1717 selva marina dr rerf21-0165 Building Permit Application Updated 10/9/18
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,, City of Atlantic Beach Building Department **ALL INFORMATION
4 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
-est pr IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 1717 Selva Manna Dr.Atlantic Beach,FL 32233 Permit Number: R F z t -
Legal Description 30-29 09-2S-29E SELVA MARINA UNIT 5 LOT 2 BLK 10 RE# 172014-0000
Valuation of Work(Replacement Cost)$23,297.40 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition DAlteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial ❑Residential
• If an existing structure,is a fire sprinkler system installed?: DYes ❑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: RE-ROOF;50 sq 3/12, 10 sq lesstan 1/12
We need to attach to the building permit of this job
Florida Product Approval#OWENS CORNING SHINGLES FL-10674,Certainteed FlintasticGTA FL-2533 for multiple products use product approval form
Property Owner Information
Name Aubrey Roberts McGovern Address 1717 Selva Marina Dr
City Atlantic Beach State FL Zip 32233 Phone (415)271-3561
E-Mail audreyroberts@live.com
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Quality Discount Roofing LLC Qualifying Agent Roger D Zeigler
Address 3481 St.Augustine Rd. City Jacksonville State FL Zip 32207
Office Phone (904)396-5000 Job Site Contact Number Mark Kimbrell(904)769-4027
State Certification/Registration# CCC1329885 E-Mail permittinggdrllc@gmail.com
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer Bridgefield Casualty Insurance Company OR Exempt 0 Expiration Date 09/28/2021
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 BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
(Signature of Owner or Agent) (Signature of Contractor)
Signed and sworn to(or affirme.)before me thi day of Signed and sworn to(or affirmed)before me this/�ay of
3(.wvt ,a I ,by _ i Q .4. ' m. - , _2i (,by O �.' e-
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_0.✓" Notary Public State of Florida .e►� Notary Pubic State of Florida
Stephen M Knuth +� 11 Stephen M Knuth
r My Commission GG 973989 •
[ ]Personally Known OR •,, Expires 03/29/2024 XPersonally Known OR i My C)rru3/29/2 24 973985
f Expires 03/292024
produced Identification , [ ]Produced Identification
Type of Identification: Type of Identification:
NOTICE OF COMMENCEMENT
(PREPARE IN DUPLICATE) �/� !lPermit No._ Tax Folio Ilo 1 4Dq- WOvState off10 'r,(I c'; County of Du V
To whom it may concern:
The undersigned hereby informs you that improvements will be made to certain real property,and in
accordance with Section 713 of the Florida Statutes,the following information is stated in this NOTICE OF
COMMENCEMENT. F`
Legal description of property being improved: — 2 , v •- 2 t L
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lam{ Z -.a Lt (D
Address of property being improved: i 1 1 11 141 C+y ,�^ -Dr.
c tcck tL 3C L33
General description of improvements: A't- ( G
Owner A J d reA4 .7 oke.'f 5 W aC ovf { / _
Address I R IR 3t'VQ I"\C;.ti t(1C -DI(, p" �ll"I) c 1_)CCn(h, t}"�. 32Z 3.3
Owner's interest in site of the improvement
Fee Simple Titleholder(if other than owner)
Name
Address } 1 -�
Contractor Q ua %-II Li IJ i:5 CCU' I V :�j (�!)('t tie
Address ;)4I --1 .1 Pu/�^`�Ti !1C ?J Ja tIon elle -FL 32ZO i
Phone No. C1'0�1" 3 q t O() Fax No. 1041- b4 6 " 8 Z 6 j
D
Surety(if any) o
Address Amount of bond$ arx
o) D
Phone No. Fax No. a O
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Name and address of any person making a loan for the construction of the improvements.
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acr
Name Y S v
m ^Y
AddressCC cr
Phone No. Fax No. 0 /.....
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Name of person within the State of Florida,other than himself or herself,designated by owner upon whom vrn o a o
notices or other documents may be served: o li-g z p
(NIy-0aF-fx
Name 4,t E o o z O
Address p Z ce o x
Phone No. Fax No.
In addition to himself or herself,owner designates the following person to receive a copy of the Lienor's Notice as
provided in Section 713.06(2)(b),Florida Statutes.(Fill in at Owner's option).
Name
Address
Phone No. Fax No.
Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a
different date is specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER ki. ' I L\
Signed: DATE
Before me th s ' • y of����ZZLI in the
Cgguunty of Duvall tate of Florida,h--a§§�personally appeared
i Mi� lu;hc'�{-� +►1c RCS Cy�1 herein by
himself/her f and affirms that all statements and declarations herein
are true and accurate
eNotary PubdW State of Flonda
Benjamin K DeGluman
i4 . jT My Commtsaron GG 990884
of Expi o 04/2412024 '
Notary Public at Large.State of •Jf1 afr Coun v of 7X I.,
My commission expires: IC' as J
Personally Known or
Produced Identification P t N....