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Home My Public Portal AboutJAYCEE PARK.pdfDATE ISSUED: 06 -21 -2013 WORK DESCRIPTION WORK LOCATION OWNER NAME ADDRESS CITY, ST, ZIP PHONE NUMBER CONTRACTOR NAME ADDRESS CITY STATE ZIP FLOOD ZONE BUILDING VALUATION SQUARE FOOTAGE OCCUPANCY TYPE TOTAL FEES CHARGED PROPERTY IDENTIFICATION # PROJECT VALUATION CITY OF TYBEE ISLAND BUILDING PERMIT SPRINKLER SYSTEM - JC PARK 00 VAN HORN CITY OF TYBEE PO BOX 2749 TYBEE ISLAND GA 31328 -2749 CITY OF TYBEE PO BOX 2749 TYBEE ISLAND GA 31328 -2749 P $ 0.00 $7,200.00 PERMIT #: 130399 TOTAL BALANCE DUE: $ 0.00 It is understood that if this permit is granted the builder will at all times comply with the zoning, subdivision, flood control, building, fire, soil and sedimentation, wetlands, marshlands protection and shore protection ordinances and codes whether local, state or federal, including all environmental laws and regulations when applicable, subsequent owners should be informed that any alterations to the property must be approved by the issuance of another building permit. Permit holder agrees to hold the City of Tybee Island harmless on any construction covered by this permit. This permit must be posted in a conspicuous location in the front of building and protected from the weather. If this permit is not posted work will be stopped. The building contractor will replace curb paving and gutter broken during construction. This permit will be voided unless work has begun within six months of the date of issuance. Signature of Building Inspector or Authorized Agent: P. 0. Box 2749 - 403 Butler Avenue, Tybee Island, Georgia 31328 (912) 786 -4573 - FAX (912) 786 -9539 www.cityoftybee.org 93 Contractor Affidavit under O.C.G.A. § 13- 10- 91(b)(1) By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13- 10 -91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of (name of public employer) has registered with, is authorized to use and uses the federal work authorization program commonly known as E- Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13- 10 -91. Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13- 10- 91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows: Sz /t Federal Work Autllorization User Identification Number 041,0U/Pori Date of Authorization JT.3LAiii .1412/GAr /Ott/ LL C. Name of Contractor ,1C PA2K TekiGAT/on! Name of Project ti-Y aF I;'e r,AA)0 Name of Public Employer I hereby declare under penalty of perjury that the foregoing is true and correct. Executed on , , 201_ in (city), (state). Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF ,201_. NOTARY PUBLIC My Commission Expires: FOR 4//t,e_e_.- 1 Urgent fl DATE CO7•/7 9 -�S A.M. TIME p M While You Were Out M //% OF PHONE / �J 45 ' V196 AREA CODE NUMBER EXTENSION TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN RETURNED YOUR CALL WANTS TO SEE YOU MESSAGE ,y A / lq $a ,5L( a adams- SIGNED 9711 CITY OF TYBEE ISLAND CONTRACTOR REGISTRATION APPLICATION Date New Renewal License # Business Name f- r ' L �, DATE FEE Administrator , Location r )' io Zoning Approval REQUIRED Mailing Address 4 / - LI -7 l / Phone (1 L) I l Email � / ,j a_ I ,w.T --- oz-lee-7- ` • Federal ID # _ 2 (7 -7 2- NAICS Code —(� Business Type (circle one): Sole Proprietor Partnership Corporation L C ` Other: Type of Contractor ❑ General ❑ Electrical ❑ Mechanical ❑ Plumbing ❑ Other Has this business or anyone connected with this business been cited or charged with any violation of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State R- ir''- -e Commissioner or any Rule or Regulation of the City or County within the past 12 months? (circle one) YES . e (If YES, list details) 1. Include a copy of your local business license. 2. Any business that requires state licensing must include a copy of state license. List person(s) authorized to request inspections: I hereby make application to the City of Tybee Island for a Contractor Registration. I certify that the above statements are true and correct. I understand that the processing fee of $20.00 is non - refundable. I further understand that the provision of false information on this applic ion may result in the revocation of this registration by the City of Tybee Island. Applicant Signature Date -JO ` /3 Printed Name Received by Date ROUTING APPROVAL BY DATE FEE Administrator REQUIRED Contractor Registration 20.00 Zoning Approval REQUIRED Reason for den /al: City of Tybee Island 403 Butler Avenue Attention: Contractor Registration, P.O. Box 2749, Tybee Island, Georgia 31328 -2749 Telephone (912) 786 -4573 FAX (912) 786 -5832 www.citvoftybee.orq Affidavit Verifying Status for City Public Benefit Application By executing this affidavit under oath, as an applicant for a City of Tybee Island, Georgia, Business License or Occupation Tax Certificate, Alcohol License, Taxi Permit, Contract, or other public benefit as referenced in O.C.G.A. Section 50 -36 -1, I am stating the following with respect to my application of a City of Tybee Island: iness License or Occupational Tax Certificate, • Alcohol License. (circle all that apply) • Taxi Permit, • Contract • Other public benefit for individual, business, corporation, partnership, or other private entity). 1) lam a United States citizen. OR 2) (printed name of natural person applying on behalf of I am a legal permanent resident 18 years of age or older or I am an otherwise qualified alien or non - immigrant under the Federal Immigration and Nationality Act, 18 years of age or older and lawfully present in the United States. * In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violatioryof Code Section 16 -10 -20 of the Official Code of Georgia. SUBS I AND SWO N BEFORE ME ON THIS THE DAY OF , 20 Notary Public My Commissi ' Expires: Signature of Applicant Date A A hfe,an �.1 Printed Name * Alien Registration Number for Non - citizens JERR S A. BRYANT Notary Public, Chatham County GA My Commission Expires May 22, 2016 Note: 0. C G.A. § 50- 36- 1(e)(2) requires that aliens under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended, provide their alien registration number. Because legal permanent residents are included in the federal definition of "alien", legal permanent residents must also provide their alien registration number. Qualified aliens that do not have an alien registration number may suppiy another identifying number below: OCCUPATIONAL TAX REGIST *pit TION PAID City of Port Wentworth, Georgia JUN 2 2013 � 3 , [53 NEIC AIWA Ire Ck# Expires December 31' Date: � Legal Name of Business: 4 i2k Associated Trade Names of the Business: .L« Leta.gc s Location Address of Business & Telephone: % /22/ a)/ j 7-7,) 7 Mailing Address & Telephone (if different from location): 112 -41-47-/ 767 Name of Owner: SSN /Tax ID Number: 5-g--.2,.. c"..1 North American Industry Classification System Code (NAICS) Number: Number of Full -time & Part-time Employees: 1 /° / The undersigned herby certifies that the approved statements are true and correct to the best of his/her knowledge and belief. Signature: 00—J -- Title: * Please Note: The information provided will be provided to the Georgia Department of Revenue. Refusal or failure to provide information will also be provided to the Georgia Department of Revenue. For City use only: Account # Customer # Amount Paid: Date Paid: Processed by: Approved by Mayor and Council: Date Approved: /3 - 99 Date CITY OF TYBEE ISLAND BUILDING & ZONING DEPARTMENT P.O. Box 2749 Tybee Island, GA 31328 Phone (912) 786 -4573 Fax (912) 786 -9539 PLUMBING PERMIT APPLICATION 2-07//3 Location of work (street address) Contractor �--- � ,s - �� L L Address of Contractor Telephone number of Contractor Name of Property Owner L 77/ 7 144-, //,,p2_4// Mailing address of Property Owner Telephone number of Property Owner �d' j R Date work will be ready for inspection, if known Z At-e Estimated cost of construction A-New Work Replacement Oil Gas Permit Number Electric Backflow Preventor Disposal Unit Domestic Water Connection to Main Drain Roof or Area Drainage or Vent Piping Fire Protection Sprinkler System; Number of Heads/Nozzles Grease / Oil Trap Hose Bib Hot Water Heater Icemaker Lawn Sprinkler System Plumbing Fixture Residential House Sewer Connection to Main Sewer Cleanout 01, Sewer Stub �. Vacuum Breaker CO - Z ( _— Water Meter v C Water Service Line — New Residence v 3 , Water Service Line — Replacement -Pr Water Softener v , (P Other \ 1