1808 Tierra Verda Drive RESO21-0028 rev. 6-4-21 Revision Request/Correction to Comments **ALL INFORMATION
HIGHLIGHTED IN
erA
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
� Phone: (904) 247-5826 Email: Building-Dept@coab.usPERMIT#: IZ�
❑ Revision to Issued Permit OR ❑ Corrections to Comments Date: 6/4 IG---
Q �
Project Address: t &0 V ( I errcx. VQr d e-
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Contractor/Contact Name: C...0)CZE 47Th
IL / _ /(� G QC
Contact Phone: � --� Email:
Description of Proposed Revision/Corrections:
Pcci.-4 _co r m
affirm the revision/correction to comments is inclusive of the proposed changes.
(printed name)
• Will proposed revision/corrections add additional square footage to original submittal?
❑No ❑ Yes (additional s.f.to be added:
• Will proposed revision/corrections add additional increase in building value to original submittal?
❑No ❑*yes (additional increase in building value:$ ) (Contractor must sign if increase in valuation)
*Signature of Contractor/Agent:
(Office Use Only)
❑ Approved ❑ Denied ❑ Not Applicable to Department Permit Fee Due$
Revision/Plan Review Comments
Department Review Required:
Building
Planning&Zoning Reviewed By
Tree Administrator
Public Works
Public Utilities
Public Safety Date
Fire Services Updated 10/17/18
" -i. Building Permit Application Updated 10/9/18
,,..:-. i City of Atlantic Beach Building Department **ALL INFORMATION
`ori_ 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Buildinn_Dept,n.co2h tic IS REQUIRED.
Agar _ \Slit ;',e;cri,- ve--f' --- int AA)0-.,666 r^rmi- N_.Y.k=.: 1 . C)2( _ 002_
Legal Description -.1-(kt-CAS . +) '4\` f N�"&or RE# 10542., 5- �
Non-Heated/Cooled D<
Valuation of Work(Replacement Cost)$ /o�oO Heated/Cooled SF
3�-z' 09 -zs -Q 9C sr,v4 -,goer �; Zy
• Class of Work: ' New X.Addition DAlteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial AResidential
• 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) 4No
p Describe in detail the type of work to be performed: �\ j l [ /Aced 6 StO Q�cS'1
t;: �3 r�. M�n�0 b � JO'���s a' �'0-��10•,� +0 0� rT�A�i�lie
z55
Florida Product Approval# for multiple products use product approval form
Property(pwner Information
Name WS-1912-"k6 J;n. Address 1pp
0c'S 1') - c'- V eac, 9 C
rt.' 4 4c. 1O-As .c_ e.&oLAA statF, LZ z p 3ad3 3 Pt.::.:-,e
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Nimile ui Cy;Iipoily COONS Cd C1-.. i renc..fCO Liifai yi1ng Agent
Address /g9( 6,6.. Iae&Jo5 ittv iz— .S- City Ad 013G x5ck State FL Zip AL�3aa33
Office Phone nj 0 1 ,o S 6 g3o Job Site Contact Number ,0.;,-,..r.--
State Certification/Registration# E-Mail C.4 0 C FaIne:c._e 6„,1 1 ,Co.,
Arrhitort N:IMP Q. Phnr..o ft
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt 1(Ik 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
l
nmmenrnri prier to th,, eon i -� .+it-.n.i+k-+L!!!work vv!! t+n performcd to rIc..r rh...t...,J.,,.,�,. ..t..n•t... .,...- _ . !.:-it._-.
r ...o of n p.r
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 riistricts state aeenries nr
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. F YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY = RE
RECORDING" R NOT CE OF COMMENCEMENT. 4-'
(Signa . •c-Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed•-fore me this c day of Signed and sworn to(or affirmed) before me this 3?dayrof
)l)0c � y r1.'
.lb C ii l> , );;mac aaDi ,( yJ. Ott '- '
or"ki, Notary Pubtic State of Ronda Y°4y Nota Public State of Florida
k Roberta D Carlisle k Notary
4
My Commission GG 251658 y Roberta D Carlisle
[;X ersonally Known R [� ersona.ly Known ORarv Expuas 09/151 022 Pr ll ‘o`M1 E P fes 09%5ios 2 251658
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