1726 ATLANTIC BEACH DR - ROW24-0041 miscBuilding Permit Application Updcred10/9/18
City of Atlantic Beach Building Department "ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
F Phone: (904) 247-5826 Email: Building-Dept_@coab.us IS REQUIRED.
lob Address; 1726 Atlantic Beach Or Permit Number:
Legal Description NIA RE# 169505 1680
Valuation of Work (Replacement Cost) $ 1800.00 Heated/Cooled SF Non- Heated/Cooled
■ Class of Work: ❑New DAddition DAlteration ❑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 trees be removed in association with proposed roiect? ❑Yes must submit separate Tree Removal Permit ❑No
Describe in detail the type of work to be performed: Install 702' UC of 24ct FCC along Atlantic Beach Dr to extend service.
JB2004978
Florida Product Approval # for multiple products use product approval form
Property Owner Information
Name DAVID CHANEYY Address 1726 ATLANTIC BEACH DR
City ATLANTIC BEACH State FL Zip 32233 Phone N/A
E-mail NIA
Owner or Agent (If Agent, Power of Attorney or Agency tetter Required)
Contractor Information
Name of Company Southeast Utilities on behalf of Comcast Qualifying Agent William Paul Herrington
Address 5934 Richard StrBet____ City JACKSONVILLE State . FL zip 32216
Office Phone 407-797-2997 Job Site Contact Number
State Certification/Registration # EC13005951 E-mail SBROWNOCONC3RUEX,LQM
Architect Name & Phone #
Engineer's Name & Phone #
WorkersCcmpensat 1on Insurer INOCMNITYINSURANCE OFNORTH AMERICA COMPANY OR Exempt ❑ Expiration Date
Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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
RECOMYOURN(8��EOF COMMENCEMENT.
r Q i
{Signature of Owner or Agent) (Signature of Contractor)
Signed and sworn to (or affirmed) before me this 3L day of
&—, by I re P
(signature pf ary)
[ ) Personally Known OR
[eroduced Identification }}
Type of Identification:`1��lp
Signed and sworn to (or affirmed) before me this day of
[ ] Personally Known OR
[ ] Produced Identification
Type of Identification: _
by
(Signature of Notary)
RIGHT-OF-WAY / EASEMENT PERMIT APPLICATION "ALL INFORMATION
City of Atlantic Beach HIGHLIGHTED IN GRAY IS:. .
SDO Seminole Road, Atlantic Beach, FL 32233 REQUIRED.
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
Job Address 1728 ATLANTIC BEACH DR �.....:.:. Permit Number
Contractor Information
Company Southeast Utilities on behalf of Comcast Qualifying Agent Shellie Brown
Address402 Ellis` Rd 5 CjtyJacksonyille State FL 2ip32254 . _
Phone(816) 683-7224 Emailsbrowri@congruex.com
State Certification/Registration #EC13005951
Architect Phone
Email
Engineer Gina Gavagni Phone (850) 363-3284 EmailBgayagni@seublities.com
Workers Compensation Insurer[" Ilndemnity Insurance. Co of North America OR Exempt❑Expiration Date
■ Permittee declares that prior to filing this application they have ascertained the location of all existing utilities, both aerial
and underground and the accurate locations are shown on the sketches.
• Whenever necessary for the construction, repair, improvement, maintenance, safe and efficient operation, alteration or
relocation of all, or any portion of said street or easement as determined by the Public Works Director, any or all said poles,
wires; pipes, cables or other facilities and appurtenances authorized hereunder, shall be immediately removed from said
street or easement or reset or relocated hereon as required by the Public Works Director and at the expense of the
Permittee unless reimbursement is authorized,
■ All work shall meet City of Atlantic Beach or Florida Department of Transportation Standards and be performed under the
supervision of Tim.Sa€yard (Project Superintendent)
with (Company Name) SEU Phone (904) 531-6m
All materials and equipment shall be subject to inspection by the Public Works Director.
• All city property shall be restored to its original condition as far as practical, in keeping with City specifications and the
manner satisfactory to the City.
• A sketch of plans covering details of this installation, as well as a copy of a recent survey shall be made a part of this permit.
Calculations showing any increase in impervious area on owner's lot or in the City right-of-way are to be included with
this application.
• The permittee shall commence actual construction in good faith within 30 days. If the beginning date is more than 60
days from date of permit approval then permittee must review the permit with the Public Works Director to make sure no
changes have occurred in the area that would affect the permitted construction.
■ It is understood and agreed that the rights and privileges herein set out are granted only to the extent of the City's right,
title and interest in the land to be entered upon and used by the holder, and the holder will, at all times, assume all risk of
and indemnify, defend and save harmless the City of Atlantic Beach from and against any and all loss, damage and cost of
expenses arising in any manner of the exercise or attempted exercises by the holder of the aforesaid rights and privileges.
•. ThgPtublic Warks Dirsptor shall be notified 24 hours prior to starting work and again immediately upon completion.
CA --e— -- 1 Date to _Z(.24
Permittee (signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL r
�1 da of c be—y— 20 -1
The foregoing instrument was acknowledged this y
by [-(eICe�-e, L4 )Ii,, who personally appeared before me and
printed narne of Permittee}
acknowledged that hejslLa signetf the instrument voluntarily for the purpose expressed in it.
[ j Personally Known �`�) c�-�?•/ �]!
Signature of Notary Publie� ofAertda o,,A- v Cr�rOirilG� �oduced Identification (Type) s_+,r��rd, s6q�,2ip
H:NApplications & Forms\Word Do cu ment5\201801001 Right -of -Way Easement Perm itApplication.docx ReVision Date: 1411/18