1021 Atlantic Blvd 961 TENT22-0001 COAB Permit Form with Conditions - Culhane's Tent PermitOWNER:ADDRESS:CITY:STATE:ZIP:
EQUITY ONE ATLANTIC
VILLAGE INC 1600 NE MIAMI GARDENS DR NORTH MIAMI
BEACH FL 33179
COMPANY:ADDRESS:CITY:STATE:ZIP:
TYPE OF
CONSTRUCTION:
REAL ESTATE
NUMBER:ZONING:BUILDING USE
GROUP:SUBDIVISION:
177602 0040 SECTION LAND
JOB ADDRESS:PERMIT TYPE:DESCRIPTION: VALUE OF WORK:
1021 ATLANTIC BLVD 961 TENT parking lot tent for
Culhane's $0.00
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
BUILDING PERMIT 455-0000-322-1000 0 $55.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $59.00
LIST OF CONDITIONS
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property
that may be found in the public records of this county, and there may be additional permits required from other
governmental entities such as water management districts, state agencies, or federal agencies.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT
IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLORIDA BUILDING
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
1 of 1Issued Date: 3/16/2022
PERMIT NUMBER
TENT22-0001
ISSUED: 3/16/2022
EXPIRES: 9/12/2022
TENT PERMIT
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
Building Permit Application updated 10/ 9/ 18
i! ....:, City of Atlantic Beach Building Department ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
w IS REQUIRED.Phone: (904) 247-5((826 Email: Building-Dept@coab.us
i
Job Address: 10 Z t R 4Q/4 2. e ,`Y Permit Number:Z 1
Legal Description RE# I-77('C)Z-- 664-Cl)
Valuation of Work(Replacement Cost)$Heated/Cooled SF Non-Heated/Cooled
Class of Work: New Addition Alteration Repair Move Demo OPool Window/Door
Use of existing/proposed structure(s): Commercial Residential
If an existing structure,is a fire sprinkler system installed?: Yes ONo
Will tree(s)be removed in association with proposed project? Yes(must submit separate Tree Removal Permit) ENo
Describe in detail the type of work to be performed:L__
PcR._k•<lEi TIr. c Lo l
Florida Product Approval# IA/ i fl for multiple products use product approval form
Property Owner Information
Name it,( L 't" rVE C P'-L1 Address q 6 A-- Yst t- -f r R i .tJl0
City State Zip 1223'; Phone 2-C641 'i J
E
Owner or Agent(If Agent,Power of Attorney or Agency Letter Required) _ s- -_ e
1
O Com'
Contractor Information Gc fr - & cam:--,
Name of Company itNi i it-- Qualifying Agent
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt o 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
RECORDING YO)00T1TI E O CO ENCEMENT.
ir 1,0-
Signature f Owner 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 day of
by by
Signature of Notary) Signature of Notary)
Personally Known OR Personally Known OR
Produced Identification Produced Identification
Type of Identification: Type of Identification:
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1 UNITREN-01 GGARCIA
ACORO` CERTIFICATE OF L BILITY INSURANCE
DATE MMDDmYn
16.,3114/2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AME) EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTI E A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,t 'olicy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions le policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of h endorsement(s).
PRODUCER gliACT Georgette Garcia
The Browning Agency more Eel:(904)2853430I Ac,Nor(904)28535722109SawgrassVillageDr
Ponte Vectra Beach,FL 32082 tatEms:georgetteclbrowningagency.com
NSURER(SI AFFORDING COVERAGE NAILS
INSURER A:AXIS Insurance ComDanY 37273
INSURED INSURER 6,_--
United Rent-All of N.E.Florida,Inc.
4743 Blanding Blvd NsURERD:
Jacksonville,FL 32210
INSURER E:
INSURER F:
COVERAGES CERTFICATE NUMBER: REVISION NUMBER;_
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELC AVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDI, OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HA SEEN REDUCED BY PAD CLAIMS.
NSR i
TYPE OF INSURANCE ---- ISwUBRD POLICY NUMBEF I ypDryyyYi 1, n, i
UNITStP
1
A ' X COMMERCIAL GENERAL Lueury EACH OCCURRENCE 3
1,000,000
CIAIIIIS-MADE XJ OCCUR AIUNFL003-029661-0 5/8,2021 518/2022
sNTE°
i f
100,000
5,000
MED E%PLAr.a a a_1___—.----._
PERSONAL 6 ADV INJURY 8 _- 1,060,000
NI AGGRE TE WAFT s PER: NERAL AGGREGATE r;
2,000,000
X 1 POLICY 11,TER1LOC PRODUCTS-COMP/OP AGO $2! .000
OTHER:
A AUTOMOBILE Lwp fly cam BINE DD SINGLE LIMO 1,000, 000
X ANVAUTO A1UNFL003-029661-0 5/8/2021 5/ 8/2022 BOOILYINRIRY(Fa person) $
DOES ONLY _ SCHEDULEDUry y
j I BODILY INJURY(Peraodde n) $
X AUTOS ONLY X AUTOS OiVw7
OFPERrf )AMAGE $
A UMBRELLA LIAR
I!X I OCCUR
4---
I EACH OCCURRENCE $
1,000,000
X EXCESS UM3 i-------,
111
CLAMS-MADE A5UNFL003-029662-0 5/8/2021 5/8/2022 AGGREGATE
DED RETENTIONS
1,000,000
WORKERS
COMPENSATIONPER
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AND EMPLOYERS'LIABILITY
YIN
I STATUTE St
ANY PROPRIETOR/PARTNERIEXECUTNE Si..EACH ACCIDENT .
QE IC t FInNH)ExC.UDED't N/A
DISEASE-EAEMPLOYEE$ttpXX lllye de
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under EL.DISEASE-POLICY LIMIT SIDESCRIPTIONOFOPERATIONShnebw,
A Equipment Floater Al UNFLO03-029661-0 1 6/112021 51912022 ALS-$2500 Deo 600,000
j
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remake Sall .,may be aaadMd If more space le required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Gulhane's Irish Pub
THE EXPRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
967 Atlantic Boulevard
Atlantic Beach,FL 32233
AUUTTHHI/
OOR,
X
IZZEEDD REPRESENTATIVE
I;I
ACORD 25(2016/03) 1988-2015 ACORD CORPORATION. All rights reserved.
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