363 ATLANTIC BLVD UNIT 10 SIGN21-0020 • ,, JVJr, 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
`n v~ IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: S(P 3 07ht. /3 C l/' Ste fl /1-f-/mhc *sr,4 Fr, Permit Number:•S t.,E ) Z ` — 00��j
Legal Description 'r i( 4)1 04 h(//i .,-) (I/Tie C 301;3 RE# /(/9 73 i) WOO
Valuation of Work(Rblacement Cost)$ 3 t Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New DAddition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): (Commercial DResidential
• 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 performed: /
in sf 1) PV S fr-. rn f Sin yvih'h religfig c/ thfirri-/ ea-et-5 Oyu 0 dl/�f/k /��'L
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Florida Product Approval# for multiple products use product apprdval form
Property Owner Information
Name 6/c Hat- LG C Address PLO. r' 3'5 11 y Z
City ll`J`—A j Ji5V)11-?... State pt. Zip 3 2LDD(.p Phone (3 577 spi-7L/ti,S'
E-Mail TGir4Z d /J> Gjiv/:',Limi
Owner or Agent(If Agent, Power df Attorney or Agency Letter Required)
Contractor Information
Name of Company Ash Stills' 06/4 Pi &1S)'/r7S Qualifying Agent J/Eh ('dChr.yh
Address 2/(.1Ufa- Jd �'1 $)u f City J46kJ3Y1 t411c- State p1- Zip 30/ZA.,
Office Phone �1IL ) 7LY-7y4-1(o Job Site Contact Number
State Certification/Registration# S 13 3( 313 E-Mail Z3 f1 "1-40-1//k7,1 , Le)r
Architect Name& Phone#
Engineer's Name&Phone# /
Workers Compensation Insurer LDC�'j{ fl A ' 'ii LL G. OR Exempt❑ Expiration Date 01/Dc612 Z
Application is hereby made to obtain a permit to do the work installations as indicated. I certify that no work dr ins al lation 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 NOTIC • COMMENCEMENT.
..•••••!-,---.....„,..... Ary _.--- i c4A-..4 ...ti 6L,........,_______
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0 eer or Agent) (Signature of Contractor)
Signed and sworn to(or affirmed)before me this day of Signed and sworn to(or affirmed)before me this-30 day of
+ ,'2D2k ,by .„,r r , .o�leArrta ' ..x4- , Z-'5Z\ ;y J .�CacA�w�
• _ — _ —__,___ _ ` , 1 . A
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4e'P'Y PVA(, Notary Public State of Florida I :4.: ure of Notary) 1. �- Si; tture o Notar�i _ _ 4,
r ; Jacqueline F Tacandong I ( ;ar &- ASHLEY MARIE NUSS II
0 c , My Commission 2G 193555 ► ' ` • ' Notary Public•State of Florida
4°7,,�-'Per VIV l�nownSi 0 [.'Personally Known OR `;'���`�`.f Commission#HH 150633
ro u e U c io [ ]Produced Identification a'�` ' My Comm.Expires Jul I!,2025 F
Type of Identification: V f �C 'x Type of Identification: Bonaec through National Notary Assn.
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1"thick HDU - 19"Height Dimension letters(painted Pantone 282 - Navy Blue)
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1"thick HDU S logo 151'
painted Brilliant Gold 1"thick HDU - 6"Height Dimension letters (painted Pantone 282 - Navy Blue)
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