540 ROYAL PALM ROOF21-0041 Building Permit Application Updated 10/9/18
,., . City of Atlantic Beach Building Department **ALL INFORMATION
5 � 800 Seminole Road, Atlantic Beach, FL 32233
HIGHLIGHTED IN GRAY
n 10" IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 51'16�� go Li Ci( Pa(r•-1 Permit Number:
Rooc z 1- C.30,--i1
/ 2 S 2`i r✓ / 1 12/P 0F P7' RE# / 71S/lo -Oc�oa
Legal Descriptior'_ 3/ +�(,, —1 - /
Valuation of Work(Replacement Cost)$ $.50� '--) Heated/Cooled SF Non-Heated/Cooled
Un,1- 2A !-" I Z( 01f:-/ 7
• Class of Work: ❑New Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
_�idegerc,''
• Use of existing/proposed structure(s): ❑Commercial f�Resntial
• 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 perffoorrngd:ro U F, 0. ,i to,u 1 Raw A.1 I n .r'(•-a,t•i (`n o a, c,•c Y +G^e�
Cop-yie (~e re 1"-o c F r`e.•,• �-e_
v 01-
,5rctnu (G tt,1 GA F
Florida Product Approval# G (.--5 2.'9 3. R-367 for multiple products use product approval form
XProperty Owner Information
Name ,('-eu r g e-- r--rind 1 e-1 Address
City rn.elro f e State F1--. Zip .32 C. 6.G. Phone 710 — k g 2 '
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company (`r)e c‘c.- Roca G'r n S Ga r.krr,e.k ualifying Agent ►-% i 1- _
Address 2o5C' �, r C.rct4. .-=. , i City I.Jti)ti3,.� (kJ,State Ft . Zip ,3a"ic
Office Phone 22 t -c>r> c c, Job Site Contact Number
State Certification/Registration# R-C- DG`+7 3 4c) E-Mail T'- C.O.Mc�c t+a.. Cd ti, c"... L . /1c,f,_
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exemptxpiration Date (I - S-- 2--2
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.
��I Owner or Age ) (Signature of ontractor)
/'
e a s orn to(or . i re .ay of Si ed and sworn to(or ffirmed) e .rem : day of
0 , 2P 2-j b LOQ d : A anis- , 2 04 ,bye-11:41.0 • s • -
__ it /`;-J,( --- -
.•i n PI n0iiIN " r' WILLIAM C.MEDLIN
'�` fk, " Commission#GG 917974 -.''
""' Commission#GG 917974
� .o;: Expires November 4,2023 I ) Expires November 4,2023
[ I Personally Known OR r"t`�P Bonded ThruTroy Fain Insurance 800-3857019 PersonallyKnown OR o oP
p f Produced Identification
Produced Identification
BondedThruTroyFainInsurance860-3857019
Type of Identification: FL :>L Type of Identification: •
NOTICE OF COMMENCEMENT
Permit No. ROC)F--z I —0C;11 I Parcel ID/Tax Folio No.
State of Florida, County of Duval
•
THE UNDERSIGNED hereby give notice that the improvement will be made to certain real property in accordance with
-- Chapter 713, Florida Statutes,the followinginformation is provided in this Notice of Commencement.
•'u Description of property(legal description of property and address if available):
5K0 R.0vet' Palm Qr^. / ( iic1—, S- 2c? 9" A P . P`- of Le,
2 z 2 3? Un i t- Z A' L c #- Z! ei / " S
2. General Description of improvements: 7
Co Pte Fe_ CerOC)
gOwner Information:
a)Name and Address: 1 c L"\d i e-`I - d / ,5 y /2/d e'-.m 12 d M e-b-k: F.'s ,-�Z C G,c
b) Interest in property: (hug, e.-r—
c)
c)Name and address of simple titleholder(if other than owner):
4. Contractor Information:
a)Name and Address: Inonahc, Ro,, Vit., 3 con.f.--��tcrJZd50 �cr r Cr rc(�e So.,,,{-�
b)Phone Number: z"; _00 S S z 7._c
Pep f--(4,-,..e_ B c_ t---
5. Surety Information:
a)Name and Address: u
b)Phone Number:
c)Amount of Bond: $
6. Lender Information:
a)Name and Address: ),1 i A
b)Phone Number:
7. Person within the State of Florida designated by owner upon whom notices or other documents may be served as
provided by 713.13 (1)(a) 7,Florida Statutes:
a)Name and Address: 10 t A-
b)Phone Numbers of Designated Person:
8. In addition to himself'herself, Owner designates ij /A of to receive a
copy of the Lienor's Notice as provided in Section 713.13 (1) (b), Florida Statutes.
a)Name and Address:
b) Phone Number of person or entity designated by owner:
9. Expiration date of Notice of Commencement(the expiration date may not be before the completion of construction
and final payment to the contractor,but will be one(1)year from the date of recording unless a different date is
specified:
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE
NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, 'PART I,
SECTION 713.13, FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND
POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING
YOUR NOTICE OF COMMENCEMENT.
Under p-nalty of•erjury, I declare that I have read the foregoing notice of commencement and that the facts stated
ther- e true • he/i::t of my,knowle ge and belief.
Ltd_ati I—Lc_
k,- 6lerneX\e'Llitetri
(Signat / of Owner or Ow'er's Authorized OII'ficer/Director/Partner/Manager Signatory's Printed Name&Ti Office
The forehoing instrument was acknowledged before me this ) 5 day of \jI)al , 20
by C44140,Cai4 S as f•
(Name of Pe ) (Type of Authori ,i.e.Officer/ ttomey) (Name of Party Instrument was Executed for)
1`�.S1;PY,is;4 WILLIAM C.MEDLIN 2
` �_
* :,,g Commission#GG 917974 `'NOTARY PUB ATE OF FL/O�RID
, Expires November 4,2023 �WI�M� C l � c;
P•
,', ''•O.`.f`O'' Bonded Thru Troy Fai1lnsura�ce d _ ` Print Name: ,,L
00„. 7019
❑ Personally Known
oc#2021147897,OR BK 19761 Page 1522, �''IdentificationType: L-- r!] L—
umber Pages:1
ecorded 06/15/2021 03:14 PM,
)DY PHILLIPS CLERK CIRCUIT COURT DUVAL •
Revised 1/18/18
OUNTY
ECORDING $10.00