375 SEMINOLE RD DWAY22-0025 ri-''r,- Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department **ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
�0lur- IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us --77 C
Job Address: -1 S �
�. n l nol e R ocka A�«(13237__ ,FL2 Permit Number: 1-- `10"1\`1 Z 2--0 0C_S
Legal Description 10-15 11,0-2.5-291E COD
vO i�Of1 2-Sa 1 fair r V- 2_13 RE# 17 DI-4 35-- DOOD
Valuation of Work (Replacement Cost) $ 124 C /spa Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration DRepair DMove ❑Demo DPool DWindow/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? DYes(must submit separate Tree Removal Permitt,
Describe in detail the type f wor to be perfor ed: Qfl3 Qxisil Ar)Velsay, l#-i0 1 Fro i- U�a1k om ar-Jo. 4
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Florida Product Approval# for multiple products use product approval form
Propert Owner Information ,^�''
Name �i'nd� Fr Address 31g SQWl 11101 e ooU
City / \-Iai\hc: .�Q(;tC_h i`. State PL Zip 372 33 Phone 78(cr- 2,3- 14(
E-Mail flOOc1le-3 a be11SUU1-1n• n€t-
Owner or Agent (If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Qualifying Agent
Address City State Zip
Office Phone Job Site Contact N • ser
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt 0 Expiration Date
Application is hereby made to obtain a permit to do the irk and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and th. 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 F ANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
REC IVIG Y 'UR NOTICE OF COMMENCEMENT.
(Si: ture of Owner or Agent) (Signature of Contractor)
Si ed a • sworn to or affirmed before me this/. Ida of Signed and sworn to(or affirmed)bef. - me this day of
(�a.:�:- __--- .,�._ _. _ —_ - - �/.rI , by
I . • �41WAIW�'
Ly '.,..f, E ERIN MAlS
MY COMMISSION ' GG 26618 :I+ f,rrry (Signature of Notary)
i o.l:�,`,:•'' EXPIRES:Oc .ber 14,2022 I
—yl
[ ]Pe nally Known OR [ ]Personally Known OR
roduced Identificatio [ ]Produced Identification
Type of Identification: /-7 Type of Identification:
SSS,->>,, Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
`` City of Atlantic Beach Building Department GRAY IS REQUIRED.
illi .n
800 Seminole Rd, Atlantic Beach, FL 32233
"'toll 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 ISSUANCE OF AN OWNER-BUILDER PERMIT.
Job Address: .51S SUMt \ota \o ad -A# oti\I c. QAC\\ . FL -'r
Owner Name: \-100k F rt-,\ 1 Phone Number:—3 1 g(O"2a nil (D1��
Mailing Address:3-PS IMW.- City: r1k1 �.BC-Y 1 State: FL Zip: 2L .33
- ci1.6.
Notarized Signature of Owner
The,ygoingirument was acknowledged befor e thisg) day of /�iC. , 20,?2 the State of Florida, County
of UV
$rr�= s� •
llir
i ""•'!,E.,, Signature of Notary Public '
•.,4 ERIN MARIE SIM.'•t aw ;•; My COMMISSION u GG 266182 I ] Personally Known OR roduced Identification
r, r XPIRES:October 14,2022
Type of Identification: T
Updated 10/24/18
i- 1.-:,/,-,,fi(
RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
S,' City of Atlantic Beach HIGHLIGHTED IN GRAY IS
800 Seminole Road,Atlantic Beach, FL 32233 REQUIRED.
Ji /
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
Job Address 315 S ti\OIIlQ, I ►OOd -33 Permit Number
Contractor Information c/
Company (.t) r\ e r- Qualifying Agent
Address City State Zip
Phone Email
State Certification/Registration#
Architect Phone Email
Engineer Phone Email
Workers Compensation Insurer OR Exempt o 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 Cit of Atl tic Bea or FI ida Department of Transportation Standards and be performed under the
supervision of OW11 .( .\
Q (\LO Fr� (Project Superintendent)
with(Company Name) Phone-1 8.�O'2. --11-1(9 6
• 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 SCI 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.
ttu• The blic Works Director shall be notified 24 hours prior to starting work and again immediately upon c pletion.
WI Date y 2'0/g"�--
Permittee(signed in esence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL
The foregoing instrument was acknowledged this 'Uv day of /1 / ,20 20•9 -)--
by L/ &I 5/ 7� ,who personally appeared before me and
(printed na of Permittee)
acknowledged that he/sjle signed the i • ent .,r ntarily for the purpose expressed in it. ""�, _ _
" � ERIN MARIE STEHL
, / /' ....� r My COMMISSION#
• GG 266182
,,,,,, EXPIRES:
[ )Pers y Known --__`_` _ Ocro� r 1 2022
ignature of Notary ••. ' F orida [ roduced Identification(Type) �._��_- _-
H:\Applications&Forms\Word&Excel Document Originals\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
"ND�� REVOCABLE ENCROACHMENT AGREEMENT **ALL INFORMATION
if-4 a ..
City of Atlantic Beach
AA 1 HIGHLIGHTED IN GRAY
800 Seminole Road,Atlantic Beach, FL 32233 IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
exi ingunder th�.e laws of the State of Florida, hereinafter referred to as "CITY" and
aerr 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. k
This work is generally described as ,t-(re q- (�GL (•o a l
Any facility maintained, repaired, erected, and/or installed in t e exercise of the privilege grant&remains subject to
relocation or removal on thirty(30)days'notice by CITY to USER,said rptice to USER shall be given bycertified mail, return
receipt requested,to the following address 315 SQ( if\o IP. ookd — A�cAA�IC gC , FL 3223.3
• 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
liaabbiliitii, are hereby assumed by the USER.
U, Date 0
Property Owner/A en (signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this 2�> day of 4re.e C , 20 ��L�
by �� /(/ , 1 �j� ,who personally appeared before me and
rinted name of Signer) `/
(P /
acknowledged that he/she signed the i rument voluntarily for the purpose expressed in it.
`
ERIN MARIE STEHL Department Approval:
w - u MY COMMISSION#GG 266182
ignature of No - , • lc,State of Florida EXPIRES:October 14,2022
[ ] Per pally Known
[ roduced Identification(Typed - (--- Scott Williams, Public Works Director
H:\Applications&Forms\Word Documents\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
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OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA. y
CERTIFIED TO:
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NOTES ACCEPTED BY i
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JOB # 15-048 DATE OF FIELD SURVEY: 04-26-15 DATE OF ISSUE: 04-28-15 SCALE: 1" = 20' S
CLOSING COORDINATED BY: MAP NOTES: ,
RICHARD T. MOREHEAD TITLE & ESCROW, INC. 1. BEARINGS ARE BASED ON THE ASSUMED BEARING OF N 4500'00' W ALONG THE
444 THIRD STREET SOUTHWESTERLY BOUNDARY LINE OF SUBJECT PARCEL.
NEPTUNE BEACH, FL 32266 2. BY GRAPHIC PLOTTING ONLY, THE CAPTIONED LANDS UE WITHIN FLOOD ZONE X AS
(904) 247-5147 SHOWN ON THE NATIONAL FLOOD INSURANCE MAP DATED JUNE 3, 2013, COMMUNITY i
NUMBER 120075, PANEL _0409 H
(�• 3. THIS SURVEY REFLECTS ALL EASEMENTS do RIGHTS OF WAY AS PER RECORDED PLAT. UNLESS i
• n: OLD REPUBLIC OTHERWISE STATED, NO OTHER TITLE VERIFICATION HAS BEEN PERFORMED BY THE UNDERSIGNED. i
• waudn..r.uoe.cv�y 4. THIS SURVEY IS NOT VALID WITHOUT THE ORIGINAL SIGNATURE AND EMBOSSED SEAL OF THE ,
' CERTIFYING SURVEYOR.
CHARLES K. CERTIFICATE LEGEND:
..• I HEREBY CERTIFY THAT THIS SURVEY WAS MADE UNDER MY RESPONSIBLE CHARGE • - PROPERTY CORNER ,
MCINTOSH µ° MEETS TME MINIMUM IECHMCAL STANDARDS AS SET FORTH BY THE FLORIDA OBSTRUCTED NO EVIDENCE
BOARD OF PROFESSIONAL SURVEYORS AND MAPPERS IN CHAPTER 5.1-17, FLORIDA
���� AD►UMSIRATIVE CODE, PURSUANT TO SECTION 472.027, FLORIDA STATUTES. FOUND OR SET 0
PROFESS/DIAL SURVEYOR , •r•. CONCR i
&!NAPPER/5302
--X-- = FENCE i
1692 COVINGTON LANE
ORANGE PARK.rt 32003 CHARLES K. McINTOSH R RADIUS
(PRONE)904-524-3411 REGISTERED SURVEYOR AND MAPPER / 5502 STATE OF FLORIDA L - LENGTH