1963 COLINA CT DWAY23-0040 Building Permit Application
Updated 10/9/18 **ALL INFORMATION
City of Atlantic Beach Building Department HIGHLIGHTED IN GRAY
IS REQUIRED.
800 Seminole Road, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address: 16( (.0 ) LA i l r P ' r? �fi Permit Number: . P`-/2.3- 00 4
Legal Description 31- ' / , /1 v " 4 1' ; RE# I4 �/O — 4.3(4
Valuation of Work(Replacement Cost)$ Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition ❑Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ElCommercial ❑Residential
• If an existing structure,is a fire sprinkler system installed?: ❑Yes ❑No
• Will tree(s) be removed in association with proposed project?❑Yes(must submit separate Tree Removal Permit) ❑No
Describe in detail the type of work to be performed:
• r\::74 \/.0
Florida Product Approval # for multiple products use product approval form
Property Owner Information
Name Address
City State Zip Phone
E-Mail
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 Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer �/�' _OR
Exempt ci Expiration Date /7D
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
OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
YOUROTCOMMf NC ENT.
A._
(Signature of Owner or Agent)
ned and sworn to(or affir �j •j before me this Z day of
`S 20 23, ••y 1�'� e' s• 4 ak . h
w_ 1410,4#41 —�J .
— r° • GINDLESPERGER
.n : - COMMISSION#GG 353178
�'r*�7c; EXPIRES:October 6,2023
For-e�° Bonded Thru Notary Public UnderNriters
(Personally Known OR '
[ ] Produced Identification
Type of Identification:
/. .-----
(Signature of Contractor)
Signed and sworn to(or affirmed)before me this 2 i day of
A y , 14 Z) ,by Is \ Le A-\,- II
(Signature of Notary)
,11,,E TAB ITHA MESHAW
Notary Public-State of Florida
'' Commission N Hli 22744
)(,,]Personally Known OR c.,4;,-;''',;e3:1 My Commission E�tpires
[ ]Produced Identification -''%°',;;''
July 22, 2024
Type of Identification:
:< 1 RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
City of Atlantic Beach HIGHLIGHTED IN GRAY IS
800 Seminole Road,Atlantic Beach, FL 32233 REQUIRED.
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
Job Addressr1J J.
Permit Number
Contractor Information
Company 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 12
• 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 City of Atlantic Beach or Florida Department of Transportation Standards and be performed under the
supervision of (Project Superintendent)
with(Company Name) -- Phone
❑ 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 exercise or attempted exercises by the holder of the aforesaid rights and privileges.
• The Public Works Director shall be notified 24 hours rior to starting work and again immediately upon completion.
�� 1�/l�,.z, ✓ ( � `� ' Date � Z 7/7 3
Permit of a(signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this 7 7 day ofS�(N , 20
Z.L`Zi7 , I
by �� ( ` ,who personally appeared before me and
(printed name of Permittee)
acknowledged that he/she signed the instrument voluntarily for the purpose expressed in it.
N Per-••- .• - - •f NotaryPublic,State
P -HABIT■e
of Flo• rida [ ] Produced Identification(Type) �': ESHAW
ni o ary Public-State of Florida
Commrssron # HH 22744
°�„,• My Commission Expires
July 22, 2024
FOR INTERNAL OFFICE USE ONLY
riL.:1,y j.J,' TREE & VEGETATION AFFIDAVIT
City of Atlantic Beach PERMIT#
1 cI Community Development Department
\', 800 Seminole Road Atlantic Beach,FL 32233
/� (P)904-247-5800
"'f)s,s/r/
ADDRESS
1 � () ,,
SUBDIVISIONBLOCK LO
i r, 9T
!r'` !'te' t Ir- ,
, (�
RE# '�� RESIDENTIAL [3 COMMERCIAL OTHER
APPLICANT INFORMATION
NAME _ 1 ` Y ,, / t PHONE#
a, I�
ADDRESS h� i / CELL#
r-
•
•
CITY STATE ZIP CODE
EMAIL C]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 preapplication 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.
/HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IS CORRECT: Signature of Property Owner(s)or
Authorized Agent
SIGNATURE OF APPLICANT PRINT OR TYPE NAME DATE
)( ___5' ..ik, 'Ut..c_ a____ I
S 'e e✓� K_ /�f / P I:17 ca v l 1 t?'-2--2- lZZ
pk
County of L ,0\i'a-' ? —, — A
Identification verified: L
1110 i
Oath Sworn: [3 Yes ❑No
IP 4111b.. do
nx?us•. TONI GINDLESPERGER Notary Signature
*` MY COMMISSION#GG 353178
k*:„ci
EXPIRES:October 6,2023V(=,�: P`• My Commission expires
I
' Jr?'' Bonded Thru Notary Public Underwriters
04 TREE AND VEGETATION VI 03. 7.2018
,FFIDA
REVOCABLE ENCROACHMENT AGREEMENT **ALL INFORMATION
City of Atlantic Beach 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 existing under
the laws of the State of Flo!' a,hereinafter referred to as"CITY" and
/P / u% . - of Atlantic Beach,Florida,hereinafter referred to as"USER".
o
�, 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 °ii' ,`i%
CITY OF ATLANTIC BEACH
I . : • it-„, ,
800 SEMINOLE ROAD
j ATLANTIC BEACH, FL 32233
(904)247-5800
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
I 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 $110.00 Fee.
JOB ADDRESS
OWNER or CONTRACTOR (Print)
Signature LL ate
C? — Z — ), a 23
POINT OF REVERSE CURVATURE S'B'j4
�
�S MAP SHOWING SURVEY OF � j
Go 4\11 !/I LOT 30, SELVA NORTE' UNIT ONE, AS RECORDED IN PLAT '
,I• BOOK 39, PAGES 94, 94A, AND 94B OF THE CURRENT 11
\1°%'' ' \ PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA. \ IV
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1 0.2' S89'08'46"W 175.00' D.s 1.31472� `�
i (S89'30'48'W 176.18' FIELD) IFOU
ND I/ ON NOTES: SELVA MARINA UNIT NO. 12-B
1. THIS IS A BOUNDARY AND TOPOGRAPHIC SURVEY
2. BEARINGS ARE BASED ON SOUTH 42'37'55" EAST
AS PER PLAT
3. EASEMENT AS PER PLAT.
4. NO BUILDING RESTRICTION LINES AS PER PLAT. L-
5. BENCHMARK USED IS A PK NAIL AND DISK SET ON A
TRANSFORMER PAD AT THE NORTHEAST CORNER OF THE
PROPERTY. ELEVATION=10.89 (N.G.V.C. 1929)
THIS PROPERTY APPEARS TO LIE IN FLOOD ZONE
'V (AREA OUTSIDE OF 0.2% ANNUAL CHANCE
FLOODPLAIN) AS WELL AS CAN BE DETERMINED
FROM THE FLOOD INSURANCE RATE MAP No. THIS SURV-Y WAS MADE FOR THE BENEFIT OF
12031C0407H, REVISED JUNE 3, 2013 FOR DUVAL SI WHEN .MURPHY & PATRICIA K. MURPHY.
COUNTY, FLORIDA.
'NOT VALID WITHOUT THE SIGNATURE AND THE DO W. BOATWRIGHT, P.$.ltic '�
ORIGINAL RAISED SEAL OF A FLORIDA LICENSED
SURVEYOR AND MAPPER.' FLORIDA LAC. SURVEYOR•,and,MAPPIIIII No. LS 3295
BOUNDARY WITH IMPROVEMENTS UPDATE — MAY 22, 2015 FLORIDA LIC. SURVEYING & MAPPINi, BUSINESS No. LB 3872
CHECKED BY: BOATWRIGHT LAND SURVEYORS, INC. `~DAZE: '
DRAWN BY: Cl- JULY 2, 2004
FILE: 2015-569 I 1500 ROBEtt1 DRNE, JACKSONVILLE BEACH, FLORIDA 241-8550 I SHEETS OF t
tIIIA REF. 2004-0882 -- —
NOTICE OF COMMENCEMENT
State of I-1 !�( Tax Folio No.
County of To Whom It
May Concern:
The undersigned hereby informs you that improvements will be made to certain real property,and in accordance with Section 713 of the Florida Statutes,the
following information is stated in this NOTICE OF.COMMENCEMENT.
Legal Description of property being improved:
•
• mO00a) c o
Address of property being improved: O c 2 o "
Oz -< a
--Ivro -+ No
General description of improvements: _ p -G = o- N
j E F Qco
Owner: 1'' Address: _ O o
Cn
cnN '
Owner's interest in site of the improvement: --o,
o mw 0
Fee Simple Titleholder(if other than owner): — o o 0
m
Name: -- n
53m
Contractor: 0 rn
rn
Address: c) -0
0 rn
Telephone No.: Fax No: A u
Surety(if any) 0
c
Address: Amount of Bond$ _ D
Telephone No: Fax No: _
Name and address of any person making a loan for the construction of the improvements
Name:
Address:
Phone No: Fax No:
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may be served:Name:
Address: Telephone No:
Fax No:
In addition to himself,owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 713.06(2)(b),Florida Statues. (Fill in at
Owner's option)
Name:
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a different date is specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
X r
Signed:L? k. Date: 2a2..3
Before me this ---' day of Z in the County of Duval,State
Of Florida,has personally appeared epk L U!', h
Notary Public at Large,State of Florida,County of Duval.
My commission expires:
Personally Known: •it7AL or
Produced Identification:
R'v; A� TONI GINDLESPERGER
Tau leta� ;,. MY COMMISSION#GG 353178 am: . _
EXPIRES:October 6,2023
IF".;'.°`° ' Bonded ihru Notary Public Underwriters