2021 SELVA MADERA CT - REVISION 12/1/17 CITY OF ATLANTIC BEACH
r ` -0 800 Seminole Road
-� Atlantic Beach,Florida 32233
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REVISION REQUEST/ CORRECTIONS TO PLAN REVIEW COMMENTS
Date 42- cY-/7 Revision to Permit Corrections to Comments Permit# /7—RA DP-306 5
Project Address ZO J ./ - _ 4 ,-Hei c., i--.‘,._ 3 C( FL.-- .22
Contractor/Contact Name /4 (..iii c.. ��Lv;iy-e- -14
Phone ?(),(t 24 2- iF3 5-.Z Email / (±, 36 C I(`(,(4c,(vb, `„4/,c Co C-<-
Description of Proposed Revision/Corrections: Revision Review Fee Due $
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Additional Increase in Building Value $ Additional S.F.
By signing below,I affirm the Revision is inclusive of the proposed changes.
(printed name)
Signature of Contractor/Agent(Contractor must sign if increase in valuation) Date
(Office Use Only)
Approved / Denied Not Applicable to Department
Revision/Plan Review Comments
Department Review Required:
:tiilrling �j- id��
.lann�ing : Zoni b g a Reviewed By
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Tree A s m i n i,. .-,-r ,
Public Works / 2-- y _ I
Public Utilities
Public Safety Date
Fire Services
., , i TREE & VEGETATION AFFIDAVIT AFFAVIT 1
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Cvi y (.,f Athho�t oc Beachli
. _. ,• Department of Community Development
Planning&Zoning Division
; =o`':s , 800 Seminole Road Atlantic Beach,FL 32233
(P)904 247-5800 (F) 904 247-5845 PERMIT# /
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SECTION I-APPLICANT INFORMATION 1 Owner(s) f Legal Authorized Agent*
NAME OF APPLICANT I/ 44 (
NAME OF COMPANY
{ ADDRESS OF COMPANY
� 1
PHONE CELL , r/ r
7o( 213s� 5.00,6 EMAIL GtGlo 3p cl f t-b uv�,,i7 e.Co a4
CONTRACTOR CERTIFICATION NUMBER
//
ATLBCH BUSINESS TAX RECEIPT NUMBER
SECTION II-SITE INFORMATION
STREET ADDRESS OF PROPERTY �zi 5,4,Le-, /dale L/C, /2— (A.1---
let':C_ ge^�r gc FL ?...22-?.R
If an address has not been assigned to this property,contact the AB Building Department at(904)247-5826 to request an address.
LEGAL DESCRIPTION
LOT BLOCK SUBDIVISION
REAL ESTATE NUMBER LOT OR PARCEL SIZE: SQ FT AC f�
RESIDENTIAL COMMERCIAL OTHER(SPECIFY)
I affirm that I have reviewed the provisions of Chapter 23, "Protection of Trees and Native Vegetation"of the Municipal Code of
Ordinances for the City of Atlantic Beach, FL and/or I have participated in a pre-application meeting with the Administrator of those
regulation:. Subsequently,I affirm that no regulated trees and no regulated vegetation will be damaged, destroyed and/or removed
from the r Bove-.- ibed or ad-acent properties in conjunction with this project.
I,
SIGNATURE OF OWNE• SIGNATURE OF OWNER•
Signed and sworn before me on this ' day of DtCQ,� ��, z' ,by State of r( °rid
La c1/4 ,1.i nen �-
pf bn a � � County of Dal � 1 �
Identification verified: V-Uanoz( ` to¢,\ ` ``Q nSt
Oath sworn: � Yes �- No l
lt:
, YPU�J'w JENNIFER JOHNSTON„ ... . .. . iii
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• * *_ MY COMMISSION#GG 042984 Notary Signa, e
o EXPIRES:October 27,2020
00' Bonded Thru Notary Public Underwriters - My Commission expires: