1207 SEMINOLE RD POOL22-0023 TREE AFFIDAVIT q;\
TREE & VEGETATION AFFIDAVIT FOR INTERNAL OFFICE USE ONLY
City of Atlantic Beach PERMIT#4 oLZZ —OOZrr? Community Development Department
800 Seminole Road Atlantic Beach,FL 32233
-DR 9 (P)904-247-5800
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SITE INFORMATION f
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ADDRESS t,,�V ( „Se./1"(r"/C) e 461‘. /�G/2 /7
SUBDIVISION S e' Ick , \ of-tack. 3 n I`{ I BLOCK l LOT
RE# 1 / I E:39 z- O oo o ❑ RESIDENTIAL ❑ COMMERCIAL El OTHER
APPLICANT INFORMATION
NAME 004 LAS W , Gre4c, Id PHONE# (94 S65
ADDRESS /, (J 7 `5e.4/1.1)de /)cy, CELL# i•- 4Q
L/
CITY /(7/4i /4L 13C_ 7 ' STATE /11. ZIP CODE 3x233
EMAIL CS -ee(S. \i-g co/i 5/. JU CA OWNER ❑ LEGAL AUTHORIZED AGENT
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 HEREBY CERTIFY THAT ALL
INFORMATION PROVIDED IS CORRECT:Signature of Property Owner(s)or Authorized Agent
1-0 ,LO 7
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SIGNATU E OF APPLICA I T PRINT OR TYPE NAME DA
SIGNATURE OF APPLICANT(2) PRINT OR TYPE NAME DATE IN
Signed and sworn before me on this 1 day of v ep--t-- ,202 z_by State of .F
County of
r
Identification verified:
....---X
Oath Sworn: ❑ Yes ❑ No _ _ __
�A N'Yl1Rlf f11�'.A'lP1lN _ T:›A----"- --
-,1-1,: :°';'.',•;:,
•i ONI GINDLESPERGER Notary Signature
'':"' e, • MY COMMISSION#GG 353178
•.,, ;�. EXPIRES:October 6,2023 My Commission expires
'• Bon,ed Thru Nott Public Underwriters
I :MJF F2 �E' ry
04 TREE AND VEGETATION Aro..01.2018