1832 TIERRA VERDE DR DWAY24-0015 fs=n,- . BUILDING PERMIT APPLICATION FOR INTERNAL OFFICE USE ONLY
PERMIT# D1',vA`fiZ4- DO1-5
• i City of Atlantic Beach Building Department
iv 800 Seminole Road, Atlantic Beach, FL 32233 **ALL information required to process
-On ' Phone: (904) 247-5826 Email: Building-Dept@coab.us
Job Address 18 3a T i arc._ V e- 'de, �-r I Ve RE# 1679 I Z-S
Legal Description go }. a8 / .5611.4._ T►exT' pita-box 38 QPLY•ec a0 Aid- a:�sil-
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Valuation of Work(R:.lacement Cost) 2 rj 0 QQ c-'2 Heated/Cooled SF Non-Heated/Cooled SF
•Class of Work: In New ❑Addition ['Alteration epair [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) ❑ No
Describe in detail the type of work to be performed:
5o•l1- rock_ P1O SM- CO e dr,Ue- , wi+h 3F- Q,(}e"5ion IC.1c(- )•Ick , Gleo^in) 61'4
uPdcMAy pre, Iu,ast i i f\ G-tLeratrkce_ 1.,.;) 1-b IN-4"h G Ber4,f,1 SU;de_Ji fie S
Florida Product Approval# (For multiple products use Product Approval Information Sheet)
Property Owner Information Name (t„,, w Pci viAj1•U,1) 3-6Aiwt.def.„2Iice Phone —NO- 310 - IW'l
Address le --1-,eim veir3 e_ (}rive. City A-4-61A1 L f fr.) State p_' Zip 3a2,3--
Email
Email Owner or Agent(If Agent,Power of Attorney or Agency Letter Required)
Contractor Information Name of Company I yIS Cfer�-title (iceden5 Phone got-1_ 65s- 7373
Address J4( iii, �,Y(�_ �,7 f Vd J City u� Ve (,‘ State p( Zip -3,„ 2\
Qualifying Agent ..k.4j kC-S4_ht,,nt State Certification/Registration# 4O ?).55
Email c C ' JI S i, Gr t., 1-; Ve, yc—'.s 0ilk/1,j(Coll Job Site Contact Number ao!-•r_ s-16 - b q��
Worker's Compensation Insurer (46.r4-PC.ruQ4-((-(,I OR Exempt ❑ Expiration Date
Architect's Name ,l 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
INSPE TION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
�i ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT
Ic5Signature of Owner or Agent) ---s ----i'
(Signature of Contractor)
. I I
Si:ned and sworn to(or a.• med)bef. e m this day of Signed and sworn to(or a it ed)before me this I3 day o
UV
. . 'I by "0_ ,, II .4 01 )1 Atal Zo y __.ittj7,11,4,01_____
Signature of Notary _ V - Signature of Notary
[ ] Personally Known OR [ ] Produce Ide ification [ ] Personally Known OR [ ] Produced I ntification
L
Type of Identification: `" • Type of Identification: !L
I <►a° °&�. TONI GINDLESPERGER "'•711TTONIGtNDLEsPG4i21.47.hi,
`:•• ��.= EXPIRES:October 6.2027 ,.•/�`�.:� EXPIRES:October 6,2027
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I PROPERTY ADDRESS:1B2-I --- •
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E;RA VERDE DRIVE JACKSONVILLE.FLORIDA 32233 ��
JSURVEYNUMBER:FL.6'C.1.123
FIELD WORK DATE:743'21.1, REVISION DATE:SE::_:0 5J:_zU•q
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FLOOD INFORMATION: '— --'t_--„._ —�_
BY PERFORMING A SEARCH WITH THE LOCAL GOVERNING c^IJEC OF 1NTERESE
I MUNICIPALITY OR VNIIW.FEMA { ` `:'cC.l OVER DRAINAGE AND UTILITY
! GOV. L PROPERTY GO E3NINmA - EASEMENT `
LOCATED IN ZONE X.THIS PROPERTY WAS FOUND IN THE CI TY TO BE CF L- ti
ATLANTIC BEACH.COSIMUNIfY NUMBER 720CiJ5,DATED JL,03/73. —�
Cl.IENT NUMBER:L'AT 16.052 Ti
( 3--(DATE:tpi2t'2o o dcline.flor�ridanetworkrea{ty.com I '
IBJ eR:tV;:<R=.SUTSKYANDADRIAUA=OMIVAYA -- 904.613.64431 02
Zi 904,613,6443 �sH
'SELLER:MITCHELL AND PAMELA HA ESON 4 �,•
1 I CERTFIED TO:EVE KRASUCS<Y AND ADRIANA FO,btIN.AYA: -._-
LANCh1ARK T:TLE F:PST AMERICAN TITLE INSURANCE t
COMPANY,V;ELLS FARGO BANK,N-A 2930
This is page 1 cf 2 and is not valid without all pag �La n u)1 J ,, {,,< vac,.I •
_. _.__-__ e'. L4e mi- P1•56731-1915.Ftty 7:s._c91
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`___.� _ 119N h.fnal- L>f<s[M.+.Sur 1.F:Al t
1:An , 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 laws of the State of Florida, hereinafter referred to as "CITY" and
Mu.1-Fhct ' (ri. 10'Al +OA, T cyY1r.1 te- C(1 of Atlantic Beach, Florida, hereinafter
referred to as "USER".J
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 (,( ,'yU"e{{ Qr1t)L u.t-) .
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 be given by certified mail, return
receipt requested,to the following address i6 :f 7j E L& (/i ck dr'Ik,C /441114 C. t.'G-cii PI ,3A'1.?
• 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 the USER from any of the work herein under the terms of this permit and that all of said liabilities are
r-':
Y1 ss me y the USER.
/ I a
,
uL Date
Pro'lefty owner/Age t (signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL � /
The foregoing instrument was ackn_. wledged this 1 day of I'\ ter-E K , 20 Z 4// ,
by /A,\C-1:-14 IA e,J ` k N:1 i1 t n C ) (1 (printed name of Signer), who personally appeared
before me and acknowledged that he/she sign urpose expressed in it.
:•o.'`':''4. '. TONI GINDLESPERGER
r. .f.
: ,,u MY COMMISSION#HH 407122
/// :,.
'''..f+,'''g' EXPIRES:October 6,2027
Q'F fin:'
0 �-4 Department Approval:
Signature of Notary Public, St1 of Florida
[ ] Personally Known
[ ] Produced Identification (Type) c..' •L Public Works Department Date
Revision Date:05/09/2023
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 ( t3 3 -t ercc1 U L JC Jr i uk Permit Number
Contractor Information I
Company IL.C'.` `)‘, aNetA(-IV& &Cif-94A S Qualifying Agent IC V h 1— AJ\(,/ (
Address j 'i& A" • l )C. 6hid City Rh}, t,)#, l2 State Fl Zip 3 Og1
Phone 004-1— 4SS — 7.73 Email I6-4 'S , Cif .1-itJ.z,jr4 I y(n",1,0-P\
State Certification/Registration# IT"( a.) S5
Architect Phone Email
Engineer 1.-/), (4(1 hPlc(ur t1 Phone t "STC-- C`ca1 fS Email j 0)'6,n v'►'h,t,4 1 43) .ek i ao sC t'
Workers Compensation Insurer MGA(', cf.I,rC- +5✓Cti I J OR ExemptnExpiration Date CiAl/Ay
• 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 LOJ(An pei G(..--1-rj (Project Superintendent)
with (Company Name) )L 1).-k-Mj"S (IC 1(}e- (9 cl`4Cl� Phone Qoi-i-(o 73 73
• 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 3)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.
• ;, he Pu lic Works Director shall be notified 24 hours prior to starting work and again immediately upon completion.
P' � 1
� ��/��( ��� �l / Date �� � 1
l
Permittee(si/ned in pr sence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL `.--7
The foregoing instrument was knowledged this I _, day of I a I— (., ,20
by , n' ' /\\•-C l(-- --.__ - -.. =.'•_. me nd
(printed name o'Permittee) , ''.1•1:4‘N:."', TONI GINDLESPERGER
ackn wl ed that she igned the instrument voluntarilyfor the purpose ex vessel .. MY COMMISSION#HH 407122
g g p p p q�l �. EXPIRES:October 6,2027
?rf;F �..'•:
_I
\C-/ C ,, _ /( ..) [ ] Personally Known lam.
Signature of Notary Public,Statdlof FloridaC [ I Produced Identification(Type)
H:\Applications&Forms\Word Documents\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18