500 N NAUTICAL BLVD FNC22-0040 ``- '' Building Permit Application Updated 10/9/18
J
City of Atlantic Beach Building Department **ALL INFORMATION
vkW, 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
r , Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: 5 > )) k C) 1JPermit Number: FucZz�- QG`'1 O
Legal Description S\( \. J cte-testa ," C Q /Lott //? JA,c4 3 RE# 1 7a 70 Y- C366
Valuation of Work(Replacement Cost)$ r.E P"---- Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New [$A,ddition ❑Alteration fh‘air ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial Xftesidential
• If an existing structure,is a fire sprinkler system installed?: Vies ❑No
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) o
Describe in detail the type of work to be performed: . _p_.,„-,,� 2 s \ 0-UL)X2.7. C r �b,C Ul'Y% (2-0(A.2.\. v- c?\ _2_ -1,- No a,C Sk dU
Florida Product Approval# for multiple products use product approval form
Property Owner Information l ,, , 1 f, �] 1n� ,�
Name )t 1 k.\Ct WV\ \ V^1 5 C Address '��� NCL.Uil 4 Lx r Y L`-' .
City \.CA C\- -t C._ \•QGi.,Cir', State c-1 Zip 3 2-Z-2)-7, Phone C/O y-L`3 - ,211113
E-Mail Fr)S"tt✓ e f---v-+vr-e , Lv'AI'► S
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Wk.\\.c ,,,,` \A C,v k- ' t'
Contractor Information
c
Name of Company \- V-& t >Or\ C,) rl Qualifying Agent
Address City / State Zip
Office Phone Job Site Contact1L>mly6
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 ork 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 FINA CING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECQJD� )(PS, NOTICE OF COMMENCEMENT.
` 1
(Signatu'=of Owner or Agent) {{ (Signature of Contractor)
' ned and sworn to(or affir .efof a me this `` day of Signed and sworn to(or affirmed)bef a me this day of
Nrt 1 , Z O Z 2 by _ 11 t ,.�t c.0 `--Q C ,by
7
r.:,•:p- TONI GINDLESPE` Aga ire of_ :1�� (Signature of Notary)
'' MY COMMISSION#GG 35317:
:
s, EXPIRES:October 6,2023
: -
', ,_ . P'"'::F:i L °i...p e ic _.._,+rlters
�,,�I. _ - [ 1 Personally Known OR
`Pro.uced Identification L— [ ]Produced Identification
Type of Identification: Type of Identification:
Owner Builder Affidavit **ALL INFORMATION
' HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
(,-'3 )',.'
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION CONTRACTING" REQUIRES
OWNER/ BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.103(7), FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED CONTRACTORS. YOU HAVE APPLIED
FOR A PERMIT UNDER AN EXEMPTION TO THAT LAW. THE EXEMPTION ALLOWS YOU, AS THE OWNER
OF YOUR PROPERTY, TO ACT AS YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A
LICENSE.
YOU MUST SUPERVISE THE CONSTRUCTION YOURSELF.
YOU MAY BUILD OR IMPROVE A ONE OR TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY
ALSO BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF $25,000.00 OR LESS.
THE BUILDING MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE.
IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR AFTER THE
CONSTRUCTION IS COMPLETE,THE LAW WILL PRESUME THAT YOU BUILT IT FOR SALE OR LEASE, WHICH
IS IN VIOLATION OF THIS EXEMPTION.
YOU MAY NOT HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS.
IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE LICENSES
REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING ORDINANCES.
II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,THE BUILDING DEPARTMENT
SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED. .
III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO OBSERVE IRS WITHHOLDING
TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY EMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY CIRCUMSTANCES. OWNERS BEING SUBJECT
TO $5,000 PENALTY UNDER FLORIDA STATUTE NO. 455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE
OWNER SHOULD PHYSICALLY SEE THE COUNTY"CERTIFICATE OF COMPETENCY" OR THE FLORIDA"CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904-
247-5826 OR BUILDING-DEPT@COAB.US ) IF IN DOUBT.
V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I
COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUP,jNCE OF AN OWNER-BUILDER
lPERMIT.
Job Address: j 00 /L/cC lLQ<-( (3 /J.� /f- MiG'"`l-1`0 - r5-e.---c.-Z, H r
Owner Name: 0/111(!�-' 1'L` H,✓ , S .f' -- L/ Phone Number: o t-6 - -2 ��
Mailing Address: CUA/ AA-^4---4-0--'-'( / - it''.--City:Cit : /*/-4-:`1¢'Z �� State: P1 Zip: 3d 3.--?__?3.--?__
Notarized Signature of Owner ��: , ?/%
The for oin ins rument was acknowledged before me this da of Al 20�1 n theof Florida,g g 1 y /CI �� �'r State o da, County
of (A./Viz-
,
,-..__ _ \
Signature of Notary Public j (---i L
[ ] Personally Known OR [ ] Produced Identification
Type of Identification: I. _
Updated 10/24/18
Er."""1""".%"1"*.'"""""
TONI GINDLESPERGER
MYCOMPASSION#G353178 s���,P FJCPIRES:October f,2023
E •i• id'.R; Ronded Thru Notary Public Underwriters
REVOCABLE ENCROACHMENT AGREEMENT
\i , City of Atlantic Beach **ALL INFORMATION
800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
existi yrjdfr the laws the Statgvf Florida, hreinafter referred to as "CITY" and
�b ( `` G ..���� of Atlantic Beach, 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 Fe vi C�
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 tall given12y certified mail,return
receipt requested,to the following address &GO //G. `u'1 (Cit-"Of /V #.4 kkx_ q_
• 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
liabilities are ereb assumed by the USER. 411- 1
` /2� (i Date `� 7.--0"-7
Property Owner/Agent(signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this j day of r c , 20 L
by lj�J 1 ` ` lA-_11A I—' `C��` _� ,who personally appeared before me and
( rinted name of Signer)
acknow edged that he/14si: •d the instrument voluntarily for the purpose expressed in it.
�Fn{+oe'•., TONI GINDLESPERGER Department Approval:
Signature of Notary Public,State of da ,, %.„"1 MY COMMISSION#GG 353178
EXPIRES:October 6,2023
[ ] Personally Known
,aF Bonded Thru Notary Public Underwriters
[ ]Produced Identification(Type) L,- Scott Williams, Public Works Director
H:\Applications&Forms\Word&Excel Document Originals\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
- Fence Addendum Updated1/14/2021
City of Atlantic Beach Building Department
/%' 800 Seminole Road, Atlantic Beach, FL 32233 PERMIT #
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: Date:
igD0 Dcu 1 Ced, i9\O ci N .� ,�'3zz3 3 —`f5---;vd�-
Property Type: Lot Type/ Features:
Residential AOne Street frontage (interior lot)
, Commercial L More than one street frontage (corner lot, through lot,
etc.)
❑ Swimming Pool
Fence Material: Fence Height (select all that apply):
XWood ❑ Four Foot (4ft)
❑ Chain Link ,Six Foot (6ft)
❑ Vinyl ❑ Other
❑ Block/Stone (Plan details required for footings and/or
retaining walls)
❑ Other
Fence Location:
Please submit an accurate and current boundary survey showing all existing improvements (including building footprint,
driveway, swimming pool, etc.) and location of fence/wall and any gates. Plan details required for block wall footings and/or
retaining walls and any portion or fencing above 6ft in height.
Will the fence be built in an easement?
❑ Ye must submit separate Revocable Encroachment Agreement)
No
Will tree(s) be removed in association with proposed project?
❑ Yes (must submit separate Tree Removal Permit)
No
Conditions of Approval:
• Roll off container company must be on City approved list. Roll off container cannot be placed on City right-of-way.
• All old fencing and debris must be removed from job site by contractor or homeowner.
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.
MAP SHOWING BOUNDARY SURVEY OF
LOT // BLOCK 3 ,5 SHOWN ON MAP OF
SEA SPRA y
AS RECORDED IN PLAT BOOK 35 PAGES 44 1 4A OF INE PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA
• CERTIFIED FOR: SANDRA A. 4 ROBERT J. TAYLOR, Jr., 4.TX MORT. co.? AME4C/eAAJ TITLE /AJS. CO.
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NOT VALID UNLESS EMBOSSED WITH SEAL OF THE UNDERSIGNED. BEARINGS BASED ON ,e/IV LINE AS SHOWN
I HEREBY CERTIFY THAT THE Lo7 SHOWN HEREON IS IN THE SPECIAL FLOOD HAZARD ZONE X AS SHOWN
ON FLOOD INSURANCE RATE MAP 000/ FOR A TLA,U7/C BEAT e,1-/, FLORIDA, DATED 4-17-89
TRI-STATE LAND SURVEYORS, INC.
8411 BAYMEADOWS WAY SUITE #Z JACKSONVILLE, FLORIDA 32256 (904) 731-7235
LEGEND
I HEREBY CERTIFY THAT THE ABOVE LANDS WER£ SURVEYED UNDER MY
• CONC. MON RESPONSIBLE SUPERVISION AND DIRECTION, THAT THERE ARE NO
• IRON
COR. ENCROACHMENTS EXCEPT AS SHOWN AND THAT THE SURVEY SHOWN
(SET WMN CAP /LS 4144) HEREON MEETS THE MINIMUM TECHNICAL STANDARDS SET FORTH BY
"E THE FLORIDA BOARD OF LAND SURVEYORS PURSUANT TO SECTION
o IRON COR(FOUND) 472.027, FLORIDA STATUTES A
®CROSS CUT
B.RL BUILDING RESTRICTION LINE
E911 r E SENENT LARRY G. EDDY, P.L.S. No. 4144
R/W RIGHT--OF—WAY /
cov. COWERED AREA SCALE: /".=Z°'
€ QOJTERUNE
4........miral0.4°Iiir
A/C ABR CONDITIONING PAD : GISTEO ,S-iRVEYOR, S' OF FLORIDA
(R) RADIAL DISTANCE DATE: 5-/7-91
r--1 CarrarEw
F.B. /7/ PG. /Z nanca kin 91.11797-