640 Palm Ave driveway permit CITY OF ATLANTIC BEACH
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
306 INFORMATION:
Job ID: 16-RAAR-2697
Job Type: RESI DENTIAL ALTERATION
Description: ADD REAR 12' x 14' PAD AND WIDDEN DRIVEWAY .
REPAIR BROKEN DRIVEWAY SECTION
Estimated Value: $1,200.00
Issue Date: 12/29/2016
Expiration Date: 6/27/2017
PROPERTY ADDRESS:
Address; 640 PALM AVE
RE Number: 170439-0010
PROPERTYOWNER:
Name: SALT AIR HOMES
Address: 226 TALLWOOD RD JACKSONVILLE BEACH, FL 23250
PERMIT INFORMATION: PUBLIC WORKS: UTILITY DEPT.:
All concrete driveway aprons must be S"thick,4000 psi,with fibermesh from edge of pavement to the
property line. Reinforcing rods or mesh area not allowed in the right-of-way. (Commercial driveways-
6"thick).
Full erosion control measures must be installed and approved prior to beginning any earth disturbing
activities. Contact the inspection Line(247-5814)to request an inspection from Public Works 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(Advanced Disposal and Realco Recycling).
Container cannot be placed on City Right-of-Way.
Full right-of-way restoration,including sod, is required.
All runoff must remain on-site. Cannot raise lot elevation.
Maximum driveway width within the City right-of-way is 20'.
,,D 0
S�,y 111bkCrO
iniftf.p
,PANC'WIT" ALL 'IT
,I Q,,4TLkNTIC REALTI ORDWANCES AND THE FLORIDA
mus e su im e as a evision to t e ui ding Department.
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
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 RT1
concrete box with metal lid. Cleanout to be set to grade and visible.
FEES:
PLAN CHECK FEES $28.00
BUILDING PERMIT FEE $56.00
STATE DCA SURCHARGE $2.00
STATE DBPR SURCHARGE $2.00
Total Payments: $88.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND ME FLORIDA
BUILDING CODES.
oCity of Atlantic Beach
Building Department
800 Seminole Road
Atlantic Beach,Florida 32,233-6445
Phone(904)247-5826 - Fax(904)247-5845
t�,'J�' E-mail building-dept@wab us
City web-site: htp:/Avw,.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address:L!q 0 PAL!nn AVLz Department review required Yes No
B Join
Applicant: SB(--T P' Ifz 'anning &Zonln
Project: C)N )C, 12 C-7 C_ IZU C)P, K 'ublicworki"
(ties
u JIG UAW
Fire Services
Review fee
P@pt Sionature
Other Agency Review or Permit Required Review or Receipt
of Permit Verified B Date
Florida Dept.of Environmental Protectio,
Florida Dept.ofTranstportation
St.Johns River Water Management District
AMY Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tabs=
ftOtherMn
APPI ICATJ
rReviewing Department First Review: NApproved. ElDenred.
(Drole one.) Comments: Prod,17 0ppVr+vven4- appy-ovelifs
(B:UI:LD
_ IND -5 00"'r
PLANNING &ZONING Reviewed by: lz�� 7Date: /2-616
TREEADMIN. Second Review: EjApproved as revised. El D evn fie d
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date,
FIRE SERVICES Third Review: ElApproved as revised. EJDenied.
Comments:
Reviewed by: Date:—
Revised 05114/09
OFFICE COPY
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
10 800 Seminole Road,Atlantic Beach FL 32233
5
Office:(904)247-5826 - Fax:(904)247�5845 1 G-IR 04 A R - 2(,9 _7
Job Address: 6qO PAIvv\ Aji-:: - —Permit Number
Legal Description
'Z"(9
Valuation of Work(Replaccrainit Cost) Heated/Cooled SF.Non-Heated/Coled
• Class of Work(Circle one): E� Addition Alteration [RaPm-r Move Demo Pool Window/Door
• Use of emsting/proposed structure(s)(Circle one): Conamercial
• If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No
Submit a Tree Removal Permit Application if my trees are to be removed or Affidavit of No Tree Removal
Describe in detail the type of work to be performed:
?Ei'kl'z- ilr 9 4 q AVG& OF 90WVSQ J�Rt UEW-1 A�IN -7 X�70 bN W- QJ LOT- 7 X 0 (IJ wtul tfr 0 t' 41"
Florida Product Approval# oultiple Products use product appo,ai l.4
Property Owner Information
Name: 5Ai;rA,(L Hmiiis Address:
city .ck� ( Zzpt
AEJONAce, V State Fr-Zip �2 Flione �EQU- -4 Z
E-Mail (D. Vi�AtAi (d Cx2vjCAz,,T-- t4j_2W�F
OwnermAgent (IfAaeaPow--fAfte�.iAgewyL�
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 AT70RNEY BEFORE
RECORDING YOUR N6T]7(t OF COMMENCEMENT.
Contractor Information:
Name of Company: Qualifyin kr,�nt:
Address:
Office Pbo—ne _Ci —State Zip
Job Site/Co
ct Number
State Certification/Registration# E-Mail
t
Architect Name&Phone#
Engineer's Name&Phone#
Worker's Compensation Exempt , pastu,nume
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hereby certify that I have read and examined this applic lo and know the same to be true and correct AllProvisions oflaws and
rdimances governing this type Kwork will be complied tv, whether spe�
resume to give authority to via ate or cancel the provisi Wedheremornot. Thegrantinofalaermadoesnot
0 e
erformance ofconstruction. ofany otherfe eral, state,or local law regulating construction or the
Rev.3/14/16
Map 0�puft �qo 2 0 F004N- IW1/16,1�7PM
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CITY OF ATLANTIC BEACH OFFICE COPY
---CONSTRUCTION PERMITWITHIN CITY-RIGHTS OF WAY AND EASEMENTS
800 Semincho,Road
Atlantic Beach,Florida 3223�5445 9N-247-5800
Fax 904�247-5845
Date 12- - [PER IT
IS:Job Address (oqO RA-LVA AV:P- SU i:DBY T1 E CITY
Permitee 00 VSfi_> L-JfZAI,�T— Telephone* S33
Permittee Address: o-fa Alz
Requesting Permission to Construct: 4)(2we kmiy .
Location: (Reference to Cross-Street) *- PAL-M AV&_
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 Utilifies/Municipalities:
Jacksonville Electric Authority Yes No Date:
Bell South Telephone Company
Ferrell Gas Yes No Date:
Yes( No Date:
Comcast 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 reamted 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
Superintendent)located at 640 'R --&&VIZ&___Vk��(Contractor's Pro' t
A!�� Ai.'s ,
4. All materials and equipment snail De subject to inspection by the D—Telephone 30 ,,—iec.7
5. All city property shall be restored to its original condition as far as irector or Public Works or his designee.
and the manner satisfactory to the city. practical, in keeping with city specifications
6. A sketch of plans Covering details of this installation, as well as, a copy shall be made a
part of this permit. Calculations showing any increase In inivervic,"==lot or In the cit
Rightof y are t�—beims;application.
7. 1 his perrinittee shall commence actual construction in good faith with_days. If the beginning date is
more than 60 days from date of permit approval, then permittem 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 am 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: Data 17- 1-201(V
eauare me mrs I dayof.,\:jn� in the County of Duval,
State Of Florida'has Personally a d ('0-SZ.
Notary Publi?at Large,state of MTMIC of a.
MycituIVISSIONlIF9110M
ne.
A
My_mr"ss=.P wz.
Personally K
Produced menuricahan EXPIRES:Octol
OFFICE COPY
R.O.W. Permit Attachment of for
R.O.W.Permit#—issued 20 Atlantic Beach, FL 32233
Owr�cr's Name:
Property Address: 6LfO AUE .
Aal-Ar"'M�- &A-, 52-755
Subdivision:
Lot#/Block#:
R.E.#: t-70 WSJ - 0010
REVOCABLE ENCROACHMENT PERA41T
THIS REVOCABLE ENCROACHMENT PERMIT, issued on this _ day of
, 200 , by Atlantic Beach, Florida, a municipal corporation organized and existing
under the laws of the State of Florida, hereinafter referred to as "CITY"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 die property of die City of Atlantic Beach for the purpose as described in the City of
Atlantic Beach Right-of-Way/Easement permit numbers noted above(copies attached).
This work is generally described as: AcAw (. bawr-kM i)Aet�W(,
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, to the following address:
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 CrrY, the USER shall replace at the USER's
sole expense, my 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 writh smooth concrete left natural in color so that it
matches the existing and adjoining sidewalks."
Page I of 2
OFFICE COPY
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. ne
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 more to the benefit of, and be binding upon, the USER and their respective
successors and assigns.
USER shall meet the ternis 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 Z- day of Z*--C-
By: &:.. �
Property Owner
(to be signed in presence of the Notary) T041GINDLESPERGER
MyQ0MMISSIQN#FF�1
STATE OF FLORIDA EXPIRES.Otbw6,M19
COUNTY OF DUVAL
On this day of 20, personally appeared before me, a Notary
Public in—md for said County and 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
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 BEACE,FLORIDA,a
municipal corporation:
Approved:
Donald D. Jacobovitz, P.E. Public Works
Director
For Permits where city sidewalk is impacted,
City Manager approval required:
Nelson Van Liere,City Manager
Page 2 of 2
TY OF ATLANTIC BEACH
800 Seminole Road
Atlantic Beach,Florida 32233
31
0 Telephone(904)247-5800
-1 FAX(904)247-5845
FT OR
CORRECTIONS TO FXA�IEW COMMENT
Dlded:Z�- I(a � Received by: Resubmitted:
Permit Number: 1� - PAA-r,- z6q
Original Plans Examiner:--)� W"t Name:
ProjectAddress: J�qO f? M AV�a
Contractor: Contact Name: fX I Vr
,P- KRALYr—
Contact Phone Contact e-mail:
Revision/Plan Check/Permit Fee(s)Due: $ S-0,06
Description of Proposed Revision to Existing Permit:
Fiamwil 06 M---(�LVV5,W- FOR- DB,� ?,kt-(o e-opc&s'f-fi�;-
' n
Triew-ab IN -rxap- � JRGrw�A*OrJ A-f�9,4-VU--
Additional Increase in Building Value: $ Additional S.F.
Site Plan Revised: Public W U Approval:
By signing below.I(print nme) OLLVMR— affirm that the above revision
is incl i of the proposed changes.
77f,,AJ,'A � v,
Signature of Contractor/Agent(Contractor most sip ifinerense in valuation) Date
Office Use Only
Dole: Appro�ed� Rejected- Notified by
Plan Review Comm t
11,20,r6u,rof �-z
Department review required Yes An
U no
VI-an—ning &Zoning-)
Tree Adm—in—iSWo—r Plans Examiner
1 0
libli,Utilities -dci
7�u-blic—Safety Date �V]3116 lo�3
map Output �qo 2 0 IF' Foow�r
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SOv2GZ Fadc' THIS PLAN MUST BE
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EACH INSPECTION
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City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned to th B Iding Department.)
800 Seminole Road I
Atlantic Beach,Florida 32233-5445 Z -R ZA"k
Phone(904)247-5826 - Fax(904)247-5845
E-mail: bui[ding-dept@coatims Date muted:
City web-site: hftp://�.Coab,us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 624 0 PnLVV)j Ayc_ De artment review required es No
Sn L__T P (,�,LD, uildln,2
A _Dr
Applicant: nn ng &Zonin
ree mi or
Project: (2) 0 0 PC C—7-C— ublic Works
i ies
u JC
in Services
Review fee Dept Signature
Other Agency Review or ermItRequired Review or Receipt
of Permit Verified B Date
Florida Dept,of Environmental Protection
Florida Dept.of-Fransportagon
St.Johns River Water Management District
Army Corps of Engineers
1- 9- 97mi
Division of Hotels and Restaurants
Division of Alcoholic Beverage-ancl I'---
Other,
APPLICATION STATUS
Reviewing Department First Review: []Approved. ADenied.
(Circle one.) Comments:
BUILDING
PLANNING&ZONING Reviewed by:'O'�..'� Date:
TREEADMIN. Second Review: ElApproved as revised. DDemed.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: EIAPProved as revised. DDended.
Comments:
Reviewed by: Date*—
Revised 0&14109
ZONING RIEVIEW COMMENTS
City of Atlantic Beach
Community Development Department
800 Seminole Road Atlantic Beach, Florida 32233-5445
Oil Phone: (904)247-5826 1": (904)247-5845 Email: dreeves(gcoab.us
Date: 12/9/16
Permit: 16-RAAR-2697 Applicant: Salt Air Homes
Review: pt Address: 640 Palm Ave,Atlantic Beach,FL 32233
Site Address: 640 Palm Ave Phone: (904) 333-6607
RE#: 170439-0010 Email: o.kmut@comcast.net
Correction Comments
1. Tree Removal: Section 23-21 requires a Tree Removal Permit for any trees removed within 2 years of
this project. Please submit a Tree Removal Permit Application if any trees are to be removed or were
removed in the last 2 years. If no trees are to be removed or were removed, then please fill out an
Affidavit of No Tree Removal. Both forms we available on the city website under "Planning and
Zoning"and at City Hall.
Derek W. Reeves
Planner
dreeves@coab.us
EGIE UVE TY OF-ATLANTIC REACH- --
800 Seminole Road
Atlantic Beach,Florida 32233
Telephone(904)247-5800
REE 10 FAX(904)247-5845
14LET OR
CORRECTIONS TO EW COMMENT
Date: J (0 Received by- Resubmitted:
Mum
Permit Number:
Original Plans Examiner: ect Name:
Project Address: 6qO
Contractor: Contact Name:
Contact e-mail:
Contact Phon
Revision/Plan Check/P mit Fee(s)Due: $
Description of Proposed Revision to Existine Permit,
Additional Increase in Building Value: Additional S.F.
Site Plan Revised: Public W/U Approval:
By signing below.I Wat nerie) OLIVY--gre— affirm that the above revision
is inclu��of the proposed changes.
U&-:"\ � QU,,4- 1-2 (0 ,
Signature of Contractor/Agent(cmusemr must sip if inem._ie,.l.afin) Date
office Use Only
Date: Appuowd: JC— RejeeW Notifiedby:
Plan Review Comments:
W DeDartment review re uired Yes No
ul in
anning &Zoning
Tree Adminis ra or Plans Examiner
Public Wo
ublic Utilities
ublic;Safety
Fire Services
Date C—ludVMs R-.1
TREE & VEGETATION AFFIDAVIT OFFICE COPY
City of Atlantic Beach
Department of Community Development
Planning&Zoning Division
ro 800 Seminole Road Atlantic Beach,FL 32233
(P)904 247-5800 IF)904 247-5945 PERMIT# jfQ
'wner(s) F- Legal Authorized Agent-
SECTION I-APPLICANT INFORMATION Vb
NAME OF APPLICANT vr=7ca (2Au
NAME OF COMPANY
ADDRESS OF COMPANY
PHONE CELLQ(JL1 3F,5 --660'7EMAIL 0. VRAVr(,P
CONTRACTOR CERTIFICATION NUMBER
ATLBCH BUSINESS TAX RECEIPT NUMBER V E
SECTION 11-SITE INFORMATION DEC 1 3 2016
STREET ADDRESS OF PROPERTY 6qo PAL�WA AVE .
lfonadd�hasnotbmnmsig�toMispWerty,�ntwt�ASBuiWingD6.,,,,(�)247-5816r,=um�nWdm.
LEGAL DESCRIPTION
LOT BLOCK SUBDIVISION
REAL ESTATE NUMBER LOT OR PARCEL SIZE: SO FT AC
RESIDENTIAL k/ COMMERCIAL OTHER(SPECIFY)
I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Natim Vegetation"of the Municipal Code of
Ordinances for the City ofAtlaratic Beach,FL andlar I have participated in a pre-application meeting with the Administrator of those
regulations. Subsequently,I affirm that no regulated trees and no regulated vegetation will be damaged,destroyed andlor removed
from the&v"escribedor,d' -entprope in conjuncrion with this project.
SIGNATURE OF OWNER SIGNATURE OF OWNER
Signed and sworn before me on this 1�,t dayof I aVIV by State of
�" A - 4 b AA� am�W4 Countyof
IdentillsIn veril: U DL�
Oa th sworn: r- yes r- No
Notary V%nature U
WM:O�V.2= MY Commission expires:
RE
City of Atlantic Beach
Building Department :APPLICA:TION NUMBER
800 Seminole Road (To be assf.gned b the Building Department)
Atlantic Beach, Florida 3223' IL -7
Phone(904)247-5826 - F��(VN45)247 liDa:te muted: I AAR
E-mail building-dept@coab.us -3 EC 0 2 016
CitYweb-site; hffP:/Av�w.,oab.us
BY.
APPLICATION REVIEW AND TRACKING FORM
Property Address: PALyin AVL�- De artmentreviewre uhred Yes No
Buildin
Applicant: arming&Zonin
r In r
Project: 12 C--C— u lic Works
I fes
u I
Fire Services
Review'ee p9pt�igqa�U-re
Other Agency Review or Permit Required Review or Receipt
Florida Dept.of Environmental Protection Of Permit Verified B D to
Florida Dept.of Transportation
St.Johns River Water Management District
Army corps of Engines,
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other.
APPLI ATION STATUS
Reviewing Department First 7Revjew: fi�fApproved. E]Den,,d
"Op
(Circle one.) Comments:
rBUILDING
PLANNING &ZONING Reviewed by. /zle Date: zl�/
TREEADMiN. So d ....... rl.__ I� —
Second Review: ElApproved as revised. [_]D01,cL
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date*
--------------------------
FIRE SERVICES Third Review: E]Apprv.d a.revised. E]Denled.
Comments:
Reviewed by: Date:
Rvvissd 05/14109
"Ilz
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r317 TY OF ATLANTIC REACH-
800 Seminole Road
Atlantic Beach,Florida 32233
Telephone(904)247-5800
PAX(904)247-5845
1,T OR
CORRECTIONS TO VA�VEW COMMENT
Date: Received by- A Resubmitted:
-L2- I - I(a //10� )
Permit NumbW---
ACE�A-K-2-G
��U
Original Plans Examiner: ect Name:
Project Address: i�qO
Contractor: ContactName: fY=J -VEP- RALXr-
Contact Phme Contact e-mail:
Revision/Plan Check/—PerrmtFee(a)Due:
Description of Proposed Revision to Existing Perunit:
I A19 b, .. $� 1
Additional Increase in Building Value: $ Additional S.F.
Site Plan Revised: Public W/U Approval-
By signing below.I Wnt nsine) OLWMIr- �, V?2&tr—K affirm that the above revision
is incln��of the proposed changes.
NLA�� � 1-2 (0 ,
Signature of Contractor/Agent(C.nnftd� st sign if himass in valuatim) Date
off..Uin onl,
Appni�d Rj.tnd: Ntifi,dby-
Plan Review Comments:
review re ui Yes F-NoJ
2 niingi &Zoning
a I Examiner
rTres Administ-rator
Public Wo
ublic Utilities
Public Safety
FireSewlces Date
WP output 6qO J>N-VA 2 o f=oc.-r- 12/1116.1:SZPM
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City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned b the Building[)apartment.)
800 Seminole Road
Atlantic Beach,Florida 3223 DEC 0 2 2016 1 Z__7 A A R-ZG9 -7
x(9
Phone(904)247-5826 - Fa 4247-5845
E-mail: building-dept@coab. s U Date muted
City web-site: hhp:1Awvw.wZ.uPy-'_ __1
APPLICATION REVIEW AND TRACKING FORM
Property Address: L40 PALin(\ A-VL=- Department review required Yes No
FA OLA�l�_D BUildin
ree M1
Applicant: nning &Zomn
Project: (2 Q_C-1c C_ ublic Works
I lea
Fire Servce,
U lic-Swuly
Review fee
$_-1--� DepdSignatu're
Other Agency Review or Permit Required Revjrev�
of Pe "t=PBY
Florida Dept.of Environmental Protection
Florida Dept.Of Transportation
St.Johns River Water Managmmm District
Any Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APP1,1ZATION STATUS
Reviewing Department First Review: [�Approved. DDenled.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: YX�, Date: I
TREEADMIN. Second Review: DApproved as revised. E]Denied.
C aORK Comments:
C re.�?'( L—It-4-1 J
PUBLI UTYIE
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: E]Approved as revised. EJDemed.
Comments:
Reviewed by: Date:-
Revised 05114109
R.O.W. Permit Attachment of— for
R.O.W. Permit# issued 20 Atlantic Beach,FL 32233
Owner's Name: mdvg�
Property Address: 640 1�1�
AALAr-�W-- FW& 52--Z55;
Subdivision:
Lot#/Block#:
R-E. #: no qsq - 001 o
REVOCABLE ENCROACHMENT PERMIT
THIS REVOCABLE ENCROACHMENT PERMIT, issued on this _ day of
, 200, by Atlantic Beach, Florida, a municipal corporation organized and existing
under the laws of Tb State of Florida, hereinafter referred to as"CITY" 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 purpose as described in the City of
Atlantic Beach Right-of-Way/Easement permit numbers noted above (copies attached).
This work is generally described as: ADAwc ?Aet�10(,
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, to the following address:
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 my 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-dcscribed 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 me 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 I of 2
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 inwe 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 my of the work herein under the terms of this
permit and that all of said liabilities me hereby assumed by the USER.
DATED and SIGNED this Z— day of t)6c- --n 16
By:
Property Owner
(to be signed in presence of the Notary) T'0W11'61N PERGER
MY N#F9SIV
EXPIRES alober 6,W19
STATE OF FLORIDA Bun&d ThN%�Publc JW�
COUNTY OF DUVAL
On this day of 20� personally appeared before me, a Notary
Public in—and for said County and State, the property owner of
, Atlantic Beach, Florida, known to me to be the person(s)
described in and who executed the fo�cgoing instrument; 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:
Donald D. Jacobovitz,P.E. Public Works
Director
For Permits where city sidewalk is impacted,
City Manager approval required:
Nelson Van Licre, City Manager
Page 2 of 2
TY OFATLANTIC BEACH--
[ROVE 800 Seminole Road
Atlantic Beach,Florida 32233
D DEC 13 2016 Telephone(904)247-5800
I FAX(904)247-5845
ISIGN-REQUEST S&M,T OR
CORRECTIONS TO TEW COAMENT
'T'O
Date: (-z– J(0 Received by- Resubmitted:
Permit Number: eA _ 7_(0
Original Plans Examaner: j.ect Name:
Project Address: 040
Contractor: Contact Name—_
Contact Phm Contact e-mail:
Revision/Plan Clu�k/—Pe=tFee(a)Do,: $
Description of Proposed Revision to Existing Permit:
VA 0\VJ I N larzm V
TUMM W =aff_ � USA= orJ A,*�- ik A-v
Additional Increase in Building Value: $_ Additional S.F.
Site Plan Revised: Public W U Approval:
By signing below.I(Mint nme) 0L_tVV_=fr_ affirm that the above revision
is inclu��of the proposed changes.
ULA�� � 1'2 -
Signature of Contractor/Agent(Connsoor mmt sip ifincmaw in valuenjon) Date 0 ,
offi.n U.Only
D-b�; 16 Appwed: /
Rej.l,d Nofifled by-
Plan Review Comments:
L
De artment review uired Yes No
U111 in
anning&Zoning
TreeAdminis or Plans Esaminer
PublicWo
ublic Utilities 1,
ublic;Safety
Fire Services Date