2317 SEMINOLE RD ROW23-0030 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 Address Z 3 17 Sthq n0lG coin WI" c , r-L Permit Number �INo.1)Z J- UDsO
Contractor Information (I
Company NSI Pro Qualifying Agent J3rc mac. Purc,Zlk
Address (gc)I Fri City State FL Zip 3ZZ oZ
Phone (-1oy - 3;5 - )-7-7 G Email R'pLdrit �'i Ail ?ro AS wI+",11Z',-
State Certification/Registration# / 0 Cq .V4
Architect N/A Phone N`6 - Email Iv f f{
Engineer /Ek Phone !v l/` Email N/Pc
Workers Compensation Insurer TAP ,?ef1( /-i OR Exempt f Expiration Date J j /3 2?,
• 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 fS r 'c. - F..-c4' (Project Superintendent)
with (Company Name) Phone "1"/ - -/7 to - /$G'
• 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 30 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 prior to starting work and again immediately upon completion.
Date $/ye/ 5
Permittee(signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL
The foregoing instrument was acknowledged this i Ig day of A 9 vs ,20 23 ,
by rC,e— P(/rW I I` ,who personally appeared before me and
(printed name of Permittee)
acknowledged that he/she signed the instrument voluntarily for the purpose expressed in it.
KIM SELLERS
=•' •; MY COMMISSION#HH 358266
4.4":;‘,. • EXPIRES:February 5,2027
[VPersonally Known
Signature of Notary Public,State of Florida [ j Produced Identification(Type)
H:\Applications&Forms\Word Documents\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
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