559 SELVA LAKES CIR DWAY23-0005 -, rte
BuildingPermit Application
` Updated 10/9/18
;.
City of Atlantic Beach Building Department **ALL INFORMATION
\•1. i.; 4r��, ` 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.us
ISREQUIRED.
Address: .�U.q � `jam £ E�J(�Z 3 -(U05
.{ G f/'' Permit Number: `
Legal Description -/ l-7'Zs-'t4(' /iVt.Ll. f Li,,r'12'L.1-4 3. RE# 1-no77_ s -L?--
Valuation of Work(Replacement Cost)$ !/)Li L4 Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ENew ❑Addition1CAIteration ERepair EMove ❑Demo ❑Pool DDWindow/Door
• Use of existing/proposed structure(s): ❑Commercial eKesidential
• If an existing structure,is a fire sprinkler system installed?: EYes Rio
• Will tree(s) be removed in association with proposed prpiect? EYes(must submit separate Tree Removal Permit)
Describe in det,--).4ail the type of work to be performed:
an c-{:eAr (Akaikkiet,44- \J......4-ivedix. t y I igriNg-e---s-
Florida Product Approval# for multiple products use product approval form
Property Owner Information
l£Name SOj 6r.,G(v+,-./ Address S4 14I2 Lel
r -
City A . V . State FL Zip 3223 Phone
E-Mail
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information 1y /
Name of Company )411e/if, -7-1t, Qualifying A ent r� 4,
Address K 0 R , City A. D . State F1 Zip 32J
Office Phone Q09' 377 722 e Job Site Contact Number
�
State Certification/Registration# E-Mail t(. l/� i4 b'bc-r o , (Q',.
Architect Name&Phone# _
Engineer's Name& Phone#
Workers Compensation Insurer /44,\-7111,../51— OR Exempt❑ Expiration DateVii/Z-3
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
TO OBT IN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECO,
NG YJU NOTICE OF COMMENCEMENT. '�
l e� �-�
gnature of Owner or Agent) (Signature of Contractor)
S' ned and sworn to(or:ffir :d)before me t . day of A Signed and sworn to(or affirmed) before me this 13 `lday of
��C�(� , I _ , b Oh =- .*
e q r\. 3-. a o a 3 ,4 P i �` 411' (r
'_nature its (Si:na re of N.ta'v__
1111 •‘;•14(7,5.';,, TABITHA MESHAW
[ j Personally Known OR PersonallyKnow o ,m, t,=Notary Public-State cf Florida
•.';�Yo'' ONI GINDLESPERGER 'E commission, i Hn 22744
[ 1 Produced Identification -'4:%."••••..0-, ] Produced Identif.. it 0.r My Commission Expires
f fib .�_ MY COMMISSION 353118 July 22, 2024
Type of Identification: Ib .pe of Identificati.j:
°FOF,F;°, Bonded'Nu Notary Public Underwriters
.-+-=vi•;r RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
'' ,A, • ' Cityof Atlantic Beach
.,�.`ryi 'HIGHLIGHTED IN GRAY 1S
• e • - 800 Seminole Road, Atlantic Beach, FL 32233 REQUIRED.
�, /
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
Job Address -..5:5711 iaft[ Lkj .6*.
Permit Number
Contractor Information
Companyj . V/ /tlli L . Qualifying Agent Mtal-e..--1/11-1,1149
Address -/ o, 6 /1t fr+" fel City / MM,OeicYL. State FL Zip X33
Phone log 31t 77-Z4 Email ;n 4 e 14 WI,1P7 . edt^,
State Certification/Registration #
Architect Phone Email
Engineer Phone Email
Workers Compensation Insurer t F1 ` ,7 ,jc t OR ExemptnExpiration Date f,✓ eZ 3
• 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 met City of Atlantic Beach or Florida Department of Transportation Standards and be performed under the
supervision ofll (Project Superintendent)
with (Company Name) )4 114/1) 1t• Phone *if 7-77 /!?O3
• 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 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 ex:rcise or atte 'pted _ ercises by the holder of the aforesaid rights and privileges.
• The •...;,..• War s Di - or..'-II be not.-ed 24 •• - tart g work and again immediately upon completion.
—.., Dateyil 3/1-3
P- mitte- (sign;• in p -•ence o' otary P•lic) k
STATE OF F/strument
:•A,COUN O• DUVAL '
The foreg.• .-acknowle. 4 ( _3 t� day of ,20
by • • 1/,',,,Z �` --- whope .•_II
y appeared :-fo me and
.rinted name of Permittee) `'
Y TABIT' A Iv. SHAW
ackno edged that he/she signed the instrumen . . the purpose expressed in it. I ?'.a P B`' No -y P i o•St-'r. of Fior cti
. . �1 I& Co • ission 4 H . 22744 4
�,tia.Y"' TONIGINDLESPERGER -'Iii''Pc • mission E •if&s t#
a'•c� �Y '` �� 22, 2024 t`
J'— 1:1174..,,,,
.`��_ • my
COMMISSION#GG 353178 .0....4•••••t..
:•: uiw • - - • • tuber 6,2023 Personally Kno n Iply
Signature of Notary P••••-'1',' `;•° 10 -nouu pi NotaryPubkUndersu ers I Produced Identificat• ype)
H:\Applications&Forms\Word Documents\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
�S,,' ` REVOCABLE ENCROACHMENT AGREEMENT
i''. ,11',:;.* > City of Atlantic Beach **ALL INFORMATION
'o A : HIGHLIGHTED IN GRAY
f 800 Seminole Road,Atlantic Beach,FL 32233 IS REQUIRED.
»4
i
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida,a municipal corporation organized and
existing under the laws of the State of Florida, hereinafter referred to as"CITY" and
h + n 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 ¶ %(e,, p4GG.fr,,,„),- .
Any facility maintained, repaired, erected, and/or install d 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 _4 1
• 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
iabilities are hereby assumed by the USER. 77 7
/i,' Date l L C� Z_ 3
Pr. .a caner/Agent(signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL �f
The foregoing instrument was acknowledged this— ��..j�day of ......\ C1-<1 ,20
by O k iTh C—ThACLI P0.r1 ( ,who personally appeared before me and
ted name of r) •
ackn. •ged that he/s :ne, the instrument voluntarily for the purpose expressed in it.
f
• •Nowilmii---
-4114
Department Approval:
Signature of Notary Public,State of Florida :ot .3e� ,, TONI GINDLESPERGER
[ I Personally Known MY COMMISSION#GG 353178
[ 1 Produced Identification(Type) `_ ,� ; µ,,,- .-.,. EY,PIRES:October8,2023 Cott Williams, Public Works Director
$I ended Thru Notary Pubiic Underwrites I
H:\Applications&Forms\Word Documents\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
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�I 800 SEMINOLE ROAD
-, `�` ATLANTIC BEACH, FL 32233(904) 247-5800
`L , 9 .
SURVEY AGREEMENT
NOTICE
All new projects creating more than 250 Square Feet of impervious surface or requiring on-site storm water
retention, including swimming pools, will require pre-construction and post-construction topographic surveys,
as required by COAB, Section 24-66 and described in Bulletin 2-18, Surveys. The surveys must be new
original documents, from a licensed surveyor, signed, sealed, and dated.
Other small projects, such as fences and construction less than 250 SF,will not require a new topographical
survey, but a current original-size survey with all relevant details is still needed. These surveys,when included
as part of a building permit application,must be complete, up-to-date, and original size and scale, as produced
by the surveyor.
Copies of old surveys lacking details or copies not of original size cannot be accepted. Building permit
applications with unacceptable surveys cannot be reviewed and the application will be returned to the
applicant.
Thank you for your cooperation in this matter.
AGREEMENT
l have read and understand the Notice above and affirm that the outdated survey I am
submitting is still accurate and complete, and all structures and impervious surfaces on the
property are shown on the survey.
I further understand that, if the survey is found to be inaccurate or incomplete, a $50.00 Plan
Resubmittal Fee will be charged; or if the permit has been issued, a Stop Work Order will be
posted with the associated $110.00 Fee.
JOB ADDRESS ssq ; yit, (acil- s ,l
OWNER or ONTRACTOR (Print) 3he-\ ��/ee., ,'
Signature / D� f Date Z C„ 7 ,.,_3
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5U,pVEY /i_m-94. AreFfor aryva atc nrmv./i G/NAL SURVEY 2-5-87 r+oM'Mxwa ACs/ADAM•
g7"Ii+.� COMFY THAT THIS SURVEY, PERFCRWEC UNDER MY RESPONSIBLE DIRECTION MEETS THE
"' ^'i" 1oA`ALSTANDARDS FOR '—AND SURVEYORS 1N ACCORDANCE WTH CHAPTER 61C17-S. FLORIDA ' • FaIW Co+AEtE
...e- -.. - CODE (PURSUANT TO SECTIdN 472.027, FLORIDA STATUTES), ANO FURTHER CERTIFY THAT • !U•FOUNo 9FW
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