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1912 Oak Circle DWAY22-0042 TREE AFFI ,::5"''`' ,. TREE & VEGETATION AFFIDAVIT �w r1 City of Atlantic Beach Community Development Department PERMIT# 800 Seminole Road AtlanticC Beach,FL 32233 FOR INTERNAL OFFICE USE ONLY fArijo� (P)904-247-5800 SITE INFORMATION ADDRESS iq OJI Z 6rr`)L""�-- Lll / SUBDIVISION AV4 Y1(,ri� VA/T 17� A- BLOCK LOT 1/ RE# 1115-yRESIDENTIAL ❑ COMMERCIAL ❑ OTHER APPLICANT INFORMATION NAME 1 0 y✓\ COO 1( PHONE# Z Y7- 77Cr ADDRESS IQ a ©i4 . Gj l CELL# CITY6,d ___2 STATE FL ZIP CODE 3ZZ3 ) EMAIL `0 p (( AIWA0 Irt , apm &OWNER 11] LEGAL AUTHORIZED AGENT ri I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation", of the Municipal Code of Ordinances for the City of Atlantic Beach Florida and/or I have participated in a pre- application meeting with the Administrator of those regulations. Subsequently, I affirm that no regulated trees and no regulated vegetation will be damaged, destroyed and/or removed from the above-described property and/or adjacent properties including right-of-way. I H :Y CERTIF THAT A INF 4 RMATION PROVIDED IS CORRECT:Signature of Property Owner(s)or Authorize• A•-nt ` � (+ v or ITh Coo tz-- 4 /v 1{J SI ATURE OF L ANT PRIN OR TYPE NAME DA L SIGNATURE OF APPLICANT(2) PRINT OR TYPE NAME DATE Signed and sworn before me on this9day of LI ?O? e_by State of l Cou •y of • Identification verified: ` Oath Sworn: ❑ Yes ❑ No •.„,;., TONI GINDLESPERGER Notary Sigh-stare / A'; ' MY COMMISSION#GG 353178 • • ' ::,,:::•;•1,7- EXPIRES:October 6,2023 My Commission expires ?anded Thru Notary Public Underwriters 04 TREE AND VEGETATION AFFIDAVIT 03.01.2018