71 W 4th St ROW permit CITY OF ATLANTIC BEACH
i 800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
INSPECTION PHONE LINE 247-5814
RIGHT OF WAY PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-ROW-2594
Job Type: RIGHT-OF-WAY PERMIT
Description: extend existing culvert pipe on west side of driveway
Estimated Value:
Issue Date: 12/6/2016
Expiration Date: 6/4/2017
PROPERTY ADDRESS:
Address: 71 W 4TH ST
RE Number: 170823-0020
PROPERTY OWNER:
Name: LANGAN, IAN T
Address: 71 W 4TH ST
PERMIrINFORMATION: UTILITY DEPT.: PUBLIC WORKS:
Avoid damage to underground water/sewer utilities. Verify vertical and horizontal location of utilities.
Hand dig if necessary. If field coordination is needed,call 247-5834.
See attached Utility Map.
All runoff must remain on-site during construction.
Full right-of-way restoration, including sod, is required.
FEES:
Fence/ROW $35.00
Total Payments: $35.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
City of Atlantic Beach � APPLICATION NUMBER
BUISSd
mg Department - �;7r- (Tvb€assignedbythe Suildinng Department.)
800 Seminole Road
Atlantic Beach,Florida 32233-5145 NOV 18 z016 I b e W - aSti V
Phone(904)247-5826 Fax(904)247-
rg _1
�ru7>
E-mail building,tlept@ab.us BY: Date routed.
City web-site: hop:#/ .coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: Ll',�' a Department review re uired Yes No
Building
Applicant: �W(�4-r Planning&Zoning
Tree Administrator
Project: •LX_ t(1 aa, �/ �t1
b(� W)-St !S4t driap—Wltk
Public Safety
Fire Services
kteview fee $ Dept Signature 7G
Other Agency Review or Permit Required Review or Receipt Date
Of Permit Verified B
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:
APP CATION STATUS
Reviewing Department First Review: PJApproved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING
Reviewed by: Date: 2 G
TREE DMIN. > Second Review: ❑Approved as revised. ❑Denied.
WORKS Comme s:
IF TILII ES /
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised O6H4109
l'
City of Atlantic Beach APPLICATION NUMBER
Building Departmente p� (To be assigned by the Building Department.)
n e Road
AtlanticBeach,Florida 32233-5445 ..R 'JLT� Ib QOa - as`l y
Phone(904)247-5820 Fax(904)247-5845! 16 2016
r 9A E-mail: building-dept@mab.us Date routed: I I wrI I--+'
Cityweb-site: http://www.00ab.us k;
APPLICATION REVIEW AND TRACKING FORM
Property Address: Ll'1�1 "a 4FireeSewi�OsM
t review re uired Yes No
r.r, /
Applicant: ��1 �v�1 oning
11 strator
Project: �Xi Q.(i (A (1 U U� 1 Q
�n w t s de dri�Q awl
s
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified B
Florida Dept.of Environmental Protection
Flonda 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.
APPLICATION STATUS
Reviewing Department First Review: /Approved. ❑Denied.
(Circle one.) Comments: ,fErLp h �fiH,t /
BUILDING
PLANNING&ZONING
Reviewed by: Date: L
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
CITY OF ATLANTIC BEACH
- - - - -- CONSTRUCTION PERMIT WITHIN CITY RIGHTS OF WAY AND EASEMENTS
500 Seminole Road 904-247-5800
Atlantic Beach,Florida 322335445 F. 904-247-5845
Date ilZf7ZZolb PERMIT# IL'— OW- -
Job Address 7 j l4✓ 40 } ISSUED BY THE Cm
Permitee: —Z. Telephone# 101 - 311 -of 8t-��
Permittee Address: 1 1 3ZZ3
Requesting Permissionno Construct: +e �- t o oe LJ4
I n n
Location: (Referenceto Cross-Street)�,�..,,1 61
1. Applicant declares that prior to filling 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 in led too the following Utilities/Muni,Gipalities: R e # 32ZlOi
Jacksonville Electric Authori l� No ( ) Date: J1Z1( /Zai,
Bell South Telephone Com No ( ) Date: /r 4l� r ,��
Ferrell Gas No ( ) Date: /t / IC / 7,1g
Comcast ,fd' No O Date: It r r6 77-r`
2. Whenever necessary for the'fico girrmtOrl t, 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 Pemiiftee 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.
B. 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 I/n
Signed -'• C�,, Data
Before me this day of uJ th�QO he ul t
State Of Florida,has Peraeoallyappearetl 117=ij
HNSTONNotary Public at Large,State of Florida,Counh Duval. rNS W]991My commission expires: *27,2a20Personally Known: prKK prq�rnXtm
Produced Ident�catron: Ol.
R.O.W. Permit Attachment of for
R.O.W. Permit# issued '20 Atlantic Beach,FL 32233
Owner's Name:
Property Address:
Subdivision:
Lot#/Block#:
R.E. #:
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 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 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).
Thi,�s work is(�generap�ly described as: isfy +, g e�C G u
'Sr , OV r:4e t..-Q, - b L .J�
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 stake 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 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 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 ham less 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 j_ day of At. g,fes ,2011.
By:
Property Owner
(to be signed in presence of the Notary)
STATE OF FLORIDA
COUNTY OF DUVAL
On this I_'� day of L 0)bk/ 20 11p personally appeared before me, a Notary
Public in and for said County and State, J)-kJ ct\ o.n Gl F L , 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.
.g✓';lT.h.,k�k IIMIFERJOHNSrON
No Public ili fors Coun and State wr coxuisslos;r cc wesa
ty " sxalass:omx.sr.zoza
i.,arhs°l mm rvNo4ryP abWW wim
CITY OF ATLANTIC BEACH, FLORIDA,a
municipal corporation:
Approved:
Ozz
Donald D. Jac vi .E. Public Works
Director
For Permits where city sidewalk is impacted,
City Manager approval required:
Nelson Van Liere,City Manager
Page 2 of 2
IJEC [ CITY OF ATLANTIC BEACH
(OWNER / BUILDER AFFIDAVIT
NOV 1 7 2r
I. FLORID TUTEE; CHAPTER 488, FLORIDA STATUTES, PART 1 -CONSTRUCTION
G"R QUIRES 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 ACI'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 BUIL) OR
IMPROVE A COMMERCIAL BUILDING AT A COST OF 525,000.00 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,THE 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 THE BUILDING CODES AND ZONING REGULATIONS. IT IS
YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE
LICENSES RFOUIRFD 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 WORKERS BECOME EMPLOYERS AND SHOULD ALSO
OBSERVE IRS WITHHOLDING TAX AND/OR FORM 1098 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; 1 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.
71 W 1 1 "K-
ADDRESS 30U 9tl25
ADDRESS PONE N
-T L�a.
PRINT,f/V/Nf�.E � —s
SIGNATURE DATE
Beforeme Mie Ia dayof Nwui,a.i 20 Ikdn Me wuntya
Duval.State of Flonde,has personally appearad bedn by Mmself I hersell aM eMms Mal
all Statements and declarations am(Ne a1M accurate. 1
Notary Public at Large,Slate of ,County ofJ
DPm 10,lvAvn O� Y�'•"!j}. JENNIFER JOHNSFON
m.Pmacse lmmniceum- MYCOMNISSIGNYGG M1gN
v'' r El(PNiES:
w •✓,�i` BsnCstliku No aMbsf2>,2g2g
Ury PuMe LNdwrnllen
Notary Signature:
1 BLOCJOvna.BuiIMM aev's.D IlW
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