG 41 State Fi, Zip 3/...2- Phone 1310t_ytfb VTipp
E-Mail Cati-0-4. 4 I 0.144- . 01
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
Contractor Information _
Name of Cof pang ,1, n _ 1 „n I Qualifyin Age t -t. /k,,, ,»-i.
Address (X�/y City �y,,,/Y i' ` State �l zZip 52233
Office Phone 20'/ 76).707 Job Site Contact Number 9o> X 2 -2?g..5
State Certification/Registration# p?q//C5g?oz--/ E-Mail jSk.-Aelt ( ; c- ,,,,dec.,,,4,,,,ittie,rrii.i
Architect Name&Phone# J
Engineer's Name&Phone# �� r--,
Workers Compensation Insurer 3 mC _ n S. joR Exempt❑ Expiration Date {//1722,
Application is hereby made to obtain a permit do t work and installas as indicated.I certify that no worK/or 1/172,2-,
Application 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 OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR • •• . :E,6 RE
RECORDIN � O NO(�TIC F COMMENCEMENT.
��"" I, li r * 7,►'1..LO / j ,
(Si ature of Ow r or ) / , (Signature of Contractor)
Si ed an sworn to(or affirrped}befor: a thi d.y of :• and sworn to(or aff�•d)bet. a m: hi/ e day •t
U� 257X,by---\0 ■. a J 4ffi . 217( , • _ �._a ,A / `.
%��% fir ���
(Signature of Notary _ _ �� It ign � �
w
' III ,=aJ'""`•. JONATHAN O SMITH
f '<
y Notary public•Stat•of FIP O fl?sk., TONI GINDLESPER��
[ ]Personally Known OR `..S A Commission#GO 20414 ]Personally Known • ' f- •:0°:
[ ]Produced Identification I xn MY Comm,Expires kb a 2022 [ ]Produced ldentifica :n *'- MY COMMISSION#GG 353178
:,,,,•�::, •; EXPIRES:October 6,2023
Type of Identification: —— Type of Identification: •61 F• . •„ , •
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