1811 - 1813 SEMINOLE RD COMM21-0043 "'''', Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
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,\ ,, ,. .-; ' 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
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0) Phone:lI (904 247-5826 Email:lBuildin Dept@coab.us IS REQUIRED.
_______\21.-/ bAddress: I l I (3 )U lc f2-((1 � Permit Num r ZI _ w4
0-010 09 n Cli\aLcdrYo
Legal Description �{-�� ��� �a/�C Y� REq /tag(p3� Ooc.)
Valuation of Work(Replacement Cost)$ '"l./ Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ONew EAddition [✓Alteration FIRepair UMove [Memo Hi Pool UWindow/Door
• Use of existing/proposed structure(s): OCommercial IJResidential
• If an existing structure,is a fire sprinkler system installed?: DYes ENo
• Will tree(s)be removed in association with proposed project? EYes(must submit separate Tree Removal Permit) LJNo
Describe in detail the type of work to be performed: / / t,i, t r4 /4 7 F`4e4, ri, 26
s
(�1 i y"S (CLUB
Florida Product Approval# 6l for multiple products use product approval form
Property Owner Information (�
Name a 6- Y k. Address\55 4l fXrI /�
City an. -6 �h tate Zip 3sO Phone —1 I L{�-� - h3,,:)(5---
E-Mail
V �r T_LILQ&k PS fes#'_• Ct>rn
Owner- Agent (If Age t, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company 4titst4/Nt ems,—, LC-, NQualifying Agent 51.--ii A.) inI J2(1A 7:6/Address Or7fj- rd /314,4 ti I- City/F.4/mkgL$(:1, State Zip?ya-?i
Office Phone /S_y op C-6 j Job Site Contact Number 'C'/ €')1: 1543
State Certification/Registration#el( r2s'i/( E-Mail i<1-44 TE3geid 0 T/`14lf .C
Architect Name&Phone# _ /
Engineer's Name& Phone# �.
Workers Compensation Insurer 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
RECORDI - t OTICE 0
_ F_CD IMENCEMENT.
_
(Signature of Owner or Agent) (Signature of Contractor) (
-Crne and swoto(or affirmed before me this I day of Si ed and swo to or affirmed)before me this day of
, by , ‘116. .i.) - U,( ,by e :A .411 I . •.
Ililliliriiilik 0
`
(Sign. . - • otar Signature of• •tary)
- raw Paulsen
rsoey Paulsen Orl NOTARY PUBLIC
Iv)Personally Known OR '� . .1NOTARY PUBLIC Personally Known OR .: : STATE OF Fi.;`tRIr-A1 I Produced Identification.. f STATE OF FLORIDA [ I Produced Identification -i + .3r_ COMFY*GG2 i.74,3
Type of Identification: 1+t• Conim#44212743 Type of Identification: '-'',Ji-.111114:e.
_,. . ' ____FFJcpir+ae 4/34/2022
- V ' Expires 4/30/2022