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801 ATLANTIC BLVD ROW24-0021 Building Permit Application Updated 10/9/18 City of Atlantic Beach Building Department 800 Seminole Road, Atlantic Beach, FL 32233 Phone: (904) 247-5826 Email: Building-Dept@coab.us Job Address: _______________________________________________________ Permit Number: ____________________________ Legal Description ________________________________________________________________ RE# _________________________ Valuation of Work (Replacement Cost) $_________________ Heated/Cooled SF ___________ Non- Heated/Cooled_____________  Class of Work: □New □Addition □Alteration □Repair □Move □Demo □Pool □Window/Door  Use of existing/proposed structure(s): □Commercial □Residential  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: Florida Product Approval #______________________________________________ for multiple products use product approval form Property Owner Information Name ______________________________________________ Address _________________________________________________ City ____________________________________ State _______ Zip _______________ Phone ________________________________ E-Mail ______________________________________________________________________________________________________ Owner or Agent (If Agent, Power of Attorney or Agency Letter Required) _________________________________________________ Contractor Information Name of Company _______________________________________ 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 □ 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 YOUR NOTICE OF COMMENCEMENT. ___________________________________________________ (Signature of Owner or Agent) Signed and sworn to (or affirmed) before me this ____ day of ___________, ________, by ____________________________ ________________________________ (Signature of Notary) [ ] Personally Known OR [ ] Produced Identification Type of Identification: ______________________________________ ___________________________________________________ (Signature of Contractor) Signed and sworn to (or affirmed) before me this ____ day of ___________, ________, by ____________________________ ________________________________ (Signature of Notary) [ ] Personally Known OR [ ] Produced Identification Type of Identification: ______________________________________ **ALL INFORMATION HIGHLIGHTED IN GRAY IS REQUIRED. 801 ATLANTIC BLVD AT&T A02VZ8N PROPOSES TO PLACE 15' OF HANDTRENCHED AND 100' OF 1.5" OF INNERDUCT FROM THE EXISTING HH TO THE CUSTOMER PROVIDED CONDUIT AT 801 ATLANTIC BLVD. BLUE STREAK LLC CHRIS THOMPSON 5131 Doolittle Rd. Jacksonville FL 32254 904-705-4812 904-705-4812 PERMITS@BLUESTREAKLLC.COMCGC1522911 SONNY ELDRIDGE 904-401-0928 177641 000038-2S-29E .63 B DE CASTRO Y FERRER GRANT PT RECD O/R 12936-975 RIGHT-OF-WAY/EASEMENTPERMITAPPLICATION**ALLINFORMATIONCityofAtlanticBeachHIGHLIGHTEDINGRAYIS800SeminoleRoad,AtlanticBeach,FL32233REQUIRED.PERMITTEERESPONSIBLEFORNOTIFYING811ANDOBTAININGUTILITYLOCATESJobAddress601ATLANTICBLVDAT&TAO2VZSNPermitNumber_________________________ContractorInformationCompanyBELLSOUTHTELECOMMUNICATIONSDBAAT&TFLORIDAQualifyingAgentSONNYELDRIDGEAddress9400HISTORICKINGSRDCityJACKSONVILLEStateFLZip32257Phone(904)699-1259EmailG10982@ATT.COMStateCertification/Registration#______________________________________________________________________________________Architect______________________________________Phone_____________________Email_______________________EngineerSONNYELDRIDGEPhone(904)4010928EmailG10982@ATT.COMWorkersCompensationInsurerJ7AT&TORExemptilExpirationDate•Permitteedeclaresthatpriortofilingthisapplicationtheyhaveascertainedthelocationofallexistingutilities,bothaerialandundergroundandtheaccuratelocationsareshownonthesketches.•Whenevernecessaryfortheconstruction,repair,improvement,maintenance,safeandefficientoperation,alterationorrelocationofall,oranyportionofsaidstreetoreasementasdeterminedbythePublicWorksDirector,anyorallsaidpoles,wires,pipes,cablesorotherfacilitiesandappurtenancesauthorizedhereunder,shallbeimmediatelyremovedfromsaidstreetoreasementorresetorrelocatedhereonasrequiredbythePublicWorksDirectorandattheexpenseofthePermitteeunlessreimbursementisauthorized.•AllworkshallmeetCityofAtlanticBeachorFloridaDepartmentofTransportationStandardsandbeperformedunderthesupervisionofRONBIRD(ProjectSuperintendent)with(CompanyName)AT&TPhone(904)303-8190•AllmaterialsandequipmentshallbesubjecttoinspectionbythePublicWorksDirector.•Allcitypropertyshallberestoredtoitsoriginalconditionasfaraspractical,inkeepingwithCityspecificationsandthemannersatisfactorytotheCity.•Asketchofplanscoveringdetailsofthisinstallation,aswellasacopyofarecentsurveyshallbemadeapartofthispermit.calculationsshowinganyincreaseinimperviousareaonowner’slotorintheCityright-of-wayaretobeincludedwiththisapplication.•Thepermitteeshallcommenceactualconstructioningoodfaithwithindays.Ifthebeginningdateismorethan50daysfromdateofpermitapprovalthenpermitteemustreviewthepermitwiththePublicWorksDirectortomakesurenochangeshaveoccurredintheareathatwouldaffectthepermittedconstruction.•ItisunderstoodandagreedthattherightsandprivilegeshereinsetoutaregrantedonlytotheextentoftheCity’sright,titleandinterestinthelandtobeentereduponandusedbytheholder,andtheholderwill,atalltimes,assumeallriskofandindemnify.defendandsaveharmlesstheCityofAtlanticBeachfromandagainstanyandallloss,damageandcostofexpensesarisinginanymanneroftheexerciseorattemptedexercisesbytheholderoftheaforesaidrightsandprivileges.•ThePublicWorksirctors,allbenotified24hourspriortostartingworkandagainimmediatelyuponcompletion.L4t4Date7Z7Permittee(sigr6dInpresenceofNotPublic)STATEOFFLORIDA,COUNTYOFDUVALTheforegoinginstrumentwasacknowledgedthis____ _ _ _ ___dayof_______________________________________by50t\CWJ.b,fJiv’,whopersonallyappearedbeforemeand—)(printednatheofPermittee)acknowledgedthathe/5hesignedtheinstrumentvoluntarilyforthepurposeexpressedinit.tOhi:“olaryPubhc.StaiAOtda(VI[]PersonallyKnown“‘MyCommissionExpires:8/1512026‘SignatureofNotaryPublic,StateofFlorida[]Producedldentificatio____ ___ ___ __ _ __ _ __ ___ ___h:\Applications&Forrns\wordDocuments\201801001Right-of-wayEasementPermitApplication.docxRevisionDate:10/1/18