2331 W Oceanforest ACC20-0006 Submittal City of Atlantic Beach APPLICATION NUMBER
p►v, Building Department (To be assigned by the Building Department.)
s 800 Seminole Road 1.Q 0 00,
445 L LJ
Atlantic Beach, Florida 32233-5 ( /
Phone(904)247-5826 • Fax(904)247-5845
E-mail: building-dept@coab.us Date routed: 1
City web-site: http://www.coab.us 111
APPLICATION REVIEW AND TRtKING FORM
_ tt •
Property Address: _ 1Da f Department review required Yes No
Buildin
Applicant: 1< e.,�,; 1 e--l�( ( Planning &Zoning"
Tree Administrator
Project: PRUG(Z J t DOJAct- Lj <blic Works
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Approved. ❑Denied. I 'Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by:7,72... q. Date: (6'-'Z�/
TREE ADMIN. Second Review: Approved as revised. I 'Denied. Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ' 'Approved as revised. Denied. I Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
ry,r City of Atlantic Beach ''"' "'"" '` '" APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
f ' j2 800 Seminole Road �y� el(> 7i'1 /'1 ��/�tic_
r '-` Atlantic Beach, Florida 32233-5445 JAN 1 6 LULU `-�`>lJ t J IJIJ
J Phone(904)247-5826 • Fax(904)2 845 -
i,;itvr E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us �Y'
APPLICATION REVIEW AND TRACKING FORM
Property Address: ti)-72i, I, asa_rgrp�sf Department review required Yes No
Building _
Applicant:
I`\ e: C-
I ( --Planning &Zoning
Cgee Adminis gator
Project: (� GCL.. J( DlA.)A( 1L blic Works .‘-',
Public Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APP ICATION STATUS
Reviewing Department First Review: Approved. LI Denied. ❑Not applicable
(Circle one.) Comments:
BUILDING
•PLANNING &ZONING _ We/19
Reviewed by , ,,4:4,Z., . /Date:
TREE ADMIN. Second Review: { 'Approved as revised. ❑Denied. ['Not applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: Approved as revised. ['Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
-' ''r Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
\, 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
�;t
Phone: (904) 247-5826 Email: Building-Dept@coab.us Q � /IS REQUIRED.
Job Address: 7.33i 0,, fort, t j . `V Permit) Number: ' ` ��J-cvUI�RED.M/l
Legal Description 1•17--111 Si ._ i _z"1 6 (9G�nf K /Ail- 3 [.3L. 8 RE# I6 '4 '1(3,-JOaaq
Valuation of Work(Replacement Cost)$ 3gJ 3 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Xliesidential
• 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›fVo
Describe in detail the type of work to be performed: � I ri` (cu,re¢r tA;,Ltkvd,:‘ ) p-t;�/tt c e w l f
V),--tat Pi I, 1,90 1 Srta,11 �wu moo, CJu/6 •0,11- 51-09d forlI\ wIPAI414
Florida Product Approval# for multiple products use product approval form
Propert Owner Information /�
Name i 4- V idet ,Re-0,A.) _ Address Z'33/ LV ()can gr S7i- c-Vc
City 44/14,"/L. i. State r 1, Zip 3-0,33 Phone 2,11 `fly qlD 3
E-Mail IAA Y1-leen St-ID 0 (07"n6d. (pi,
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
Contractor Information
Name of Co any )42'Li81i'/ . Qualifying Agent )# 1c
. �' �
Address l O Th per? iti . city 44�,A Se.� State FL Zip 322,73
Office Phone *Li 37'i 72_z 6 Job Site Contact Number K if )!.,rf�41 9esI 371 /407
State Certification/Registration# E-Mail n A C 1.44-k41,..--)/
. C.a"--*
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer Le OR Exempt n 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
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
REC a !DI, YOUR e ''OF COMMENCEMENT.
•• lily , I• 411111%) . �— ; _/%�sA/,'
(Signa ure of Owner or Agent) (Sig : re of Contractor)
Signed and sworn�7 �,t,o(or a it ed)before me this -')day of kgned and sworn to(or affir pd b-f r- me his Say of
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'Y: .''••. TONI GINDLESPERGER y ,: TONI GINDLESPERGER
[ ]Personally Know `4: [ rsonall Known OR �,o
[_ : ,a. :,: MY COMMISSION#GG 353178 ''P :.
[ ]Produced Identifi • • • " [ ]Produced Identification ge ;._ MY COMMISSION#GG 353178
Type of Identificatio . '•'?;*• EXPIRES:October 6,2023 Type of Identification: , "='..�'. . EXPIRES.October 6,2023
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