1024 MAIN ST RFNC21-0070 ,.,('''-'-'7-/,. .,
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
"4ora� IS REQUIRED.
Phone:
A(9904) 247-5826 Email: Building-Dept@coab.us
Job Address: 102.41J1 1A 1,) s Permit Number:)R ENOL ( 007 O
Legal Description 6-3:4 ' i S -.2cE Ca,i-( ().r(A'dtk (i.C4A M ..off"- ( 3.f3L {f(c{RE# 170'7'7 c- C c,Ca
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Valuation of Work(Replacement Cost)$ L'i L2 H 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 ❑Residential
• 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) ❑No
Describe in detail the type of work to be performed: lgervvit Uz-!) C, '(,avti) C-C--X-C'r ec'PLy°‹-t%t.✓/T1.c •`-,g-4,(..)
61 p9u., L )!7
Florida Product Approval# for multiple products use product approval form
Property Owner Information
57-6e 1.4004 Address /O71-01VIAJ 6
City HtrA''
. , ri (6FAC$J State _ Zip Phone g �/� q4s/d'
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company QM$r 7z 604r'67.7,..)47-- 40 Qualifying Agent \_10^-1 ) GJ✓r S "—
Address /2z,e-44.At AG-cd d4i/e City J/9t,C51/ 14/4-CC- State ft_ Zip`3 Z 13 3
Office Phone 4!79 72( -17$-} Job Site Contact Number
State Certification/Registration# E-Mail G70CFE e 0_,)_ C/'1C, • C`�•--,
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt/Expiration Date -7////Z 3
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 OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY :FORE
RECORD N 0 1;41,, • CE OF COMMENCEMENT.
?ignature f Owner Agent) Jo,✓�- (Sig ,d9' Contractor)-Sc '
Signed and�sw1 rR to'(or affirm:3T foremecPOday of Si ned and sworn to(or affirmed) before me this ,,aO day of
PAY , , U.:P1 , • SAIL 2t-IPI R. Z , c_0o7r . • •- " L.. _ • v •
�1r.— ..err. -- —
i•n.tureor ,o '• •- �' ;
°44 No':. ublic State of Florida
Rn is D Carlisle �.► 00# Notary Public State of Florida
Mif mmission GG 251658 ,� Roberta D Carlisle
[personally Known OR a•. t 09! 5!2022 [4 Personally Known OR % gyp` My Commission GG 251658
[ ]Produced Identificati [ ]Produced Identificatio
os w Expires 09/1512022
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Type of Identification: Type of Identification:
Fence Addendum Updated1/14/2021
A " City of Atlantic Beach Building Department
6 -
��.,+ 800 Seminole Road, Atlantic Beach, FL 32233 PERMIT#
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: Date:
10 Lt./ ww l 5 T .-V/ZD/2
Property Type: Lot Type/ Features:
/Residential %One Street frontage (interior lot)
❑ Commercial 0 More than one street frontage(corner lot,through lot,
etc.)
0 Swimming Pool
Fence Material: Fence Height (select all that apply):
/Wood ❑ Four Foot(4ft)
❑ Chain Link Or Six Foot (6ft)
❑ Vinyl ❑ Other
❑ Block/Stone (Plan details required for footings and/or
retaining walls)
❑ Other
Fence Location:
Please submit an accurate and current boundary survey showing all existing improvements (including building footprint,
driveway, swimming pool,etc.) and location of fence/wall and any gates. Plan details required for block wall footings and/or
retaining walls and any portion or fencing above 6ft in height.
Will the fence be built in an easement?
❑ Yes (must submit separate Revocable Encroachment Agreement)
f? No
Will tree(s) be removed in association with proposed project?
❑ Yes (must submit separate Tree Removal Permit)
/ No
Conditions of Approval:
• Roll off container company must be on City approved list. Roll off container cannot be placed on City right-of-way.
• All old fencing and debris must be removed from job site by contractor or homeowner.
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 AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
Q 10��20 410WEST PLAZA SCALE: 1" = 20'
50' RIGHT OF WAY UNIMPROVED PUBLIC ROAD
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