564 Aquatic Drive HENS17-0001 05.04.2017 tf A)511-ODOI
t =�'`lr BACKYARD HEN PERMIT APPLICATIONs is, BACKYARD I
r i j) City of Atlantic Beach
z Community Development Department
800 Seminole Road Atlantic Beach, Florida 32233-5445
1..4011.19 r Phone: (904)247-5826 Fax: (904)247-5845 Email: Building-Dept@coab.us
SECTION 1: PROPERTY INFORMATION
Property Address: J t I A(u''Ti L hcl-. RE# 171M3 3 `5l 8 8
Property Owner Information
Name::Uu A RusSfL.L Phone: ("03431 - 3310
Email: f�2uSSt:c.L.Da e 1L , c Fax: ( ) -
Address: 56'1 A aysTJ& AL City:AFL, (lj F) State: ft Zip: 32.a3 3
Tenant Information(if applicable)
Name: --_--N-4.,.sg ManyC-t-- Phone: (901/ ) ` d y - 71/7,
Email: - iv b) LC2 IV141� . L crYvN Fax: ( ) -
SECTION 2: ITEMS REQUIRED FOR APPROVAL
Er Backyard Poultry Seminar Certificate From the Duval County Agricultural Extension Office.
❑ Passed Inspection of Property Including coop/pen size,construction and location as wellas screening.
tApproval Letter from HOA(if applicable) -
Payment of$50.00 To be paid upon satisfaction of the above requirements. JUN 2017
S Number Hens to be Kept on Property(limit of 5)
SECTION 3: SIGNATURES _ I Y.lS p f l
I certify that the information contained herein is true and correct to the best of my knowledge. I hereby
acknowledge the terms of Ordinance 95-17-113 and swear to follow all requirements therein. Further, I hereby
grant permission for the City of Atlantic Beach to enter the property listed above for the purpose of inspecting
for compliance and agree to remove all hens and associated structures upon the termination or expiration of
temporary ermit and/or this if in'nce.
- ( ► 31/4)1‘°\ - SCII S Pettyture of Pro Owner Print Name tv
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State of� LCl8 County of Qu\to,
Signed and sworn to before me this 1 qday of -Su" :C__ , 20 l' by .
l :% JENNIFER JOI NSTON
1 .`,./a�•
" MY COMMISSION#GG
Signa a of Notary blic 'r` ""`.;,:.1
EXPIRES:October 27,2020
042984
�pinn't 3oh,ns-hen A11~ ..
°P'� Bonded Thru Notary Public Underwriters
Print Name of Notary Public SEAL
❑ Personally Known 1
Q Produced Identification,Type of Identification: a,(��J i..„,,1/4.sItCLrt L
Updated: 1.17
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