380 12TH ST DEMO19-0001 rqL-1r'fj. DEMO PERMIT PERMIT NUMBER
rs
CITY OF ATLANTIC BEACH DEM019-0001
800 SEMINOLE ROAD ISSUED: 1/17/2019
ATLANTIC BEACH. FL 32233 EXPIRES: 7/16/2019
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL WORK MUST CONFORMTO THE CURRENT • 1 OF • '
• OF • OF ORDINANCES .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
NOTICE: In addition to the requirements of this permit,there may be additional restrictions applicable to this property
that may be found in the public records of this county, and there may be additional permits required from other
governmental entities such as water management districts,state agencies,or federal agencies.
JOB ADDRESS: PERMIT TYPE: DESCRIPTION: VALUE OF WORK:
380 12TH ST DEMO COMPLETE DEMO HOUSE $20000.00
TYPE OF
ZONING: :D •
• • GROUP:
1719300000 SELVA MARINA UNIT 01
• . . ADDRESS:
J A LONG 1677 WELLS RD STE D RD ORANGE PARK FL 32073
• ADDRESS:
PETER & AMY POLLAK 380 12TH ST ATLANTIC BEACH FL 32233-5514
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT
IN YOUR 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.
LIST OF • . •
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
1 PUBLIC WORKS EROSION CONTROL INSTALLATION INFORMATIONAL
Notes:
Full erosion control measures must be installed and approved prior to beginning any earth disturbing activities. Contact the Inspection Line(904-247
-5814)to request an Erosion and Sediment Control Inspection prior to start of construction.
2 PUBLIC WORKS ON SITE RUNOFF INFORMATIONAL
Notes:
All runoff must remain on-site during construction.
Issued Date: 1/17/2019 1 of 2
DEMO PERMIT PERMIT NUMBER K
�. CITY OF ATLANTIC BEACH DEM019-0001
8
ISSUED: 1/17/2019
00 SEMINOLE ROAD
ATLANTIC BEACH. FL 32233 EXPIRES: 7/16/2019
3 PUBLIC WORKS ROLL OFF CONTAINER INFORMATIONAL
Notes:
Roll off container company must be on City approved list(Advanced Disposal,Realco Recycling,Shapells,Inc.,Republic Services,Donovan Dumpsters,
Phillips Containers,JDog/Dennis Junk Removal). Container cannot be placed on City right-of-way.
4 PUBLIC WORKS RIGHT OF WAY RESTORATION INFORMATIONAL
Notes:
Full right-of-way restoration,including sod,is required.
5 PUBLIC WORKS CONSTRUCTION SITE MANAGEMENT INFORMATIONAL
Notes:
Provide construction site management plan,including location of silt fence,dumpster,portable toilet. Right-of-Way Permit is required if using right-
of-way for construction parking.
6 PUBLIC WORKS RUNOFF INFORMATIONAL
Notes:
All runoff must remain on-site. Cannot raise lot elevation.
7 PUBLIC WORKS DOCUMENT IMPERVIOUS AREA INFORMATIONAL
Notes:
Strongly suggest thorough documentation of impervious areas be recorded.
8 PUBLIC WORKS SLAB DRIVEWAY REMOVAL INFORMATIONAL
Notes:
Slab and driveway to be fully removed.
9 PUBLIC UTILITIES UNDERGROUND WATER SEWER UTILITIES INFORMATIONAL
Notes:
Avoid damage to underground water and sewer utilities. Verify vertical and horizontal location of utilities. Hand dig if necessary. If field
coordination is needed,call 247-5878.
10 PUBLIC UTILITIES DISCONNECl' AND CAP INFORMATIONAL
Notes:
Disconnect and cap water and sewer lines.
11 PUBLIC UTILITIES INSPECTION PRIOR TO DEMOLITION INFORMATIONAL
Notes:
Must call the Inspection Line at 247-5814 to request an inspection of the disconnected and capped water and sewer lines prior to demolition.
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
DEMOLITION 455-0000-322-1000 0 $100.00
PW REVIEW BUILDING MOD OR ROW 001-0000-329-1004 0 $25.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL: $129.00
Issued Date: 1/17/2019 2 of 2
rS�:L`JfJ� City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Buildin epartment.)
800 Seminole Road CEll -3 _ O Y V D O'
�r Atlantic Beach, Florida 32233-5445
A4. Phone (904)247-5826 • Fax(904)247-5845 JAN 0 � 1 Z
E-mail: building-dept@coab.us 2 T ` Bate routed:
City web-site: http://www.coab.us i? _U
By—
APPLICATION REVIEW AND TRACKING FORM
0 12 - �� De ent review required Yes No
Property Address: 3s
Building
Applicant: .J L o t�,_D Planning &Zoning
Tree Administrator
Project: HQ as C E/)A C__�) ublic Wor s
ublic Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By S
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLI ATION STATUS
Reviewing Department First Review: MApproved. [—]Denied. ❑Not applicable
(Circle one.) Comments:
BUILDING /
PLANNING &ZONING Reviewed by:
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
—1 "Vi � City of Atlantic Beach APPLICATION NUMBER
a� Building Department (To be assigned by the Buildi?.Department.)
800 Seminole Roadhh
Atlantic Beach, Florida 32233-5445 V 1
Phone(904)247-5826 • Fax(904)247-5845
r; E-mail: building-dept@coab.us Date routed: Z
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: � I De ent review required Yes o
Building
Applicant: J l_O/,,,D Planning &Zoning
Tree Administrator
Project: L_AQ(-XS C F_/V/ c---) ublic Wor s
ublic Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By S
Florida Dept. of Environmental Protection
Florida Dept. of 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
Reviewing Department First Review: MApproved. ❑Denied. ❑Not applicable
(Circle on ) Comments:
BUILDIN
PLA &ZONING Reviewed by: Date:
TREE ADMIN. Second Review: []Approved as revised. ❑Deni []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
Building Permit Application Upd to
City of Atlantic Beach OFF
I C doy
800 Seminole Road,Atlantic Beach,FL 32233
_ Phone:(904)247-5826 Fax:
"(904)247-5845
Job Address: 3�0 I Q`IL
f-L- Permit Number:
a3-4110 a5- 34 4 5GT a �,�; �Mt 3 -2 3 -
Legal Description Lag Cpi(h?t EC7 d/6 I I� ti's- �� �,t a _RE# :1 ict-30 faCCXD—
Valuation of Work(Replacement Cost)$o10,000 Heated/Cooled SF iV( r:A Non-Heated/Cooled—.—.QP't
• Class of Work(Circle one): New Addition Alteration Repair Move emo Pool Window/Door WrZIN
• Use of existing/proposed structure(s)(Circle one): Commercial esidentia U
• If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No N/A Z N
• Submit a Tree Removal Permit Application if any trees are to be removed or Affidavit of No Tree Removal J ' 0
Describe in detail the type of work to be performed:
OraF30
V U U o
Florida Product Approval# for multiple products use product apwo�l fprq
O
Propertv Owner(Information r G Q 0 Q
Name: �-fv+ r O Address: -1(0 ��^ J Utv- 1-7_J u.
City State Zip_?:J23 3 Phone 3 - 192-S,- r- w
E-Mail (,1Vlq ( �of
L.. _ E .
Owner or Agent(If_62ent, Powtorney tgency Letter Required) p, I� m
Contractor Information -,. I•-- w o
an W U
Name of Com U) w w
Company: Qualifying Agent: Jobn LoocA w
Address I X17 l t)P I k5 gell STa D CityState. P C zip j
Office Phone -Q(r1 -3073 lob Site/Contact Number_9Q4 -Zl b 3 -5r:)&q w
State Certification/Registration#cnCnS9_ 3�S E-Mail jnVr�, )Ca1C%,Ccm
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation 1 12&_ky— ACYIP,-Ir 03 OG,-0
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.NOTICE:In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county,and
there may be additional permits required from other governmental entities such as water management districts,state agencies, or
federal agencies.
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 A5AR
EY BEFORE
RECOIjf.�ING YOUR NOTICE OF COMMENCEMENT.
r'
(Signature of Owner or Agent) Contrattor)
(including contractor)Signed and sworn to(or affirmed)before me this�� day of ed and sworn before me this�day of
dY `IK 7016 by ?Mr A. P,(1p% _ h A4,U
WILLIAM LI r!��r )
IV(Signature of Notary)
Commission#GG 092039
@k�tK3tgg2QR [ ersonally Known OR ,+�P
` BRENDA JOHNSON NORTH
"( f1�d�idedhd ia�tese6nor800 385 [ ]Produced Identification ] My coN evUSSION#GG2919
_____ Type of Identification: "i'it EXpRZES:June 15,2020
e,. CEI
City of Atlantic Beach EC
V� APPLICATION NUMBER
Building Department (To be assigned by the Building.Pepartment.)
i✓ 800 Seminole Road ,.,• `,
Atlantic Beach, Florida 32233- JAN 0 2 LU 1J � � Q�_ 1�'!V C)0
Phone(904)247-5826 - Fax(904 7-5845
E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: O� l _ Dgp4qqent review required Yes No
Building
Applicant: L Q Planning &Zoning
Tree Administrator
Project: LAQ(-)E E E-1-NA C-7) ublic Wor s
ublic Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date l/
of Permit Verified By � �5
Florida Dept. of Environmental Protection
Florida Dept. of 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
Reviewing Department First Review: [aApproved. ❑Denied. [—]Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by,.-
► Date:
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
lyubec clr�
�S I-L17
Comp. By: John Long
Date: 12/18/2018
Rev: 11/15/18
Public Works Department
City of Atlantic Beach
Permit No:
Address: 380 12TH STREET ATLANTIC BEACH, FL
Required Storage Volume
Criteria:
Section 24-66 of the City of Atlantic Beach's Zoning, Subdivsion, and Land Development Regulations
requires that the difference between the pre-and postdevelopment volume of stormwawter runoff be
stored on site. Volume of Runoff is defined as follows:
V=CAR/12
Where: V=Volume of Runoff
C=Coefficient of Runoff
A=Area of lot in square feet
R=25-yr/24-hr rainfall depth(9.3-inches for Atlantic Beach)
Predevelopment Runoff Volume:
Lot Area(A) = 14,573 ft'
Runoff Coefficient
Area Lot Area
Description (ft) (ft) "C" Wtd"C"
Impervious 2,640 14,573 1.00 0.18
Pervious 11,933 14,573 0.20 0.16
Runoff Coefficient(C)= 0.34
Runoff Volume
V= 0.34 x 14,573 x 9.3 / 12
V= 3,896 ft3
Postdevelopment Runoff Volume:
Lot Area(A) = 14,573 ftZ
Runoff Coefficient
Area Lot Area
Description (ft) (ft) "C" Wtd"C"
Impervious 6,957 14,573 1.00 0.48 ISA= 47.7%
Pervious 7,616 14,573 0.20 0.10
Runoff Coefficient(C)= 0.58
Runoff Volume
V= 0.58 x 14,573 x 9.3 / 12
V= 6,572 ft3
Required Storage Volume
DV= Postdevelopment Runoff Volume-Predevelopment Runoff Volume
DV= 6,572 - 3,896
DV= 2,676 ft3
Retention Pollak onsite Retention w-grnd for rear drainage only 12.18.18 12/18/2018
<as yL,JJ'
Comp. By: John Long
Date: 12/18/2018
Rev: 11/15/18
Public Works Department
City of Atlantic Beach
Permit No:
Address: 380 12TH STREET ATLANTIC BEACH, FL
Provided Storage:
Elevation Area Storage FRONT AREAS[TWO V DEEP]
(ft) (ft) (ft')
0.0 909 0 BOTTOM
1.5 565 1,106 TOB
Elevation Area Storage FRONT AREAS [TWO 8"DEEP]
(ft) (ft) (ft')
0.0 139 0 BOTTOM
0.7 90 77 TOB
Elevation Area Storage REAR/SIDE AREAS
(ft) (ft) (ft)
0.0 638 0 BOTTOM
1.0 491 565 TOB
Inground storage=A"d"pf
A=Area= 1145.5
d=depth to ESHWT= 3.0
pf=pore factor= 0.3
Inground Storage= 1031.0 ft'
Required Treatment Volume= 2,676 ft'
Supplied Treatment Volume= 2,777 ft'
Retention Pollak onsite Retention w-grnd for rear drainage only 12.18.18 12/18/2018
fl
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH,FL 32233
(904)247-5800
BULLETIN 4-18
To: All Permit Applicants. BUILDING DEPARTMENT
From: Dan Arlington, CBO APPROVED
City Building Official
Date: October 30, 2018
OFFICE COPY
Re: DEMOLITION OF STRUCTURES.
1. It is the responsibility of the contractor to:
a. Contact JEA to disconnect electric power.
b. Disconnect and cap.off water, sewer, and gas lines.
2. Silt fences must be in place and approved by Public Works before beginning
demolition.
3. All underground tanks, concrete slabs and foundations must be removed with the
buildings, unless otherwise approved by the City. The site should be left graded and
clean for Final Inspection.
4. Removal of any trees requires a separate Tree Removal Permit, per COAB Code
Of Ordinances, Section 23-21.
5. Protection of trees and vegetation during construction is required, per COAB Code
Of Ordinances, Section 23-32.
6. Prior permission from the Building Department is required before blocking any part of
the right-of-way or side walk.
Dust and wind-borne debris generated from the demolition of a structure is considered
unsafe and a hazard to the public health, safety, and welfare of residents in the
surrounding areas.
When demolishing a structure, the following steps are required to ensure that the
minimum dust and debris leaves the property:
1
7. At least two hoses, with nozzles, capable of reaching to all areas of the property must be
on site with an adequate water supply.
8. The structure must be sprayed with water for one hour before demolition begins.
9. The hoses must be used continuously during demolition, wetting down the structure, the
debris pile, and truck beds when being filled.
ASBESTOS.
10. All roofing and siding made from asbestos containing materials (ACM) are considered
friable and must be removed from the structure, following NESHAP Guidelines, before
demolition begins. This includes all commercial and one and two family residential
dwellings.
Please call for a Pre-Demolition Inspection, before demolition begins, and a Final
Inspection, when demolition is complete.
OFFICE COPY
BUILDING DEPARTMENT
APPROVED
11/01/18
2
MAP SHOWING BOUNDARY SURVEY OF
LOT 8 (EXCEPT PART RECORDED OFFICIAL RECORDS BOOK 119, PAGE 344). BLOCK 2 SELVA MARINA UNIT ONE,
AS RECORDED IN PLAT BOOK 23, PAGE 4, OF THE CURRENT PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA.
CERTIFIED TO:
CONTANCE A. LANGSTON, TRUSTEE OF THE HELGA R. NEWELL LIVING TRUST DATED SEPTEMBER 28, 2017
ATTORNEYS TITLE FUND SERVICES, LLC
N 3364t�C3' E
N ?�•c9EP5JRPC
23.2PT
Q)\ r�40 /
VNN `ry� LOT 7
• BLOCK 2
6.
0.9" 1
• h
/ h S�.>• 2q i W
?.*• s
O S�OO m
Ck ^ Afp
PO 4y�30 0RY �� EXCEPTION
N
(OFFICIAL RECORDS BOOK
7
J5. 'CQ )01 380 Qf y 119, PAGE 344)
®p�0 LOT 8
I WELL BLOCK 2
PC
29.8' 5.00'
J. 0. (DEED)
GO
z ' z L-1 0•7' LOT 30
ti BLOCK 14
LOT 32
o °�' �� y r 3.9 BLOCK 14
00
n vOo
ATLANTIC BEACH
(n C s " RECORDED IN PLAT BOOK 5• PACE 69
G " 0.8'
0.6'
,.r
o I S
83-41'46r W
gg.61' (MEASURED) L-1
S 83.42'00 w S 83'08'17" W
100.0o' (PLAT) 24.78' (MEASURED)
LOT 9 S 83.42'00" W
BLOCK 2 25.00' (DEED)
L-2
S 04'34'38" E
LEGEND: 19.88' (MEASURED)
—X— - CHAIN LINK FENCE S 06'18'00" E
�- = HOG WIRE FENCE 20.00' (PLAT)
WOOD FENCE
O - CONCRETE L-3
O = SET 1/2" REBAR STAMPED PSM/6146 S 15'57'27" E
0 - FOUND 1/2" IRON PIPE NO IDENTIFICATION 133.34' (MEASURED)
(UNLESS OTHERWISE NOTED)
0 - 4"x4" CONCRETE MONUMENT PC = POINT OF CURVATURE PRC = POINT OF REVERSE CURVATURE S 15'54'09" E
A/C - AIR CONDITIONER PT = POINT OF TANGENCY PCC a POINT OF COMPOUND CURVATURE 133.57' (DEED)
NOTES: REVISIONS
1. BEARINGS ARE BASED ON THE PLAT __ BEARING OF --N-0-CII-It _W___ ALONG THE
WESTERLY BOUNDARY LINE OF SUBJECT PARCEL. DATE DESCRIPTION
2. BY GRAPHIC PLOTTING ONLY THE CAPTIONED LANDS LIE WITHIN FLOOD ZONE __x__ AS SHOWN ON THE
NATIONAL FLOOD INSURANCE MAP DATED JUNE 3. 2013, COMMUNITY NUMBER 120077, PANEL _Q4QR H
3. THIS SURVEY REFLECTS ALL EASEMENTS & RIGHTS OF WAY AS PER RECORDED PLAT &/OR TITLE COMMITMENT
IF SUPPLIED. UNLESS OTHERWISE STATED, NO OTHER TITLE VERIFICATION HAS BEEN PERFORMED BY THE UNDERSIGNED
4: THIS SURVEY IS NOT VALID WITHOUT AN AUTHENTICATED ELECTRONIC SIGNATURE AND AUTHENTICATED ELECTRONIC SEAL.
JOB # 34002 DATE OF FIELD SURVEY: 11-04-2017 SCALE: 1"
Ray Thompson CERTIFICATE
I HEREBY CERTIFY THAT THIS RVEF' DE UNDER MY RESPONSIBLE CHARGE
SURVEYING, Inc. AND MEETS THE STANDARD m T FORTH BY THE FLORIDA
BOARD OF PROFESSID L 5 A QMCH APTER 5J-17, FLORIDA
Going the DISTANCE for YouADMINISTRATIVE C ANT it&JROR1DA STATUTES.
1825 University Boulevard West
Jacksonville, Florida 32217 v RAYMOND THOMPS
(Phone)904-448-5125 REGISTERED SUP, OR Alft*&PPER a 146 STATE OF FLORIDA
(Fax) 904-448-5178 S'�BUSINE S 7469
LAND SURVEYS 0 CONSTRUCTION SURVEYS t S4RVFy BDIVISIONS
Building Permit Application Updated 12/8/17
City of Atlantic Beach
800 Seminole Road,Atlantic Beach,FL 32233
Phone:(904)247-5826 Fax:(904)247-5845
Job Address: 360 avfUpa(ji _ Permit Number:
J3-41(p as- (=- .344 e tea _.__.._......._
Legal Description Lp ">>_tL1�7c7 n/R 11`t-" �rMt�L��
' �ai� RE# -I...143c7
Valuation of Work(Replacement Cost)$o10,0UC) Heated/Cooled 5F Iy( IIA Non-Heated/Cooled Iv1 f)
• Class of Work(Circle one): New Addition Alteration Repair Move emo Pool Window/Door
• Use of existing/proposed structure(s)(Circle one): Commercial esidentia
• If an existing structure,is a fire sprinkler system installed?(Circle one): Yes No N/A
• 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: pF eXa-ao rnC� Y�C�, rZrr wCJ_X �S
Florida Product Approval# for multiple products use product approval form
Property Owner In/formation r
Name: -fv+ I O Address:
Cit
E-Mail State�—Zip 3 22-3 3 Phone
V* A( 0 ( -
Owner-or Agent(ff gent, Powe of Attorney Agency Letter Required)
Contractor Information
Name of Company: Qualifying Agent: )Cbr) L�jr
Address Itn17 _LA-11),PI k5 Z" S 7 CityCC;aCQe_ State P Zip
Office Phone Sjnu-Q(04 -3073 Job Site/Contact Number Cl()4 -LI 6 3 -
State Certification/Registration 4C(AC S53/41Z E-Mail jnl� two (alp( ,ccy-n
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation 1 c- 5ux- 2nneXIT a 03 QG7.
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.NOTICE:In addition to the requirements of this
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county,and
there may be additional permits required from other governmental entities such as water management districts,state agencies,or
federal agencies.
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 ATTOR EY BEFORE
RECO{IiIN/�G YfO�UR NOTICE OF COMMENCEMENT.
Aq-
(Signature of Owner or Agent) ( ignatur o Contractor)
(including contractor) ,,'1 'a
Signed and sworn to(or affirmed)before me this�� day of S' ed and sworn t (or aff' med before me this�day of
dY l6K 7016 by ?LAG(' A. Po(10%k_ by ��ifl {�ANJ
WILLIAM LI r
E
nature otary) (Signature of Notary)
Commission#GG 092039
I'k�Q�t4�gIf324p�0�4R [ ersonallyKnownOR ��^ 13RENDAJOHNSONNORTH
( I�audWd§rdThd�iatifiscrhiaa8003857p�g [ ]Produced Identification ] rgyCOMMISSION#GG2919
Type of Identification: "�'i�► tplRFs:June ls,2020
PUBLIC UTILITIES PLAN REVIEW COMMENTS
Date: Application#:
Project Address:
Check Box Check
APPLICATION TRACKING COMMENTS to Add Box to
Comme Print
Underground Avoid damage to underground water and sewer utilities. Verify vertical and
Water Sewer horizontal location of utilities. Hand dig if necessary. If field coordination is
Utilities needed, call 247-5878.
Meter Boxes Ensure all meter boxes, sewer cleanouts and valve covers are set to grade
Sewer Cleanout and visible. ❑ ❑
A sewer cleanout must be installed at the property line. Cleanout must be
RT1 Sewer covered with an RT1 concrete box with metal lid. Cleanout to be set to grade ❑ ❑
Cleanout and visible.
A reduced pressure zone backflow preventer must be installed if irrigation will
RPZ be provided or if there is a private well on the property. Backflow preventer ❑ ❑
Backflow must be tested by a certified tester and a copy of the results sent to Public
Utilities.
Plans note the building will be unsprinkled. If plans change, any fire line
Sensus installed must be metered with a Sensus touch-read meter in a properly sized
Touch-Read vault and an appropriate backflow preventer installed. Backflow preventer ❑ ❑
Meter must be tested by a certified tester and a copy of the results sent to Public
Utilities.
Fire Sprinkler
Backflow If fire sprinkler system is provided, call 247-5878 for backflow requirements. ❑ ❑
Requirement At a minimum,will require a double check backflow preventer.
Fire Line Fire lines must be metered with a Sensus touch-read meter. Meters larger ❑ ❑
Meter than 2" must be installed in a vault as noted in JEA specifications.
Utility Map See attached Utility Map. ❑ ❑
Disconnect
&Cap Disconnect and cap water and sewer lines.
Inspection Must call the Inspection Line at 247-5814 to request an inspection of the
Prior disconnected and capped water and sewer lines prior to demolition.
❑ ❑
❑ ❑
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