299 ATLANTIC BLVD ROW25-0011 Sow ,, RIGHT-OF-WAY / EASEMENT PERMIT APPLICATION
'1' City • ' . teach Building Department FOR INTERNAL OFFICE USE ONLY
r 800 Seminole Road, Atlantic Beach, FL 32233 PERMIT# 2nw 15-- Obi (
a IPhone: (904) 247-5826 Email:
� Buildin -DeP
t@coatis **ALL information required to process cess��P/-kp GlR10�TTERONSIBLR /TIFYING Al AN BTAle—�OCA?ESS �‘ �,
Job Address 77 /917 (k �lf/Q
RE# C
CONTRACTOR Name of Company 8/70-117 ` <Y rre/( Phone 7, 9—577 p 375?
Address City State Zip
Qu. ifying Agent State Certification/Registration#
Email AWE/ Job Site Contact Number
i
Worker's ••mpens. on Insurer p ,S .=,' Exempt ❑ Expiration Date
Architect Phone Email
Engine-' Phone Email
• 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.
• When e necessary for the construction, repair, improvement, maintenance, safe and efficient operation, alteration or
relocati of all, or any portion of said street or easement as determined by the Public Works Director, any or all said poles,
0wires, es, cables or other facilities and appurtenances authorized hereunder, shall be immediately removed from said street
or ea m t or reset or relocated hereon as required by the Public Works Director and at the expense of the Permittee unless
rei urse nt is authorized.
• All w k all meet City of Atlantic Beach or Florida Department of Transportation Standards and be performed under the
A I� supervi on of (Project Superintendent)
`� with o any Name) Phone _
• Al ma rials and equipment shall be subject to inspection by the Public Works Director.
�4.• All city roperty shall be restored to its original condition as far as practical, in keeping with City specifications and the manner
satis ct 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.
A//fThe mittee shall commence actual construction in good faith within days. If the beginning date is more than 60 days
from ate of permit approval then permittee must review the permit with the Public Works Director to make sure no changes
hav oc urred in the area that would affect the permitted construction.
• It I 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.
• The Public Works Director shall be notified 24 hours prior to starting work and again immediately upon completion.
"In lieu of signed, sworn and notarized signatures of the property owner, agent and/or contractor, and under penalties of
perjury, I declare that I have read and examined the foregoing application and that the facts stated in it are true and correct."
SIGN TURE 0 CI, TRACT? '
1 PRINT OR TYPE NAME OF CONTRACTOR DATE
/ / //
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SIGNATURE OF •WNER 0' AGEN PRINT OR TYPE AME OF OWNER OR AGENT DATE
Right-of-Way E• ement Permit Application 11.13.2024
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4 • toImportant Bonus Account Information-To receive this offer,the enrolled account must not be Closed or restricted at
the time of payout. Offer is good for one-time use. Signers can receive one new business checking account 11110"
opening-related offer every two years from the last offer enrollment date. Only one offer per account. Err%lpyees of
JPMorgan Chase Bank, N.A. and our al-Mates are not eligible. Chase reserves the right to withdraw this offertit any
time without notice. Offers are considered interest and m?y be reported on IRS Form 1099-INT(or Form 1042-S, if
applicable).
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