2129 Seminole Rd Siding, Deck Submittal •:' '�) 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
L i;a9'' IS REQUIRED.
P^h�oo}�ne:�7((9�041)n24�7-582'l6(�Email: Building-Dept@coab.us
Job Address: LI 2-ti .1€{! I 1 Y IO l t., pai
l MOM( t� Permit Number: I� /�
Legal Description 15-�3 l -25•-1 F 0 Ni Ml(fM( B(T 1I,UI L,1ilt rte ../RE# j oc'i12 2 ` 0200
l ry 1 S3jj��A p_tcp o/!Z ;03`'5 -.1`1 SC(/
Valuation of work(Replacement Cost)$ `T, 7, ;S 0•Z- Heated/Cooled SF 14 Non-Heated tibihr1)C
• Class of Work: ❑New ❑Addition ❑Alteration Repair ❑Move ElDemo ❑Pool DWindow r AUG• Use of existing/proposed structure(s): ❑Commercial `Residential ' UG 2 6 202
'
• If an existing structure,is a fire sprinkler system installed?: ❑Yes No
BY:
• Will tree(s) be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Peermi
Describe in detail the type of work to be performed: 1�jkn.ea S -'f/ '
rtN LtLlncl ren wood on �xatolg eie,cL >.da4:Ir, ci,.(,,i.i , fr,A Tlo Q,cks
Florida Product Approval# for multiple products use product approval form
Property Owner Information ( d
Name )y{�( . ..\( ). ) \t It\I Address i1 emlot ?-c( GG
City • )()l" 1 i Dam State FL. Zip ?, /Z 3 3 Phone lS 1 110,
E-Mail v j CO( , e t@ ma f (b4'Yl
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information t ' 1
Name of Company� ■,) , / U . A A Qualifying Agent t l i clAitt� p,I.,e,-.4.1-th.e, _
Address 1,1(I I ( 1 A V O kl 0 � 1 City '. State Zi .Z - OOffice Phone C' D-- 1 7 1 Job Site Contactsi Nuber (i)I 2- �5 (. .-
State Certification/Registration# 12(;1 I 1 Q2)(4 2-4 E-Mail YY\1 i( 1� C 00110 V al 2.-Ly (4(,4 ( OM
Architect Name&Phone#
Engineer's Name&Phone# p n Nr
Workers Compensation Insurerrr�_`t(,lit, MI011 1I1S C.0 ' OR Exempt u Expiration Date 01 / 0 i / Z.0 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 : + •TICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEME : n Y• I R 'ROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LE c : ' c R A A 0 EY BEFORE
RECORDIN)G YOUR NOTICE O� COMMENCEMENT. 4
1
(...e.yz. -,..._",,
(Signature of Owner or Agent) Mir •nature of Contractor)
Signed d worn to(or affirmed)before me this day of Sided and sworrn( r affirm efor• m-this `.a o
� � .
Vt'� J !
(Signature of Notary)
•
"' • N ata )
l- lir MIIIPP"
[ ]Personally Known ORIrsonally Known OR
[ ]Produced Identification Produced Identification
Type of Identification: Type of Identification ..
CIN J.MCI RE
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z, ,a‘ • Commission#GG 279801
;r �4.:os Expires February 14,2023
4'!,`,' BondedT6ro Troy ain Insurance t00-135-70T9
CALIFORNIA JURAT
A notary public or other officer completing this certificate verifies only the identity of the individual who signed
the document,to which this certificate is attached, and not the truthfulness, accuracy,or validity of that
document.
STATE OF CALIFORNIA }
COUNTY OF //l.g..Y/(/t- }
Subscribed and sworn to (or affirmed) before me on this / ? day of .rief' s"7 2o2/
Date Month Year
by VIA.yre CDC ie/
Name of Signers
proved to me on the basis of satisfactory evidence to be the person(s)who appeared before me.
/ —
J C URIOSTEGUI LOPEZ
Signature: Notary Public-California
Signature o Notary Public _,: = Marin County
` Commission k 2318135
My Comm.Expires2024
Seal
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or fraudulent
attachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: So/aboy ?efl'W,1 At,/P/,y /o- -
Document Date:
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Signer(s) Other Than Named Above: