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1021 Atlantic Blvd TENT22-0001 Culhane's tent permit 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)00T1 TI 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: — F.T. t.-7,---„i- ,,--:::,. ir_i_._. ,,,,efitr:, ... ,,- -__: .,.......--- -- - - -- 4-'7-r At r'' .. . 1 ''.,:, r. • I .... i....."--•. I I • "" .......---•(` .„... „.,,_,-- ..- . • ....- i -...... 4t,.c., I i 0.4; '.;;,7,--r-----' ',-• %V. 'f ., . . .• i. ' ,. • ' ::t.t.' .—."'" ;• • 4 . ....... 1• ... . ). / '!'-'4e•-- • .2 V • Al . • L3 T ii 1 ( ' t . •. . . 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G 0 Cya oa oS o ;414. .13 o I— (1) 0 113 _ XI CD Z (/) iii. cn O mQO O. cD r no -P, Crc co TFQ _ D NW N ^ ei cDCO . //A� ci) icy ` Vd CD r3 CD 1 Cfn n• a 7 n aZ r tV CO (-) v � • 0 (r) v m Cl)IN z �• 3 ;:::1 _-. CSD h. (D D o a CI) 0 011 Q ° Nn o --I ilif m ` 0C_' a w c F. 1 Co v Xm' • m 0 ^ V 0 m ��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 A c,Nor(904)2853572 2109 Sawgrass Village Dr 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 I &H 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 TION under EL.DISEASE-POLICY LIMIT S I DESCRIPTION OF OPERATIONS hnebw, 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. The ACORD name and logo: egistered marks of ACORD