1855 Hickory Ln ROW permit CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
RIGHT OF WAY PERMIT
MUST CALL BY 4PM FOR NE)ff DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-ROW-2196
Job Type: RIGHT-OF-WAY PERMIT
Description: REPLACE CONCRETE DRIVEWAY WITH PAVERS
Estimated Value: $4,300.00
Issue Date: 10/20/2016
Expiration Date: 4/18/2017
PROPERTY ADDRESS:
Address: 1855 HICKORY LN
RE Number: 172020-1434
PROPERTY OWNER:
Name: DEWEY MAIN TRUST, EDNA
Addrew: 1855HICKORYLN 1855HICKORYLANE
PERMIT INFORMATION: UTILITY DEPT.: PUBLIC WORKS:
Ensure all meter boxes,sewer cleanouts and valve covers are set to grade and visible.
A sewer cleanout must be installed at the property line.Cleanout must be covered with an RTI.
concrete box with metal lid. Cleanout to be set to grade and visible.
Full erosion control measures must be installed and approved prior to beginning any earth disturbing
activities. Contact Public Works(247-5834)for Erosion and Sediment Control Inspection prior to start
of construction.
All runoff must remain on-site during construction.
Roll off container company must be on City approved list and container cannot be placed on City Right-
of-Way. (Approved:Advanced Disposal, Realco Recycling, Republic Services,Shapell's,Sunshine
Recycling and Waste Pro).
Full right-of-way restoration, including sod, is required.
Maximum driveway width within the City right-of-way is 20'.
ildin
k&WMWQvM�MWM5$vision to the Bu &DUartment,n-rwry ""' Al� UHE �LOWDA
BUILDING CODES.
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
FEES:
Fence/ROW $35.00
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $39.00
PERAHT IS APPROVED ONLY M ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES � THE FLORIDA
BUILDWG CODES.
City of Atlantic Beach APPLICATION NUMBER
Building Department s.,
800 Seminole Road �1'�) (to be assigned by the Building Department,)
t & —ROW ._z(9(V
Atlantic Beach,Florida 32213-5445 J169
Phone(904)247-5826 Im(904)247-
E-mail: building-dept@wab.us . Daterouted: 9 /Z'C� /L ('_7
City web-site: http:/Avww.coalb.us 58
APPLICATION REVIEW AND TRACKING FORM
Property Address: 1625S H I QKogu Cr3 Department rweview re uhred Yes No
Building
Applicant: n
I ree Administrator
Project: H)fV&f�_ C) f2A Q C—LL U PC Wor
PC IMP
u PC
Fire Services
WT
Review fee
ErmOther Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept.at 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
FReviewing Department Fi�rsf Review: VApproved. E]Denled.
(Circle one.) Comments:
BUILDING -44 A&Q
PLANNING&ZONING Reviewed by: Date
TREEADMIN. SecondReview: [ElApproved as revised. ZSenied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date*
FIRE SERVICES Third Review: [JApproved as revised. ElDenied.
Comments:
Reviewed by: Date:
Revised ON141/09
City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road Sep vl�_A
Atlantic Beach,Florida 32233-5414�JA57 3 8 ivw AV 1 (0 _R0 VI) _z L9
Phone(904)247-SB26 F;;(904 -5345
E-mail: building-dept@coab.us Date routed:
Cilywelb-site: http:1Avww.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: I ass H I QKOz�:( U0 Department review required Yes No
Building
Applicant: C) Tree n Administrator
Project: PP(V&a- D RA U&LO A�K <-13-uEric-S-afety
Fire Services
Review fee $.g
Review=iBy Date
Other Agency Review or Permit Required of Permit
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Amy Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPYqATION STATUS
Reviewing Department First Review: TfApproved. ElDenied.
(Circle one.) Comments:
BUILDING
PLANNING&ZONING Reviewed by: A'_--,�ate: /'AW/
TREEADMIN. Second Review: []Approved as revised. DDenied
IC VOORKP Comments:
VC UTILITI S
PUBLIC SAFETY Reviewed by: —Date
FIRE SERVICES Third Review: F]Approved as revised, [-]Denied.
Comments:
Reviewed by: —Date:
Revised 05114109
BUILDING PERma APPLICATION - - - - - -
CITY OF ATLANTIC BEACH
800 Seminole Road,Atlantic Beach FL 32233
Office:(904)247-5826 - Fax:(904)247-5845 -Row -Z(9(��
JobAddress: ) Vq!� W,rjC0R,y LN —Permit Number:
Legal Description REjeleiffCP WA_UCWAV Fib?_ PAUeRG RE#
Valuation of Work(Replacement Cost)$_A3 Q2—.00 H-ated/Cooled SF Non-Reafted/Coolled
• Class of Work(Circle one): New Addition Alteration Repair Move Demo Pool Window/Door
• Use of existing1proposed structum(s)(Circle one): Commercial Residential
Q�
If an existing structure,is a too,sprinkler system installed?(Circle one): Yei No
Submit a Tree Removal Permit Application if any noon are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work to be performed:
RiTPVVCV DR-CoCoilaVy AND ZNSr-RUPr 13Qtt�C pl!lVej;�s AV0 kLyg-ps,
1hjEL_ 58AIG S;C ;�t- -
Florida Product Approval# far multiple products use product approval four
Property Owner Information
N c: Address: Lrj
L
ame L
City F
,JkVIL��State�
aZip Phone rl
-Mai AAALW��5q* RELI_CdMA-11t - 01A�r
, nn� (Xr
E _, , !:��ip
O%vriff or Agent (ffA�t,PcascrofAVomyorAg=y1sner
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 NOT0E OF COMMENCEMENT.
Contractor Information:
Name of Company rt roc_ Qualifying Agent: U)&tXkj&T01y "TAR-4
Address: 9-".?1�%q afol 1 9r �Wn -----—City Wir-Senlyl Lij� State Z�p 12P 4
OtbcePhone(qt) ) A+ff_(1ay0 Job Site/ContactMenber-L�") 4qq- 0tfjW
State Certification/Registration# 5q _31,5()493a_ -E-MMilILTysTome"r,-cEtq<?ge)yaKoo, c.OAA
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation
tion Is ma a to obtain a ,ermar to do the work and installations as indicated I cer4fy that no work or installation has comartmod
the a a a it and that all work will be perfamed to met the standards ofall laws regulating conetruenno in thisjurisdiction.
is it co 8 oil id ifisork is not eammuced within sit (y moths, or if construction or work is suspended or abandoned for a
to a n an tone r work is comatenced I undershot that separate Permits must be socuredfor Fleeteheal War*,Making,
c ,ii.,L�o
Hearers,Tanks andAh,Conditioners,etc.
Signat=ofPmpertyO"�:-��iAltApt�� SignatureofContructor.
Z2ffDayof(�'�" 1 01 (47 Before
RGES
myoomm"t
Expomomb,n6,2019
Notary Public: Notary
I hereby centy,that I haw read and e;camined this application and know the same to be true and correct. Allp visionsarlawsand
ordinances governing this type 9,"rk will be complied with whether spa d herein or not. The gronan of a perml doff not
performance ofconstruction. � ral, reg
presume to give authority to via ate or cancel the provisions of any otherfelea stateorlocallaw u ng construction or the
Rev.3/14/16
MAP SHOWING BOUNDARY SURVEY OF
NO
FtLOT16. ACCORDING TO THE PUT OF -SELVA MARINA UNIT N( . 12—C RE tiAlOiC115111100DED IN
Mi
FIAT 7 37, PAGE 29 OF THE CURRENT PUBLIC RECORDS gw��.
BOOK 01 DUVALF
U_ This approval verifies compliance Wth applicable
CERTIFIED TO: EDNA D. MAIN, aching, subdivision and dither local land
1M
development regulations, but does not constitute
STEWART TITLE OF JACKSONVILLE, INC., approval for the issuance of permits. Compliance
ST
VACROVIA MORTCACE COMPANY ydlh Florida Building Code and all other applicable
1. State and Federal Pamitting reqnArernents
AND WATSON OSBORNE TITLE SERVICES. 11 V.ba,canned by signature of the City of Allenfic
each Building Officisl prior to Use Issuance of a
Ilding Pencil. I
Approved Br.
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ONINEIRAL NOT$*.
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CITY OF ATLANTIC BEACH
CONSTRUCTION PERMIT WITHIN CITY RIGHTS OF WAY AND EASEMENTS
800 Seminde Road onimmomm�
AffarVe 8ftch,FWda 32233-5445 904-247-5800
Fax 904-247-5845
PLEASE SLUBMIT(2)COMPLETE SETS OF PLANS WITH APPLICATION. PERMIT#
ISSUE:SBY THE CITY__
Date E
Job Address E-mail
Permitee: T-7clr\ C, ga'a Telephone# S9 S -'s(-,C)I�
Permitee Address: SCLCV� IF
Requesting Permission to Construct:
Location: (Reference to Cross-Street)
1. Applicant declares that prior to filing this application he has ascertained the location of ail existing utilities, both
aerial and underground and the accurate locations are shown on the sketches.
A Letter of Nofifi�fion was mailed to the following Utilities/Municipalities:
Jacksonville Electric Authority Yes ( No ( Date:
Bell South Telephone Company Yes No ( Date:
Ferrell Gas Yes( No( Date*
Corricast Yes( 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 Pemnitee 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. Ali 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� �F�AL&C- N� Date:2�a.Before me this R�day
of. gLfn the County of Duval, State Of Florida, has personally appeared
S —Notary Public at Large, State of Florida, County of Duval. My
commisOlgin expires: Personally Known:
0-7-404-!5k 0 - ;2.7 1- C� Produced Identification
R.Ased 7129115
CITY OF ATLANTIC BEACH
OB OWNER/ BUILDER AFFIDAVIT
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 'CONSTRUCTION
CONTRACTING" REQUIRES OWNER I 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. ME 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 OUIBUILDING. YOU MAY ALSO BUILD OR
IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 OR LESS. THE BUILDING
MUaTRI3FQR YQUR 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
AFIERIHE CONSTRUCTION IS COMPLETE, THE LAW WILL PRESUME IHAI YOU BUILI
IT FOR SALE OR LEASE, WHICH IS IN VIOLA TION OF THIS EXEMPTION. YOU MAY NOT
HIRE AN IML191M PERSON AS YOUR CONTRACTOR, YOUR CONSTRUCTION MUS I
BE DONE ACCORDING TO THE BUILDING CODES AND ZONING REGULATIONS. It N
YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU RAVI
LICENSES REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING
ORDINANCES.
IL 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 V40RKERS BECOME EMPLOYERS AND SHOULD ALSO
OBSERVE IRS VOTHHOLDING TAX AND/OR FORM 1099 REQUIREMENTS ON THE WORKERS THEY
EMPLOY ON THEIR IMPROVEMENT TRADES
IV. PENALTY; UNLICENSED CONTRACTORS CANNOT BE EMPLOYED UNDER AN
CIRCUMSTANCES. OWNERS BEING SUBJECT TO $5,000 PENALTY UNDER FLORIDA STATUTE NO.
455-228(l). 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 WTH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN
OWNER-BUILDER PERMIT.
I q ��1:;- 4 t ra-,/ 9 s
ADDRESS PHONE NUMBER
C—� ta f,--3(k &
PR—INT MWE
SIGNATURE DATE
21) county of
asnom ma thus-Zft day of 4?
Dival,Bump afFlorda.has Parsomally.e— y hill
all statements and declandisins am"a and accumbe
Notar,Public at Lar,is State of F-tCL.Cousayof
0c) - 06,-.e 0 - Z,
I Ora GINDI-ESPERGE1
M4 mywvNf8s104#FF92 51
al C[A 0!!� EXPIRES Ectothil fi,2 11
(2- , 0.1
Notary S"tiodus, Ge�!L &
l.. Go
Permit Attachment --of for
Permit# imed — —
20--Atlantic Beach,FL 32233
Owner's Name: Property Address:
R.E.#:
Subdivision: Lot#/Block M
REVOCABLE ENCROACEmENT PERMIT
THIS REVOCABLE ENCROACHWNT pFRMff,issued on thisZ�_day of 2
StaA
Florida, hminafter refeired to as "CHY' and
by Adamic Beach, Florida, 8 Municipal corporation organized and existing IML 11 the
hereinafter referred to as"USEWI. 4;1got *�4 of Adanti. Beach, Florida,
WITNESSETH:
That the Crry does haebY grant the USER permission on a revocable bum as described herein the right to
enter upon the property of the City of Atlantic Beach for the purpose a described in the City of Atlantic
Beach Right-of-Way/Easermart permit nurubers noted above(copies attached).
This work is generally described as:
Any facility mamnamed, repaireA erected, andlor installed in the exercise of the privilege granted remains
subject to relocation or removal on thirty(30)days notice Py Crry to the USEI?,said notice to USER shall be
given by certified mail, return n'ceipt requested, to the following address:
49,n/� CAq
The depositing of said notice of cancellation in the Unit6i 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 my and all necessary repairs to my facility erected or maintained in the
exercise of the privilege herein granted and shall at all times maintain mid facility in good and safe condition.
In the event it is necessary for the CITY Or the City's approved representative or other foushised utility to
enter upon the above-described property of the CITY, the USER shall replace at the USER's sole expense,
my and all material necessarily displaced during the action of maintaining rep iring tin
adding to of the utilities and filcilities of the C , a Opera 9,replacing, or
Try or franchise utility provider.
The facallucs allowed by the permat shall meet the current requirements of the City Code, Budding Codes,
Land Development Code,and all other land we and code requirements of the MY,including
City Code Section 19-7(h)which states"Driveways that cross sidewalks: City sidewalks my 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 I of 2
The USER, prior to maknig my changes from the approved plans and/or method, must obtain written
approval from the City of Ad mic Beach,Public Wor Department,for said change. The USER shat at
dismhon of the CrIY, be rea ks the
after the day of completion. q=ted to submit as-budt drawings showing the change within thirty(30) days
This permit shall insure to the beriefit of, and be binding upon,the USER and their respective Successors and
assigna.
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 we limitations/requinments of public
right�f-wsy and otherpublic land. USER fiulhff agrees that the CITY and its offlem and employees shall
be saved harmless by the USER from my of the work herein under the terms of this permit and that an of said
liabilities are hmbyassumed by the USER.
DATED and SIGNED this 'a?(n1
1 day Of 64 1—,— 20
By:
Property Owner
(to be signed in presence of the Notary)
STATE OF FLORIDA MyCOINISSIMFF924951
COUNTY OF DUVAL S,
EXPIRES:W-W 6�2011
�d Th.W�P-bk U��
on this clay of 20, 1 personally appeared before me, a Notary Public in
the property owner of
and for said commy and State", W
L855 Wtq,-�t--v I r, Atlantic Beach,Florida,known to me to be the Person(s)described in
and who executed the foretomg ustrument, who acknowledged to me that he or she executed the same freely
and voluntarily and for the uses and purposes therein mentioned.
Notary Public in for said County and State
CITY OF ATLANTIC BEACH, FLORIDA, a
municipal corporation:
Approved:
InPU
ib c Works Directo
9'a Co 4-0 C/;-/?�
For Permits where city sidewalk is impacted,
City Manager approval required:
Nelson Van Lim, City Manager
Page 2 of 2