557 SEASPRAY ACC22-0003 new application 4-8-22 s`'S'`'1', Building Permit Application Updated l0/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
j800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: S'') 5 to 5V y Permit Number: i\Q.0 Z z - MO 3
Legal Description 3c-(or{ 11-zS-29-:si":65iray LOT 11 13L14 Z RE# /74 ` 630 2(
Valuation of Work(Replacement Cost)$ (97(!4 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: jZgew ❑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 Jeflo
• Will trees)be removed in association with proposed proiect? ❑Yes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed: "fir-'D d2.3:7 sc.IjFR.A""'E Vza02:3" —Pec K.
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Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name M'i4iVi>d t✓/C-14)( 141✓ Address - 5
7 3 5Pe4 /
City A-TLAn/T)C. Z 0"'Ci1— State fit_, Zip Phone
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information _ �1 , JON)
Name of Company 1'&+IES pf/vCiPGcet4 4CJ 6-62.4Qualifying Agent .JON)P��y i 5
Address $t-( /vka1 STIG C ��s OP-A, City J/4 / State fZ Zip 32Z3j
Office Phone ger 1o$-7 7 Job Site Contact Number
State Certification/Registration# E-Mail 3 4e./fE5 Fb r 0 1+"'Ti4/L . Cc714---t
Architect Name&Phone#
Engineer's Name&Phone# /
Workers Compensation Insurer 04')77--.2v5 r- OR Exempt ID Expiration Date ?/If l 7-12
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
TOTAIN FINANC NG, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RE D jlbU NO E OF COMMENCEMENT. /
d�O
(Signature of Owner or Agent) (Signature of Contractor)
9 -veY1 5cha.re-e.ns f;nt,
Signed and sworn to(or affirmed)before me this 7- day of ,Siigned and sworn to(or affirmed)before me this ? day of
l4pe_s L A pa,by • I4Q�T-C_ , 0l0aa, b — i - •1 ' 04
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444/4,6 Notary
Pou,blicof Florida
Notary Public State of Florida
My Commission HH 142217 , y • Jessica Dolqulat
[ ]Personally Known OR ��adr Expires 06/14/2025 [ ]Personally Known OR d2 My Commission
HH 142217
[ roduced Identification [ ]Produced Identification
Type of Identification: L. Type of Identification:
..,;---•,f.
REVOCABLE ENCROACHMENT AGREEMENT **ALL INFORMATION
.j City of Atlantic Beach HIGHLIGHTED IN GRAY
`J
.,;,„�,/,,/)I11 800 Seminole Road,Atlantic Beach,FL 32233 IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida,a municipal corporation organized and
exis ng under the laws ore StaleefFlorda, hereinafter referred to as "CITY" and
Al R�,4 AiL 0 V /-� of Atlantici3each, Florida, hereinafter
referred to as"USER".
WITNESSETH:
That the CITY does hereby grant the USER permission on a revocable basis as described herein the right to enter upon
the property for the purpose as described in the City of Atlantic Beach.
This work is generally described as L— e-
Any facility maintained, repaired, erected, and/or installed in the exercise of the privilege granted remains subject to
relocation or removal on thirty(30)days' notice by CITY to USER,said notice to USER shall be given by certified mail,return
receipt requested,to the following address J"J 7 S CA SP/Z AY 4�G ' /4r-/W'T'C 3CW c f} re' 37 23.
• In the event it is necessary for the CITY or the City's approved representative or other franchised utility to enter
upon the above described easement or property of the CITY, the USER shall replace at the USER's sole expense,
any and all material necessarily displaced during the action of maintaining, repairing, operating, replacing or
adding to of the utilities and facilities of the CITY or franchise utility provider.
• The facilities allowed by the permit shall meet the current requirements of the City Code, Building Codes, Land
Development Code and all other land use and code requirements of the CITY, including City Code Section 19-7(h)
which states "Driveways that cross sidewalks: City sidewalks may not be replaced with other materials, but must
be replaced with smooth concrete left natural in color so that it matches the existing and adjoining sidewalks."
• The USER, prior to making any changes from the approved plans and/or method, must obtain written approval
from the City of Atlantic Beach Public Works Department, for said change within 30 days after the day of
completion.
• This permit shall inure to the benefit of, and be binding upon, the USER and their respective successors and
assigns.
• USER shall meet the terms and conditions of this permit and to all of the applicable State and CITY laws and/or
specifications, to include utilities locate requirements and use limitations/requirements of easements, public
right-of-ways and other public land. USER further agrees that the CITY and its officers and employees shall be
saved harmless by the USER from any of the work herein under the terms of this permit and that all of said
.i liabilities are hereby assumed by the USER.
Otji/i 04-att. c� V/vii --- Date (23 , Z2-.
Property Owner/Agent (signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL ---, l__
The foregoing instrument was acknowledged this 6-- --) day of MCkr�k , 20 2 ,
by , /4',4Atp a V r /44144/ , who personally appeared before me and
(piffled name pf Signer) -
ackn w dgectht h /she sig ed the instrument voluntarily for the purpose expressed in it.
,I,,,, z TONTGINDLESPERGER Department Approval:
Signature of Notary Public, State of Floyd •""' ;
..: Oh 1� 41 MY COMMISSION#GG 353178
. 1
[ ) Personally Known :
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