1820 Tierra Verde signatures.pdf CITY OF ATLANTIC BEACH 1/
CONSTRUCTION PERMIT WITHIN CITY RIGHTS OF WAY AND EASEMENTS
800 Seminole Road 904-247-5800
a�h' Atlantic Beach,Florida 32233-5445 Fax 904-247-5845
PLEASE SUBMIT(3)COMPLETE SETS OF PLANS WITH APPLICATION.
Date 4/A d PERMIT#
Job Address j/y ZO �.5ve4,, yfjeaE ISSUED BY THE CITY / Q
Permitee: (/1?r, Telephone#
Permittee Address:
Requesting Permission to Construct: /' A
Location: (Reference to Cross-Street)
1. Applicant declares that prior to filing this application he has ascertained the lora on of I exisnj?4filiti ,
both aerial and underground and the accurate locations are shown on the sketche By
A Letter of Notification was mailed to the following Udlities/Municipalities:
Jacksonville Electric Authority Yes( ) No ( )
Bell South Telephone Company Yes( ) No ( Date:
Ferrell Gas Yes( ) No ) Date:
Comcast Yes( ) ( ) Date:
2. 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 Director of Public
Works, any or all of 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 Director of Public Works, and at the expense of the Permittee unless reimbursement is
authorized.
3. All work shall meet City of Atlantic Beach or Florida Department of Transportation Standards and be
performed under the supervision of (Contractor's Project
Superintendent) located at Telephone
4. All materials and equipment shall be subject to inspection by the Director of Public Works or his designee.
5. 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.
6. 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.
7. This permittee shall commence actual construction in good faith with days. If the beginning date is
more than 60 days from date of permit approval, then permittee must review the permit with the Director of
Public Works to make sure no changes have occurred in the area that would affect the permitted construction.
8. 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.
9. The Director of Public Works shall be notified twenty-four (24) hours prior to starting work and again
immediately upon completion.
OWNER
Signed an Date:�b
Before me this day of in the County of Duval,
Stat f ori a,has arZ
red
No ry lic t La tate F ,County of Duval. ;�1;:y HIRLEY G HAM o
My c issi exp" q
Pro c@�PR� S:February 14,2014
pF v Bonded Thru Notary Public Un&Wter
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. The
USER shall, at the discretion of the CITY, be requested to submit as-built drawings showing the change
within thirty(3 0)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
public rights-of-way 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.
/D
b�
DATED and SIGNED this day of _,2
XB
Property Owner
(to be signed in presence of the Notary)
STATE OF FLORIDA
COUNTY OF DUVAL D
/
On this . day of l , 200 personally appeared before me, a Notary
Public in and for said County afnd State, , the property owner of
, Atlantic Beach, Florida, known to me to be the person(s)
described in and who executed the foregoing instrument; who acknowledged to me that he or she
executpA, the same freely and voluntarily and for the uses and purposes therein mentioned.
ub is i4 for said ounty and State ^'u^',
CITY OF ATLANTIC BEACH,FLO 1 ; MY COMMISSION M DD 957760
EXPIRES:FebruaN 14,2014
municipal corporation: '?; g��d Thru Notary Pubic Under
Approved:
Ricky L. Carper,Public Works Director
For Permits where city sidewalk is impacted,
City Manager approval required:
Jim Hanson, City Manager
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