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330 Magnolia ROOF18-0102 Submittal S1.%1 :or, City of Atlantic Beach APPLICATION NUMBERrk6 Js i'°' " e' Building Department (To be assigned by the Building Depa ment.) r : - A }r 800 Seminole Road I� d 0r Q �,1 Atlantic Beach, Florida 32233-5445 I \jPhone(904)247-5826 - Fax(904) 247-5845 ,19? E-mail: building-dept@coab.us Date routed: 1 z (� �IL City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: S a o � Y R 130L f A _ • ent review required Yes No Building Applicant: i c 2 ©©P(tl.7(� &Zoning Tree Administrator Project: o (9 ae (T©cam LD Public Works Public Utilities P_©d 2G PA f Public Safety Fire Services Review fee $ _ Dept Signature Review or Receipt Other Agency Review or Permit Required of Permit Verified By Date Florida Dept. of Environmental Protection Florida Dept. of Transportation St. Johns River Water Management District A Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: 1 proved. ❑Denied. ❑Not applicable (Circle one.) Comments: UILDI PLANNING & ZONING Reviewed by: Date:/)-ae /' TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied. ❑Not applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: EApproved as revised. ❑Denied. El Not applicable Comments: Reviewed by: Date: Revised 05/19/2017 ,..,5 _''' ,s, Building Permit Applicatiiion Updated 10/9/18 r '+ ) City ©f Atlantic Beach Building Department **ALL INFORMATION .-,1 J . 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY °'i10 Phone: (904)247-5826 Fax: (904) 247-5845 Email: Building-Dept@coab.us IS REQUIRED. Job Address: 336 riG5 fJ Ip. St • 01'r10,\-C, I3 k Permit Number: Roo el-- t U - Z Legal Description I 0-15- )6, -- Z 5 ` LIC cf_<,. Z 5f1;Air 6,A-1-91 RE# ` 910 IS- 8� 5 Valuation of Work(Replacement Cost)$ WOO Heated/Cooled SF 160)5 Non-Heated/Cooled t1t • Class of Work: ❑New ❑Addition :Alteration , Repair Move ❑Demo ❑Pool ❑Window%D or FICE COPY • Use of existing/proposed structure(s): ❑Commercial XiResidential U • If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No NI/A • Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal W Describe in detail the type of wortof!,, ra e performed: �,,t 0 i ,� `ysae - VI, y ft FSC tfA"V We-AV/ I i'..5 /C5� Z ( % = J 1 Florida Product Approval# for multiple products use product ar§rc4l64 `, LLi! O h Property Owner Information 0 tX) z Name frit( 5(42CPPC L 2V LS LCA (` Address 330 m 010Vs A• 0 0 c 8 8 City Aki 6track., State Ft.. Zip 31J \} Phone cM 31L— \1 'AiO Z vcc z E-Mail ' -- 0 Q 2 a Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) F,:. m tom- Contractor Information 0 ;TX g w \\ Name of Company P tts3 G 5 Qualifying Agent LL O cr w Address ZGoI ftcct) fd,f. City ,41<borwik State k Zip 12711S- a , m Office Phone `itS YOC 54 Vi Job Site Contact Number 764 X11) ?Yl3 5 }- w el Cl State Certification/Registration# CCC l3-sOZ, t, E-Mail W V CO w S CC w Architect Name& Phone# la E Engineer's Name&Phone# Lr tr Workers Compensation Insurer OR Exempt( Expiration Date 014/Zf/2,01i 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 affirmed)before me this IL day of Signed and sworn to(or affirmed)before me this I' day of �c t,n,b.- , is) ,by outii Stv,,,,K, Peen , o- , by 4zutn Mag.' k>� . ACot, OLIO Q., P'w�'1t- o (Signature of Notary) Sin.t r- of No ar ) �r• Notary Public State of Florida �J Notary Public State of Florida ifi]Personally Known •,P w`1; Corey Allen Pease • Corey Allen Pease My Comm ssion GG 211098 PA Personally Known OR _ 'r My commission 211098 K] • Expires 0812412022 O«ted• Expires 08/24/2022 Produced Identific. 7RI Produced Identification Type of Identification: , °f^ .. .... Type of Identification:Ea. A.'w — - -