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1542 PARK TERR W - PAVER DRIVEWAY CITY OF ATLANTIC BEACH > 800 SEMINOLE ROAD �� ATLANTIC BEACH, FL 32233 '40.2 INSPECTION PHONE LINE 247-5814 DRIVEWAY - SINGLE OR TWO FAMILY DRIVEWAY MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814 PERMIT INFORMATION: PERMIT NO: DWAY17-0022 Description: REMOVE CONCRETE DRIVEWAY AND REPLACE WITH PAVERS Estimated Value: 0 Issue Date: 10/27/2017 Expiration Date: 4/25/2018 PROPERTY ADDRESS: Address: 1542 W PARK TER RE Number: 171940 0000 PROPERTY OWNER: Name: COLEMAN CYNTHIA Address: 1542 PARK TER W ATLANTIC BEACH, FL 32233 GENERAL CONTRACTOR INFORMATION: Name: Address: Phone: Name: KETTELL INC. Address: 1860 MAYPORT RD ATLANTIC BEACH, FL 32233 Phone: PERMIT INFORMATION: Please see attached conditions of approval. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOU PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. * A notice of Commencement is only required for work exceeding an estimated value of $2,500. For HVAC work, a Notice of Commencement is only required when HVAC work exceeds and estimated value of$7,500. i�L�� City of Atlantic Beach APPLICATION NUMBER 6S .; Building Department (To be assigned by the Building Department.) 800 Seminole Road 19 '\w L 7 `DO?Z_ ,� _ s�, Atlantic Beach, Florida 32233-54450�� T +� Phone (904)247-5826 • Fax(904)247-5845 'moi J;lir'- E-mail: building-dept@coab.us Date routed: J 0 /1 $5./1 7 City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: 1 s4-z Pte* (C-� & Department review required Yes No II _ Building KApplicant: E I TELL- I N Q__.- Planning &Zoning"--"N_ Tree Administrator Project: P ve-R., D RL v>-wpc y - ublic Wor< - J Public Utilities 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 ( P' 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: Approved. I IDenied. ['Not applicable (Circle one.) Comments: BUILDING c PLANNING &ZONING Date: r/77'f// Reviewed by: TREE ADMIN. Second Review: nApproved as revised. Denied. Not applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: ❑Approved as revised. I !Denied. nNot applicable Comments: Reviewed by: Date: Revised 05/19/2017 r51-tvi City of Atlantic Beach APPLICATION NUMBER r � Building Department (To be assigned by the Building Department.) s: 800 Seminole Road A 1 y 0OZ \�ll J Atlantic Beach, Florida 32233-5445 �`1 (VI / Phone(904)247 5826 • Fax(904)247-5845 % 1 01110. E-mail: building-dept@coab.us Date routed: 10 II g i 7 City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: 1 S4Z Pte, (C-12- Department review required Yes No II K N Building _ Applicant: E 1 I au-- t Q _ Plannin• &Zoning Tree Administrator Project: P t v- D i-zt ew'yclrublic Wo - Public Utilities 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 ( f)' St.Johns River Water Management District 4 C./ Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APPLICATION STATUS Reviewing Department First Review: , Approved. Denied. Not applicable (Circle one.) Comments: BUILDING PLANNING &ZONING / Reviewed by: ‘,/-* --- Date: (67- la—T.? TREE ADMIN. Second Review: Approved as revised. ❑Denied. Not applicable PUBLIC WORKS Comments: PUBLIC UTILITIES PUBLIC SAFETY Reviewed by: Date: FIRE SERVICES Third Review: Approved as revised. Denied. ❑Not applicable Comments: Reviewed by: Date: Revised 05/19/2017 .. „4,..,.„ Building Permit Application Updated 5/5/17 City of Atlantic Beach 800 Seminole Road,Atlantic Beach, FL 32233 j,,,Y Phone: (904) 247-5826 Fax: (904) 247-5845 ;� {� Job Address: ( 9G( - P•I'/Z 're4-' -‘'s CL 1/14 j 7 Permit Number: `�� ' `1/4-t r7 00 2...Z.. Legal Description 77`G 4_ L5 *-7q€ 914/27oo na l/n,tZ Cdf b 6�/Iick RE# 17/ '7 Le 0000 Valuation of Work(Replacement Cost)$ 13 1 Set 7- Heated/Cooled SF /I Non-Heated/Cooled4/1 • Class of Work(Circle one): New Addition Alterat Repair Move Demo Pool Window/Door • Use of existing/proposed structure(s)(Circle one): Commercial residential • If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No • 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: Ie-tie Co,n/,t't- an Ye i- k 4 r /4 Ce 1-);h- Pm.4 5 Florida Product Approval# for multiple products use product approval form Property Owner Information f /. j' / Name: (. li4, e,r-r -6 r. r Address: /5117 z 1/`t Itcrki-e_�uttiesok City IVV(4,.. 9 L { t a- St to r L Zip 312-3 3 Phone_geg 0-7/6 t o 6 4 40.7 E-Mail G'SL c le. .r, 7/e' 0-- 6rvt a,;/. c e' — Owner or Agent(If Agent, Power of Attorney or Agency Letter Required) Contractor Information 144-1a,1,-,6, `,"�},,�/� �C / Name of Company: !�y / Qualif i g Agent:"�14 l.P'1" Address 10 O mCc-,, �+p''l- A e-el City Arvh t,/ c✓� State rL Zip 322 3 '3 Office Phone *II 31't lZT_e Job Site/Co",tact Numbef 1C }si lief/ fell 371 /mg State Certification/Registration# E-Mail ON /6/..7P&It • teev.� Architect Name&Phone# Engineer's Name&Phone# Workers Compensation CON PA Exempt/Insurer/Lease Employees/Expiration Date Application is hereby made to obtain a permit to do the work and installations as indicated.I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all the laws regulationg construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING,SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,and AIR CONDITIONERS,etc. OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. 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. /2 .b,.. ; aGieZia _...---, ...,iairdirde- ..AIIIIIIP,111111r (Signature of Owner or Agent) (Signa . - of ontractor) (iricl.o :contractor) t`-7 Si ned nd sworn to(or a :"1, bef• me this day f Sig ed nd s torn to(or of :•)before me this` [ day of C , Ol.b . MA* ' -1 n.p Uo 0 c ' . 4. ......_..,-e-,..!:._.-..- -,re2 .22....-.2!---- .r--- WAIL Igiltift , ,,.,„ ,,, °..i '' TONI G (Sign: ure of Nota (Signature of Notary) / `.s MYCOMM1 ,; rr ,.)1 i 'a EXPIRES October 62019 7CNlGINDLESPE-;��'ii '14;,.9:q 4P' Bonded Thrc Notary P c incernriierc ( [-1). ,: MY COMMISSION tt FF 924951 EXPIRES October 6,2019 [ ]Personally Known OR \ Personally Known OR BcndedThr,Noan°b4cunderun,ers tproduced Identification 1� J C_... [ 1 Produced Identification y = .-- Type of Identification: Type of Identification: NOTICE OF COMMENCEMENT State of County of ((1 1.)1.)CLA Tax Folio No. To Whom It May Concern: The undersigned hereby informs you that improvements will be made to certain real property,and in accordance with Section 713 of the Florida Statutes,the following information is stated in this NOTICE OF COMMENCEMENT. " � Legal Description of property being improved: 1:1-6 /6-ZS -ZA t cell .Monc V n I t _I t- 1t* 3 R E I-11 @Ko Address of property being improved: I SV Z cr i,P f'rr ze. General description of improvements: RPM eve (pry,{ L d1/ +.. r� 4 (pf/Q s€ Owner: CA n711,Iirkt. 'M Address: / 5-1/z126 4/ f Y4.I 1.451- Owner's interest in site of the improvement: Fee Simple Titleholder(if other than owner): tj Name: n Q `1 ontractor: /Xeat ZilL_ Address: 1 g O goad Telephone No.: 'My 37Z c_z6 Fax No: • Surety(if any) Address: Amount of Bond$ Telephone No: Fax No: Name and address of any person making a loan for the construction of the improvements Name: Address: Phone No: Fax No: Name of person within the State of Florida, other than himself, designated by owner upon whom notices or other documents may be served: Name: Address: Telephone No: Fax No: In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 713.06(2)(b),Florida Statues. (Fill in at Owner's option) Name: • Address: Telephone No: Fax No: Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a different date i specified): THIS SPACE FOR RECORDER'S USE ONLY OWNER Signed Date: IO it 7 A 7 Before me 's i 7 day of� )S in the County of Duval,State Doc#2017245815,OR BK 18164 Page 1883, Of Florida,has personally appeared ( Number Pages:1 Personally Known: or Recorded 10/27/201710:29 AM, Produced Identification: S Z- - .-. , g -- RONNIE FUSSELL CLERK CIRCUIT COURT DUVAL Notary Public: COUNTY RECORDING $10.00 My commission expires: :r •. , - TONI GINOLESFERGO -4i as MY COMMISSION#FF 924951 11 EXPIRES:October 6,2019 yl , Bonded Thru Notary Pubic Underwriters I'• ip.,Altd- r) r to r15 4:Iwo); 1 REVOCABLE ENCROACHMENT PERMIT THIS REVOCABLE ENCROACHMENT PERMIT,issued on this day of 20 by the City of Atlantic Beach,Florida,a municipal corporation organized and existing under the laws of the State of Florida,hereinafter referred to as"CITY"and ,n f t itA (D/e..r,,a, of Atlantic Beach,Florida,hereinafter referred to as SER". WITNESSETH: That the CITY does hereby grant the USER permission on a revocable basis as described herein the right to enter upon the property for the purpose as described in the City of Atlantic Beach Right-of-Way Permit# . This work is generally described as ' Any facility maintained, repaired, erected, and/or installed in ffe ercise of the privilege granted remains subject to relocation or removal on thirty(30)days' notice by CITY to USER, said notice to USER shall be given by certified mail, return receipt requested,to the following address 154Z Air7~ f k c • 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." • 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 within 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 right-of-ways 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. I Lc. Date / 7 (( 7 Pro;•rty Owner/Agent(signed in presence of Notary Public) STATE OF FLORIDA,COUNTY OF DUVAL The foregoing instrument was acknowledged this f"7 day of 00.._4__ 20 1 7 , by hkl 4' _ 'e .` t r1 k ,who personally appeared before me and (pri ed name of Signer) ackno :ed that- e signed the instrument voluntarily for the purpose expressed in it. 0 _ A4 ,.., , Signature of Notary Public, State of F orid. Approved/Public Works Department: Personally Known ; Produced Identification '• -(o 7 S� w T c 9ISSIQN#EF 9 / C/� t z NI GISSION 8 EF 924951 `/J �� EXrit October 6,2019 s Interim Public orks Director ,,,-:.• ucrrdcd T:.,•,; "y Public Underwriters Scott 1 , I ,T1 / ._ RIGHT-OF-WAY/EASEMENT PERMIT ,f, Permit#Issued by the City of Atlantic Beach PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES Job Address 'S'/7 IP Pik' kn- z,L2 (,h,j' - Phone qOl, 7/, 6'/G 7 .. 6 �_- Permittee ht /, 7G�1 Email C. 1 ° a n �-j 71��� ,,� . Requesting Permission to Construct `I(kP ,Zc //, �.,�, �-�Vit,, ., LocationReference to Cross-Street)) SPrnnirl0le Piat1 • Permittee declares that prior to filing this application they have ascertained the location of all existing utilities, both aerial and underground and the accurate locations are shown on the sketches. • 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 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 Permittee unless reimbursement is authorized. • All work shall meet City of Atlantic '`J / Beach or FloridadaDepartment of Transportation Standards and be performed under the supe ision of /4, fL. / (Project Superintendent) located at 1 v/€/'/ vhf /$ Q /79 „,-/-R,,,/ , Z Z 3 3 • All materials and equipment shall be subject to inspection by the Director of Public Works. • 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. • 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. • The permittee shall commence actual construction in good faith within 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. • 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. • The Director of Public Works shall be notified twenty-four(24)hours prior to starting work and again immediately upon completion. i/i i, _.4, i c Date 10/i7 (( 7 Per;j ttee(signed in presence of Notary Public) STATE OF FLORIDA,COUNTY OF DUVAL ( �j The f regoing instrument was acknowledged this I`7 day of 0 20 by t I Q, 0120 kin a t\ - A&-t ' 1�e /� ,who personall a eared before me and (printed name of Permittee) ackn edged h she signed1.o�r"y';, TONI COMMISSIONI #ERGER g the instrument voluntarily for the purpose expressed in it. 1 2 , MY FF 924951 I .z EXPIRES:October 6,2019 Bonded Thru Nc:ay Public Underwater. Personally Known Signature of Notary ublic, ja f Florida Produced Identification(Type) J 4 52.-10 3" '1-7 S5--C 1 'r� 'DYJ}'d� R_, Q(2 a E) spoyv7chlilk0A.. oos of'v3 Wx") srAN jr"1") 0t � Tvy "/"PNPS 2J fiAork-r) zL 5r-1 .5 ?volt.-5 pi) 4-},c1") h1)4I2 aSneN 5/i2I rs, �, TREE & VEGETATION AFFIDAVIT 7 r..- , City of Atlantic Beach I frv._" --... Department of Community Development '','r "~ Planning&Zoning Division . 800 Seminole Road Atlantic Beach, FL 32233 (P) 904 247-5800 (F)904 247-5845 PERMIT# SECTION I-APPLICANT INFORMATION Owner(s) E Legal Authorized Agent* NAME OF APPLICANT Cr40 Airk 4lei-rm.-) i4c/j4//NAME OF COMPANY ( ADDRESS OF COMPANY Si 119Arlpef/- e ea,�oPHONE lC CELL ,/ �( � �� '�4y 37z 71,6go y j77/0063-EMAIL I n� Klt���/hC • CDM CONTRACTOR CERTIFICATION NUMBER ATLBCH BUSINESS TAX RECEIPT NUMBER SECTION II-SITE INFORMATION / STREET ADDRESS OF PROPERTY l 3 L(Z Rfi r-r8i Le t _k q--tIf an address has not been assigned to this property,con-a��ctt tthhe AB Building Department at (904)247-5826 to request an address. LEGAL DESCRIPTION 71 -6 t 'o_ 7 S_ 2A ji LOT 6 BLOCK 3 SUBDIVISION r�l✓(t WA4 U;'/2- REAL 7LREAL ESTATE NUMBER 1701,10 _000 LOT OR PARCEL SIZE: Gill SQ FT AC RESIDENTIAL \/ COMMERCIAL OTHER(SPECIFY) I affirm that 1 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 regulations. Subsequently, 1 affirm that no regulated trees and no regulated vegetation will be damaged, destroyed and/or removed from the above-described or ad'acent properties in conjunction with this project. , 1.. 410,e47ica-a— SI Ii ATURE OF OW 1 ER SIGNATURE OF OWNER Signed and sworn before me on thi47 day ofc( ,Z((7,by State of ' ( County of bC.� Vim( Identification verified: v 45 :�' 03 - 2 Oath sworn: Yes (— k. r ,....._ 4. Or 4 fa. Notary Signature trN'ii14f;�ESPER6ER 14Y COMMISSION M FF 924951 My Corn mission expires: - EXPIRES:October 6,2019 MAP SHOWING BOUNDARY SURVEY OF: LOT 6, BLOCK 3, SELVA MARINA UNIT NO. 2 AS RECORDED IN PLAT BOOK 27, PAGES 6 AND 6A OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA S: LOT 7 r t O O —+ PLAT 175 � IRO" PIPE N )r 174.63 MEASU ouND 11:TIFICATION •� N78°03110° 0,24„E "° � � N78 PIPER U ��2.� IRON PI FOUND IDENTIFICATI _ • s �' SNEor F:exe rn-. 4.- 16.0'1Cw O_ 3.l' PI 4E0 13‘. rillri 101i Y 1 0.7' 34.3. cik .33 ,.”. \ z L NOTE TREE DOWN IN THIS .$- mV —�' £o AREA - UNABLE TO COMPLETE 1 N m , , 1 o MEASUREMENTS w o .A \ 0 , c 9 ° 01 ''Ti _- A CO RED \ ➢ m 01 m 1 • 1 c� n CONCRETE 5�.• O CS� A z �m m 25. O (3l `a •• 21.0 m O O m o.5 D3 O G ua V \\\\,>) ,\ 1 \ti t. ,x 1 w 49 9 • D (n ( n v 1 C V '_ _a v\ / `mei 44.6 co 24.4 M \ C, 1 WALK co.._ VAD • O /i� CONCRETE AS •P •� \ ",I PIPE C�_ \�. n 7t� FOUND ENTIF CATION m ,J�'— ' MEASURty X0.8'1 -' % '45„ \A/ 174.73 ' PLAT o IRON PIPE Q 7 5.Q Q I. O» FO NO ID NTIFIGATION S `-' o O v 0 Sig LOT 5 w \ 0 0 ZZ o 0 3 o� Z N C 73 -n_.Z1 O > Z o -0 'Z Z 1-1 m N o P.C. NOTES' THIS PROPERTY LIES IN FLOOD ZONE X” PER FLOOD INSURANCE RATE MAP (FIRM), DUVAL COUNTY, COMMUNITY No. 120075, MAP/PANEL No. 12031C-0409-H, REVISED JUNE 3, 2013 BEARINGS BASED ON THE WEST RIGHT-OF-WAY LINE OF PARK TERRACE WEST AS BEING SI1'56'50"E 40' BUILDING RESTRICTION LINE (B.R.L.) BY PLAT P N.T.S. DENOTES NOT TO SCALE O ALL LOTS SHOWN HEREON LIE WITHIN BLOCK 3 CERTIFIED Mr -X— DENOTES 4' WOOD FENCE EXCEPT AS NOTED CYNTHIA COLEMAN ‘ 0\''C �p OF THERE MAY BE ADDITIONAL RESTRICTIONS THAT ARE NOT SHOWN ON `�\\\"'�\G� THIS SURVEY THAT MAY BE FOUND IN THE PUBLIC RECORDS OF (i DUVAL COUNTY, FLORIDA. \°C) 1 I hereby certify that this survey meets the ISI ' minimum technical standards as set forth by DURDEN1 the Florida Board of Land Surveyors, pursuant to Section 472.027 Florida Statutes and Chapter SURVEYING AND MAPPING, INC. 5J17 Florida Administrative Cod 1825-B 3RD STREET NORTH I JACKSONVILLE BEACH, FLORIDA 32250 I (904) 853-6822 FAX 853-6825 g/igezeit le") LICENSED BUSINESS NO. 6696 FLORIDA REGISTERED SURVEYOR No. 4707 H. BRUCE DURDEN, Jr. SURVEYOR'S NOTE' THE SURVEY HEREON WAS MADE WITHOUT THE BENEFIT OF ABSTRACT OR SEARCH OF TITLE AND SIGNED OCTOBER 9, 2017 THEREFORE THE UNDERSIGNED AND DURDEN SURVEYING AND MAPPING, INC., MAKE NO CERTIFICATIONS REGARDING INFORMATION SHOWN OR NOT SHOWN HEREON PERTAINING TO EASEMENTS, CLAIMS OFSCALE: 1" = 20' EASEMENTS, RIGHTS-OF-WAY, SETBACK LINES, OVERLAPS, BOUNDARY LINE DISPUTES, AGREEMENTS, - 919 4 RESERVATIONS OR OTHER SIMILAR MATTERS WHICH MAY APPEAR IN THE ABSTRACT OR SEARCH OF TITLE. WORK ORDER NUMBER: 17630 THIS SURVEY NOT VALID UNLESS THIS PRINT IS EMBOSSED WITH THE SEAL OF THE ABOVE SIGNED.