1915 N SHERRY DR DWAY24-0013 -yT BUILDING PERMIT APPLICATION
JS>s� .�\ FOR IINTERNAL
�OFFICE USE ONLY
City of Atlantic Beach Building Department PERMIT# v]±}y z4 - 00 L;
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800 Seminole Road, Atlantic Beach, FL 32233 **ALL information required to process
si' Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address ) I / ' / f -bk.) YE_ fJ o - 7 RE# i,2020 — 0322
Legal Description 7•-Vo (Qq- — a-9 E LVp /Wi WO IT' 10-C /v
Valuation of Work(Replacement Cost) /✓ Heated/Cooled SF Non-Heated/Cooled SF /vl�t
•Class of Work: ❑ New El Addition ❑Alteration ,®Repair ❑Move ❑Demo ❑Pool ❑Window/Door
•Use of existing/proposed structure(s): ❑Commercial.. Residential • If 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) Kj No
Describe in detail the type of work to be performed:
g- U/1 /t' P--q°01( FXl c77,0 ,��IV�I�JyoLJ.
Florida Product Approval# fl J� (For multiple products use Product Approval Information Sheet)
Property Owner Information Name leyyl * (MN I?JAs& YLL Phone q01/ y�t y
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Address / ?t v lY t/2 1)12.1 t/t /� City alae)?C �f�'4 StateFL Zip 3a..G f
Email .tz,1. (i/CC q ft(.Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information Name of//Company C,OLJL-tif ( j)cI'� c', Phone 9 6 j-
Address S•../ C'/Jf^L- /�-Q� 1 City�/J']` , Poj/State FL-Zip � -O a_
Qualifying Agent ,), ,T4A)1 E(_ CIeOWL_ State Certification/Registration# /.5-FG 9
Email y, Job Site Contact Number 9 6t— ��q— �I39
Worker's Compensation Ins rer C U`•' cfG�p OR Exempt El Expiration Date
Architect's Name j)� Email Phone
Engineer's Name Email Phone
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 city/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 YOU PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT
MUST BE RECORDED AND POSTED ON THE SITE OF THE IMPROVEMENT BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
/ (Signature o Owner or Agent) (Signature of C•Tactor)
Signed and sworn to(or affirmed)bef.re me this I day of Si ned and sworn to(or affir ed)before me this! Z day of
,?1) ,by A `.�L L-L , 67y b 41 /EL , C711
�Gw
Signature of Nota i Signature of Notary
,[•'(]Personally Kno n OR [ ] Produced Ide ification k] Personally Kno n OR [ ] Produced I•entification
•
Type of Identification: � Type of Identification:
•
•.i N ;:. KIM M.HU(iritS
Commission#HH 455469 ""°� • KIM M.HUGHES
Expires October 25,2027 = Commission#HH 455469
'•+.FOF P Expires October 25,2027
s=vi;, RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION **ALL INFORMATION
'4
, City of Atlantic Beach HIGHLIGHTED IN GRAY IS
7, -1 800 Seminole Road, Atlantic Beach, FL 32233 REQUIRED.
''i L;f15%
PERMITTEE RESPONSIBLE FOR NOTIFYING,YI811 AND OBTAINING UTILITY LOCATES
Job Address J WS Sfl E l V /00/2X] Permit Number
Contractor Information /�� .\
Company CPO �
�( / c"r, �f -.3 • Qualifying Agent h41 CR6
Address / C/LINP"' /11-) CityclAC6 V tateP Zip 3 P-•a
Phone / o 1- a-1 — -D.--- 3 7 Email e iA)L Jo�i2 - - ,C°w-'
State Certification Registration# J 6
Architect Phone Email
Engineer ' Tl ,_ 1 Phone Email
rWorkers Compensation Insure (1S -IAJ ‘,2C?LA P OR ExemptEExpiration Date
• 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_q Atlantic Beach or I.rida Department of Transportation Standards and be performed under the
supervision of III/10 C/a life (Project Superintendent)
with(Company Name) t l • 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 7 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.
• Th• • blic Works Director shall • notifie. 4 hours prior to starting work and again immediately upon r,Ompl ion.
✓ / / V// ,�/i ////�/_ Date
Permittee(signed in : esence of Not ry • • I j
STATE OF FLORIDA,COUNTY OF DUVAL
The foregoing instrument was acknowledged this / day of ,20 ly ,
by �i IA)/ CP-0-ba ,who personally appeared before me and
(printed name of Permitt e)
��"'° KIM M.HUGHES
acknowledged that he/she signed the instrument voluntarily for the purpose expressed in it. '• ,, � Oi� ;nn#HH 455469
^'. .e Expires Or!ober 25,2027
421. ]�]Personally Known
Signa ure of Notary Public,State of Fl da [ ]Produced Identification (Type)
H:\Applications&Forms\Word Documents\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
REVOCABLE ENCROACHMENT AGREEMENT
City of Atlantic Beach **ALL INFORMATION
800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
existing under the jaws of the State of Florida, hereinafter referred to as "CITY" and
CRPI i S Co/Oc-P-- ,- C• 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 OM Ulf/, 1L vf,fr �
Any facility maintained, repaired, erected, and/or installed in the exercise of the privilege gr nted remains subje to
relocation or removal on thirty(30)days' notice by CITY to USER,said notice tt4 USER shall be 4.iven by certified mail,return
receipt requested,to the following address SS/ AO/ Ja0/ c. v 81M-`QrA.c//j
• 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 liabilities are
hereby assumed by the USER.
_ Date ' /0/
Property 0 er/Agent(signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL
The foregoing instrument was acknowledged this /1/4 day of , 20
by H eie- i s-E/L (printed name of Signer),who personally appeared
before me and acknowledged that he/she signed the instrument voluntarily for the purpose expressed in it.
9ZYL,/
Department Approval:
Signa-ure of Notary Public,Stat'of Florida
Personally Known
[ ]Produced Identification(T pec....... t>GFIES Public Works Department Date
terCTKIMM:11
:•1 Commission 0 HH 455469
October 25,2027
Revision Date:05/09/2023 -';,� Expires
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