160 MAGNOLIA ST DWAY23-0012 ROCK �s
rs= Building Permit Application Updated 10/9/18
� City of Atlantic Beach Building Department **ALL INFORMATION
f3�r�' 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-Dept@coab.us IS REQUIRED.
Job Address: /(Q D/197,o16( — /7/,� CLC/% ermit Number: INA) R�Z — W I
Legal Description /0 -� / S 9G t 7 5-‘,4/7Aa S'it i RE# c. i ,4•A?zot6W/1 /7 Ft
Valuation of Work(Replacement Cost)$ 4 zoo,00 Heated/Cooled SF OuleS fir Non-Heated/Cooled i ar6/
• Class of Work: ❑New ❑Addition :Alteration ( epair ❑Move :Memo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial LYRdential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes gado
• Will tree(s)be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) 11J.N6'
Describetin d ail the type of work to
be erformed: /t
�/(// `ell/ ./4 y y ,
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name t7�?'#e c // cSCyti Address
City LAg, .. ' •47 Stat Zip 'F' 2. 3 Phone 7Z7 ///S--- .c_F_W
E-Mail }2/1O co //7 -0 c.'/0/"-,A cc"l
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Qualifying Agen
Address City State Zip
Office Phone Job Site Contact Number
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 work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that al ork will be performed to meet the standards of all the laws regulating
construction in this jurisdiction. I understand that a se arate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS,TAN ,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 yther governmental entities such as water management districts,state agencies,or
federal agencies. 1/
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 Fl► ANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECO zzAjefOUR E OF COMMENCEMENT.
/•
(Signature f Owner or Agent) (Signature of Contractor)
Sign:d and sworn to(or affirmed)before me day of Signed and sworn to(or affirmed)be e me this day of
/i'.!./ - ,by ::'II ." I fib. , ,by
I7L'�aiMr
(Si:natur• of Agri (Signature of Notary)
Alkean . ... ".•
r
[ ]P sonally Known OR = � I ERIN MARIE STEHL
6' • MY COMMISSION N HH 290616 ]Personally Known OR
roduced Identification "•;",;:,....'.'"•,:g/ EXPIRES:October 14,2026 ]Produced Identification
�CF '` �-
ype of Ide fication: : ''� ype of Identification:
.,rte v..
Owner Builder Affidavit **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
/` 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 ISSUANCE OF AN OWNER-BUILDERS PERMIT.
Job Address: /6 CJ !' 2Ke7/z C( � � 'ef'c/ /2 ..72.23,?
Owner Name: -I1/ 'f / 2 SCi/t/ Phone Number:
Mailing Address:• - ' /I e, .S`// City: r 'ili ii-XU. State: �L Zip: ;j j
-- -
Notarized Signature of Owner e7A7i1/ �—
of
The- regoininstrument was ackno+-.ged before me this day of , 20 __5in the State of Florida, County
LV (-- 414
Signature of Notary Publi
Personal) Known R oduced Identification
. ,... ERIN MARIE STEHL [ ] Y I
j..;`;a MY COMMISSION*HH 290616
•7fq,c" EXPIRES:October t4,P026 Type of Identification: /cJ`__
Updated 10/24/18
,-I lAn ,, REVOCABLE ENCROACHMENT AGREEMENT
.pe, City of Atlantic Beach **ALL INFORMATION
800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
._______A)
IS REQUIRED.
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
r"S Ma. se)4 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 P/ace ‘20,C/ i ri 60,/ Li.vcs� .
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 shall beVven y ce/rtifi ail,return
receipt requested,to the following address /66 1/115,5,01 f„ S'TJ '/r,2,sq% "73223 5
• 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 harmles by the USER from any of the work herein under the terms of this permit and that all of said
liabilities - - ereby a sumed by the USER.
�� J, At:, Date g Gl�t
' 1//a3
Property 0 r/Agent(si ned in presence of NotaryPublic)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this 2_4/ day of Ur cLFc. V\ , 20
IP
by ----.. 40. ..(Y\ S Q. Q `• . • CN who personally appeared before me and
printed name of Sign:r)
ackno I-•ged that;L,,s • gned the instrumen :luntarily for the purpose expressed in it.
s _ Department Approval:
Signa of Notary Public,State .(�.j ida ,,pyo NI GINDLESPERGER
PersonallyKnown : ,,,
[ ] ;*: ,,: MY COMMISSION#GO 353178
{]"Produced Identification(Type) t :"�•.. EXPIRES:October 6,2023 Scott Williams, Public Works Director
"""Q f;°`" Bonded Thru Notary Public Undervrriters
H:\Applications&Forms\Word Documents\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
160 MAGNOLIA STREET, ATLANTIC BEACH, FL. 32233
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-ALL ANGLES AND DISTANCES SHOWN HEREON ARE BOTH RECORD AND MEASURED UNLESS OTHERWISE NOTED
SHEET 1 OF 2(SKETCH OF SURVEY)-SEE SHEET 2 OF 2 FOR LEGAL DESCRIPTION,AND OTHER SURVEY RELATED DATA.SURVEY IS NOT COMPLETE WITHOUT ALL SHEETS
The survey map & report or the copies thereof are not valid without the digital signature
and seal of a Florida licensed surveyor and mapper
Date of Field Work . 10-13-2022
Drawn By: Glenn ,x� r_
Order#: 198426 Le jr El!..47.1r,,❑
a
Last Revision Date: None �.!.'ti 1 5scx varrw1. Vu V
Boundary Survey prepared by: LB8111 a •? o •.0�a . * castewor..� ,�.
NexGen Surveying, LLC ; EXGEN
°;•. ..4, Kf _ cum
561-508-6272 O."<^Ct.'i�5a i .�r..4<
1421 Oglethorpe Rd SURVEYING, LLC.
West Palm Beach, FL 33405