DOG s ,,,,; DOG-FRIENDLY RESTAURANT PERMIT APPLICATION (Per Ordinance No.95-I0-102)
. 0 y ` ins
JS S,414 , Ci
f' ty of Atlantic Beach
ar Community Development Department
uA 800 Seminole Road Atlantic Beach,FL 32233
r;�/V (P)904-247-5800
AUTHORIZED AGENT AFFIDAVIT
NAME OF ESTABLISHMENT I qg5 Coffee FL DHR#
LORA DkSO()
AUTHORIZED AGENTS NAME(PRINTED) is hereby authorized to ACT ON BEHALF OF
i4/e. t<1-e J ,the owner(s)of those lands described within
PROPERTY OWNER'S NAME(PRINTED)
the attached application,and as described in the attached deed or other such proof of ownership as may
be required by the City of Atlantic Beach,Florida in applying for a DOG-FRIENDLY RESTAURANT PERMIT.
By 0I1
I
A'�U' OF PROPERTY OWNER
4 r—
e L-�.+e,l
PRINTF NAME OF PROPERTY OWNER
STATE OF C`,. r i S a
COUNTY OF (7i Vim'
Signed and sworn before me on this g2r� day of 7��‘.4.04ska ,20 2 4
By ((9\ 9c2r4'
Identification verified: ft_ OL E (e.39 9 01'7 — D0.62 ` 0
Oath sworn: ./ Yes No
P-Pc,--
NOTARY SIGNATU 1 .�'jr'iu' . COLETTE.1 POORE
1 &L -"#:: Notary Public•State of Florida
MyCommission expires: � kk ' Commission M HN 056368
p ,.,or r`•, My Comm.Expires Nov 12,2024 P
Assn. I
26 DOG-FRIENDLY RESTAURANT PERMIT APP 02.13.2019