330 2nd ST RES21-0175 -�,,,, Building Permit Application
Updated 10/9/18
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j City of Atlantic Beach Building Department / �' **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
''.--only., IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us /- 1
Job Address: •J�J 22.'6 .. .\- �ic�.,n�C_ �=.x�,�L.- Permit Number: �I l=- Z - C� `----7
1 Legal Description 5-4, 9 /62- Z S 2-- -6 i(2 -$RE# /4 9 7 6-/" 00 74-
Valuation of Work(Replacement Cost)$ bOI�V Heated/Cooled SF Non-Heated/Cooled
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• Class of Work: ❑New EAddition ❑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) ON()
Describe in detail the type of work to be performed: i`ttvjvr\ \0..J s-Tr- D rl7M -k- V" 1V a�e..•(-
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name ... ...7-7- ...c0- -- - \_-_ ,,c0,-2- Address �j�jU "2. W:), ci_ 52:2.-
City M\cy.Y -"\-\c._ -----e). e_._0...6, State '-L Zip 22 3 j Phone 5\`-\ ? :-\• 1 -Z-0
E-Mail ALX -Akc-z2t-\ - scre c \- Cor-Y-1
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Coilpany 1 'C/t Qualifying ent ROA/ ,/zki'
Address 93. 1ysr7 . �' City Stat zZip 3/2,"2,-1,-)
Office Phone '9e y� / ( 4y Job Site Contact Number / y 4'• `AI
State Certification/Registration# C C a�7'73g E-Mail ,v� A/ /fir[ " rnei951/`J4'T
Architect Name&Phone# �-
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt Expiration Date 47-7.A
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 :j " I ' NEY BEFORE
RECORDIN� /YOU$-NOTICE OF COMMENCEMENT. 't,,;"/
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(Signa re of O ner or Agent) T/ (Signature of Contractor)
Signed and sworn to r affirmed) y.fa�t!1111 t day of i ed and sworn to(or of med)before me this 2` ay of
C.P1 ,by -7 -&- • t�. ( a , OZ._ (, .�' R914/ ,..t - A .
• (Sigr� ore of Not '. IS Sig If r` 10Wr�V
Personally Known OR 0• ,�:°�dy6on �� .�v��.'Q�� [ ]Personally Known OR ;;�,...... ,, TONT GINDLESP RGER
9 p ded d �`. [ ]Produced Identification 2° :°
[ ]Produced Identification �'pL °bpc Undar''•' OQ`��� 1,7 •1;-, MY COMMISSION#GG 353178
Type of Identification: 4i'4)&8.;•""'••d��� Type of Identification: i 2023
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