1955 BRISTA DE MAR CIR - DECK , 'r 1J
CITY OF ATLANTIC BEACH
1 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL ALT/OTHER
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-DECK-722
Job Type: DECK/PATIO
Description: PAVER WALKWAY
Estimated Value: $1,500.00
Issue Date: 3/31/2016
Expiration Date: 9/27/2016
PROPERTY ADDRESS:
Address: 1955 BRISTA DE MAR CIR
RE Number: 169506-1664
PROPERTY OWNER:
Name: VAN LIERE, Frederik Nelson
Address:
PERMIT INFORMATION: PUBLIC WORKS:
Full erosion control measures must be installed and approved prior to beginning any earth disturbing
activities. Contact Public Works (247-5834) for Erosion and Sediment Control Inspection prior to start
of construction.
All silt must remain on-site during construction.
Roll off container company must be on City approved list and container cannot be placed on City Right-
of-Way. (Approved: Advanced Disposal, Realco, Republic Services, Shappel's and Sunshine Recycling.)
Full right-of-way restoration, including sod, is required.
FEES:
BUILDING PERMIT FEE $35.00
Total Payments: $35.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND IIIE FLORIDA
BUILDING CODES.
Permit Attachment of for
Permit# issued
20 Atlantic Beach,FL 32233
Owner's Name: Property Address:
R.E.#:
Subdivision: Lot#/Block#:
•
REVOCABLE ENCROACHMENT PERMIT
THIS REVOCABLE ENCROACHMENT PERMIT,issued on this sla
by Atlantic Beach, Florida, a municipal corporation organized y of !e laws State
Florida, hereinafter referred to as "CITY" ganized and existing under the laws of the State b#
ITY' and 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 of the City of Atlantic Beach for the
Beach Right-of-Way/Easement permit numbers noted above(copies espattached described in the City of Atlantic
( p� )
This work is generally described as: Pt0
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 the USER,said notice to USER shall be
given by certified mail, return receipt requested, o the following address:
/frr deuk de /104A C;,0
The depositing of said notice of cancellation in the United States mail shall constitute the notice of
cancellation and the burden is upon USER to keep the CITY informed of USER's proper address.
The USER shall promptly make any and all necessary repairs to any facility erected or maintained in the
exercise of the privilege herein granted and shall at all times maintain said facility in good and safe condition.
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 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."
Page 1 of 2
•
I
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(30) days
after the day of completion.
This permit shall insure 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.
DATED and SIGNED this 4f". day of 20/C
By: 'l/s...-,0.4.1,
Property Owner
(to be signed in presence of the Notary)
STATE OF FLORIDA
COUNTY OF DUVAL
On this 422 f da o
and for said y of f ---7 C, , 2Q( personally appeared before me, a Notary Public in
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 executed the same freely
and voluntarily and for the uses and purposes therein mentioned.
4J4q tO, .I
JgY PO4�, Notary Public State of Florida
No ublic in for s 'd Co ty and State _°ptr�� Shirley L Graham
`� My Commission FF 086990
CITY OF ATLANTIC BEACH, FLORIDA, a �� Expires 02/14/2018
municipal corporation:
Approved:
Doug ton,Public Works Director
For Permits where city sidewalk is impacted,
City Manager approval required:
Nelson Van Liere,City Manager
. .
Page 2 of 2
CITY OF ATLANTIC BEACH
OWNER / BUILDER AFFIDAVIT
I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION
CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.103(7),FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED
CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPTION TO THAT
LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY,TO ACT AS
YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST
SUPERVISE THE CONSTRUCTION YOURSELF. YOU MAY BUILD OR IMPROVE A ONE—OR
TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUII.D OR
IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS. THE BUILDING
MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE.
IF YOU SELL OR LEASE A BUILDING YOU HAVE BUILT YOURSELF WITHIN ONE YEAR
AFTER THE CONSTRUCTION IS COMPLETE,TI-IE LAW WILL PRESUME THAT YOU BUILT
IT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY NOT
1-TIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. IT IS
YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE
LICENSES REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING
ORDINANCES.
II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED.
III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO
OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY
EMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY
CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826)IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
/95S Z, S/ 9e G 5S 7
ADDRESS PHONE NUMBER
/1/4�5 a,ci (14-e." P
PRINT NAME
3`7 //Z
SIG ATURE G/ DATE
Before me this,�/ day of m/AC'/l 20/6 in the county of
Duval,State of Florida,has personally appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of ilorr a/,2 ,County of U V.3/
(]Personally Known
❑Produced Identification- --- -
YVONNE M.CALVERLEY �
;•: MY COMAQISSION t EE 184383
�: EXPIRES: •
Notary Signature. -' July 29,2016
'h,• Bonded Thru Notary Public Underwriter
F/BLDGIOwncr•Buil r AlTndavit,REVISED 4/16/2009
NNW
,es*: '3:74VIA •'
"4":- Wlaiitar
SFurface Calculatioas % 7erriffna_L-s-2
•
Find square footage of the fbillvving:
House footprinz.
Driveway
A i I sidewalks/wak,' mays
A/C pads
Detached garage/sheds
Pool Decking
Patios,terraces and/or decks
Add the total wore footage of the areas listed above then, divide the sum by
the total lot area of the property.
,,/142007
rt""'\'`' BUILDING PERMIT APPLICATION
1, r -%
CITY OF ATLANTIC BEACH
J y.
800 Seminole Road,Atlantic Beach FL 32233
,:.'p:i u Office: (904)247-5826 • Fax: (904)247-5845
Job Address: /15-5- 4,, k a, .,44,.._ (7,:,- Permit Number:
Legal Description RE#,
Valuation of Work(Replacement Cost)$ ),5-6c) Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Addition Alteration Repair Move Demo Pool Window/Door
• Use of existing/proposed structure(s) (Circle one): Commercial eside- e ti-'aft
• If an existing structure, is a fire sprinkler system installed?(Circle one): Yes el■ N/A
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work to be performed: � /
/-,<>71 k.(,�.a ..c.T77 e ,t�ew 1 5 /e/A.c.e"..c� _Simi, 2-i ie "e.e l S..c G•c 1 lee/
Florida Product Approval# O for multiple products use product approval form
Property Owner Information
Name: //e/s.,4. /4,v 6 ''----e Address: /75-5- 6-,si , .. G
City � /
f i c 4;.? c/7 Statefe Zip 32233 Phone 9r cl 3/,y e 3 s 7
E-Mail t,A4//,.<�r tcc, be//yd - Vii, Ave/
Owner or Agent (If Agent,Power of Attorney or Agency Letter Required)
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
Contractor Information:
Name of Company: Qualifying Agent:
Address: City State Zip
Office Phone Job Site/Contact Numbe
State Certification/Registration# E-Mai
Architect Name & Phone#
Engineer's Name & Phone#
Worker's Compensation
Exempt / I . rer / Lease Employees / Expiration Date
Application is hereby made to obtain a permit to do the work and in 'Ilations as indicated. I certify that no work or installation has commenced
prior to the issuance of a permit and that all work will be perform' to meet the standards of all laws regulating construction in this jurisdiction.
This permit becomes null and void if work is not commenced wi in six(6)months, or if construction or work is suspended or abandoned for a
period ofsix(6)months at any time after work is commenced. I understand that separate permits must be secured for Electrical Work,Plumbing,
Signs, Wells,Pools,Furnaces,Boilers,Heaters, Tanks and Air Conditioners,etc.
Signature of Property Owner: -7/ "r",-- c7Zo-n..4 Signature of Contractor:
Before me
this Di Day of /oa v(,Ll l 2 0/(o Before me this Day of
-fin ' .,/moo.,.,.•.
Notary Public: 'u-? fir'•`'," M.CALVERLEY , Notary Public:
' . r!„' tr: r • SSION tl EE 184383
...r,.;.aF f PIRES:July 29,2016 '
I hereby c: i, that I have read a l" At 'n '' "."fit' :' • '''- .,. iw the same to be true and correct. All provisions of laws and
ordinance. :overning this type o . . . .--7--7-- r specified herein or not. The grantin,g of a permit does not
presume to give authority to vio ate or cancel the provisions of any other.federal, state, or local law regulating construction or the
performance of construction.
Rev. 3/14/16
4
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1
tom . li, CITY OF ATLANTIC BEACH
CONSTRUCTION PERMIT WITHIN CITY RIGHTS OF WAY AND EASEMENTS
® C3.1 11
800 Seminole Road 904-247-5800
Utt1Ur Atlantic Beach,Florida 32233-5445 Fax 904-247-5845
PERMIT#
PLEASE SUBMIT(2)COMPLETE SETS OF PLANS WITH APPLICATION.
Date 3/Z ?//G ISSUES BY THE CITY
Job Address (U"$-. 1.--s A .4v E-mail
Permitee: 4/4/e pt £2 ,ft — Lit/-c Telephone#
ermitee Address:
Requesting Permission to Construct: "'Pr od--rdeg•--Ay/
Location: (Reference to Cross-Street)
1. Applicant declares that prior to filing this application he has ascertained the location of all existing utilities, both
aerial and underground and the accurate locations are shown on the sketches.
A Letter of Notification was mailed to the following Utilities I Municipalities:
Jacksonville Electric Authority Yes ( ) No ( ) Date:
Bell South Telephone Company Yes ( ) No-(-- Date:
Ferrell Gas Yes( __)- No( ) Date:
Comcast Ye8 f ) No ( ) 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 Permitee 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.
r COL_ Notary Public State of Florida
Shirley L Graham
OWNER > 9� My Commission FF 086990
�A �
Por 00' Expires 02/14/2018
Signed: 1 p7G�i� Date:3 (- . • - - day
of in the County of Duval, State Of Florid , has personally appeared
i Notary Public at Large, State of Florida, County of Duval. My
c. .r % - .l�. Personally Known:
_ Produced Identification:
Revised 7/29/15
Cd)'` CITY OF ATLANTIC BEACH
WNER / BUILDER AFFIDAVIT
I. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION
CONTRACTING" REQUIRES OWNER/BUILDER TO ACKNOWLEDGE THE LAW:
DISCLOSURE STATEMENT FOR SECTION 489.103(7),FLORIDA STATUTES:
STATE LAW REQUIRES CONSTRUCTION TO BE DONE BY LICENSED
CONTRACTORS. YOU HAVE APPLIED FOR A PERMIT UNDER AN EXEMPTION TO THAT
LAW. THE EXEMPTION ALLOWS YOU,AS THE OWNER OF YOUR PROPERTY,TO ACT AS
YOUR OWN CONTRACTOR EVEN THOUGH YOU DO NOT HAVE A LICENSE. YOU MUST
SUPERVISE THE CONSTRUCTION YOURSELF. YOU MAY BUILD OR IMPROVE A ONE—OR
TWO FAMILY RESIDENCE OR A FARM OUTBUILDING. YOU MAY ALSO BUILD OR
IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS. THE BUILDING
MUST BE FOR YOUR USE AND OCCUPANCY. IT MAY NOT BE BUILT FOR SALE OR LEASE.
IF YOU SELL OR LEASE A BUILDING YOU I-IAVE BUILT YOURSELF WITHIN ONE YEAR
AFTER THE CONSTRUCTION IS COMPLETE, TI-IE LAW WILL PRESUME THAT YOU BUILT
IT FOR SALE OR LEASE, WHICH IS IN VIOLATION OF THIS EXEMPTION. YOU MAY NOT
HIRE AN UNLICENSED PERSON AS YOUR CONTRACTOR. YOUR CONSTRUCTION MUST
BE DONE ACCORDING TO TIIE BUILDING CODES AND ZONING REGULATIONS. IT IS
YOUR RESPONSIBILITY TO MAKE SURE TIIAT PEOPLE EMPLOYED BY YOU HAVE
LICENSES REOUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING
ORDINANCES.
II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,
THE BUILDING DEPARTMENT SUGGESTS WORKER'S COMPENSATION INSURANCE BE
PURCHASED.
III. IRS WITHHOLDING; OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO
OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY
EMPLOY ON THEIR IMPROVEMENT TRADES.
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER ANY
CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(1). AN"OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE OWNER SHOULD PHYSICALLY
SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA "CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON IS A LICENSED CONTRACTOR. TELEPHONE THE
BUILDING DEPARTMENT(247-5826) IF IN DOUBT.
V.ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE
STATEMENT AND THAT I COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
/95-S ,6i-S/ ,p ,64,-- e - 9 y c3/8 035 7
ADDRESS PHONE NUMBER
/Uf/So.v a74, 6,A,-P
PRINT NAME
/- l/° 67. 9e-e---e-49 3/ /i
T RE
DATE
7U
Before me this oe/ day of /1/19/0-6/1 2016 in the county of
Duval,State of Florida,has personally appeared herin by himself/herself and affirms that
all statements and declarations are true and accurate.
Notary Public at Large,State of F/Dr'c/2 ,County of J Cr Vd/
E Personally Known
❑Produced Identification- +rr -
/ ;A;;.r.;iy = YVONNE M.CALVERLEY
*. .,r MY COMMISSION#EE 184383 1
r ..- /'-_ 's'Zip�; EXPIRES:July 29,2016
Notary Sign. ■ LULL_ .••- Bonded At,.fi`` Notary Public Onderwrile;
FJBLDGrowner-Boil••r Afiadavit;REVISED.4/16/2009
r
R ' '
sy `,r��, City of Atlantic Beach �
jvF APPLICATION NUMBER
c li Building Department , (To be assigned b the Building Department.)
r ': " � ` 800 Seminole Road MAR 2 6 2016 �� Z
�r Atlantic Beach, Florida 32233-5445 1 , — ,C
Phone(904)247-5826 - Fax(904)245.__--z_-_,_•.,--,x/o;3 �� E-mail: building-dept@coab.us z:� Date routed: c Ar i
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: /9.Ic '. -i S,IA, uk 7? A-r Department review required Yes No
Building
Applicant: Q GU -7') e lc Planning &Zoning
/' 1 Tree Administrator
Project: 73 1V Er' 0 R / e �fty
/ Jtiiit e-
Public Safety
Fire Services
Review fee $ Dept Signature i aii
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLI ATION STATUS
Reviewing Department First Review: Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: W/ l'I'`J Date: 7/2-1 fii
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ['Denied.
Comments:
Reviewed by: Date:
Revised 05/14/09
0 p;.,, City of Atlantic Beach I�. � APPLICATION NUMBER
Building Department ''D (To be assigned b the Building Department.)
r ` � 800 Seminole Road MAR 2 4 j f
zoi6 Atlantic Beach, Florida 32233-5445 ` �� Z
\�� Phone(904)247-5826 Fax(904)24 � Q
j, E-mail: building-dept @coab.us Date routed: e
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: /91c ci / Department review required Yes No
Building
Applicant: O & E Planning &Zoning
Tree Administrator
Project: Ig 1� r' / / 't ) y
/ .bI+s-6Jtilit
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: [pproved. ❑penied.
(Circle one.) Comments: SG Oc G J 6,004
BUILDING
PLANNING &ZONING Reviewed by tjAti jt,t4Date:
TREE ADMIN. Second Review: ['Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
•
FIRE SERVICES Third Review: ❑Approved as revised. ['Denied.
Comments:
Reviewed by: Date:
Revised 05114/09
V
ri��,'r'; BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach FL 32233
��JF31l r' Office: (904)247-5826 • Fax: (904)247-5845
Job Address: /9Sr s.-'4} 4. ,1/4h__,4 — Permit Number:
Legal Description RE#-
Valuation of Work(Replacement Cost) $ /5-643' Heated/Cooled SF Non-Heated/Cooled
• Class of Work(Circle one): New Addition Alteration Repair Move Demo Pool Window/Door
• Use of existing/proposed structure(s) (Circle one): Commercial , :esidentia
• If an existing structure,is a fire sprinkler system installed?(Circle one): Yes 010 N/A
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work to be performed: / n,
/.✓ier-eet___ S.y'7Tt ,tied /�y�yl3� /e/e/ 5,77te i olG�c-s 5�¢C✓�4 I /gO/
Florida Product Approval# v for multiple products use product approval form
Property Owner Information
Name: ,/ls,,,v (/,¢,v 6 -e Address: /75-75- �,-,c L2. ,,e,q„ C_ .—
City /419ti fi c 64 c 4 Statefe Zip 32233 Phone 9:0€7 3/9 635 7
E-Mail v-4 4/1/c,f eD be/sere. i, ,t,e/
Owner or Agent (If Agent,Power of Attorney or Agency Letter Required)
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
Contractor Information:
Name of Company: Qualifying Agent:
Address: City State Zip
Office Phone Job Site/Contact Numbe
State Certification/Registration# E-Mai
Architect Name& Phone#
Engineer's Name &Phone#
Worker's Compensation
Exempt / I rer / Lease Employees / Expiration Date
Application is hereby made to obtain a permit to do the work and ins llations as indicated. 1 certify that no work or installation has commenced
prior to the issuance of a permit and that all work will be perform to meet the standards of all laws regulating construction in this jurisdiction.
This permit becomes null and void if work is not commenced wi in six(6)months, or if construction or work is suspended or abandoned for a
period of six(6)months at any time after work is commenced. 1 understand that separate permits must be secured for Electrical Work,Plumbing,
Signs, Wells,Pools,Furnaces,Boilers,Heaters, Tanks and Air Conditioners,etc.
Signature of Property Owner: ----/Z,kcer c2ce-..4 Signature of Contractor:
Before me
this Day of AlCLvcI i 2 0/ ' Before me this Day of
I / ....
Notary Public: Prim-Le -71757771,,, M.CALVERLEY • Notary Public:
bri ,•' t6 4, • SSION A EE 184383
--„k_ 'RES:July 29,2016
I hereby c that 1 have read asd"'Xithil'n '�ifi&.- . 7t w the same to be true and correct. All provisions of laws and
ordinance. _overning this type o" —"". . . — -- r specified herein or not. The granting of a permit does not
presume to give authority to vio ate or cancel the provisions of any other federal, state, or local law regulating construction or the
performance of construction.
Rev.3/14/16
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