598 Seaspray Ave RESO19-0013 Voided City of Atlantic Beach
APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road APR 3 0 20 19
Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 - Fax(904)247-5845 Date routed:
E-mail: building-dept@coab.us 1,4
City web-site: hftp://vvww.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: St4S Department review required Yes No
Building
Applicant: bw 1144 Planning &Zoning
Tree Administrator
Project: AlcJ t_-AU" 04 Arl u 155 5—c W o r-k-s)
J (Tublic Utili0b
CLa-a C&- tALo.( pea�o Public Safety
f— 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
St. Johns River Water Management District
Army Corps of Engineers 61
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: ElApproved. ODenied. E]Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by. Date:
TREE ADMIN. Sec cl, F]Not applicable
PUBLIC WORKS Cor "D
PUBLIC UTILITIES
PUBLIC SAFETY Wow Date:
FIRE SERVICES Thir VA+ I- F]Not applicable
Corr
aw--crk
Date:
Revised 05119/2017
Joseph L. Leppo 29 APRIL 2019
598 Seaspray Ave
Atlantic Beach FL 32233
SCOPE OF WORK—PAVER INSTALLATION AT 598 SEASPRAY AVE
1. Paver Patio remodel (demolish existing 15' x 15' and replace with new permeable paver
installation 24' x 24')
2. New Parking Area/ Driveway installation of permeable paver installation, exiting driveway to
remain in place
- Grade and level ground to prepare for first 2 Y2" sub base aggregate of#57 virgin lime rock,
install drainage pipes and geo textile fabric
- Level and compact layer 1 of sub base aggregate
- Repeat for second layer of 2"sub base aggregate
- Place final layer of sub base and level surface with proper grade to remove surface water issues,
and allow placement of paver in modified herringbone pattern
- Border will be offset pattern; border will be secured with concrete
- Set pavers will be compacted and gaps filled with#78 crushed granite
- Remove any debris,waste material,etc.
MATERIALS:
- Belgard Eco Holland Pavers(Permeable installation method)
c o nEdison Solutions WJ
Joseph L. Leppo Mobile: 813.295.4109
Project Manager
leppoi@conedceb.com urz 6
www.conedsolutions.com L
3405 W.Dr.Martin Luther King,Jr.Blvd.9 Suite 101 -Tampa,I'L 33607
ConEdison Solutions is part of ConEdison Clean Energy Businesses,Inc.
Building Permit Application Updated 1019118
City of Atlantic Beach Building Department "ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Build i ng-Dept@ coab.us IS REQUIRED.
JobAddress: "0 _1�-&-SPiZAY A\/r� Permit Number: eS 00 13
Legal Description —RE#
Valuation of Work(Replacement Cost)$ 000 Heated/Cooled SF Non-Heated/Cooled
• ClassofWork: ONew DAddition ElAlteration DRepair DMove ODemo OPool OWinclow/Door
• Use of existing/proposed structure(s): ElCommercial
)Vesidential 2019
• If an existing structure, is a fire sprinkler system installed?: El Yes P(No
• Will tree(s)be removed in association with proposed proiect? OYes(must submit separate Tree Removal Permit) N�f4o
I
rescribe in detail the type of work to be performed: PAV1j,(, 11KA--CA_L_A_A:—x I Co 1�4srAL-L- I�JIF_w
IP Av rr e- P,40EK)w) A goz,+ D AF�ve_,4 PL6 f- 'p-4--r/0 PA Vf;4
Florida Product Approval# for multiple products use product approval form
Property Owner Information
Name ,�OSF PH L'. L-e-re Address '5 Cr'6 SIFAI-St'lll "IS
City X-5—( &4^J-TC_ Ff-4CH State F-4- Zip 3 -Z-Z3 '�Z —Phone—t)�;_6 -- _ZA4Z� -9 4:19�
E-Mail L :--I?,F Q::S:L- C,d H t_2—m,4 14 1 .L J)W7
Owner or Agent(If Agent, Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company Qualifying Agent
Address City State Zip
Office Phone Job Site Contact Number
State Certification/Registration# E-Mail
Architect Name&Phone#
Engineer's Name&Phone#
Workers Compensation Insurer OR Exempt o 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 regulating
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 ATTORNEY BEFORE
REC G YOUR NOTICE OF COMMENCEMENT.
(Signature of Owner or Agent) (Signature of Contractor)
11— b0o.11 ethis c4r1dayof Signed and sworn to(or affirmed)before me this day of
r� �JENNIFE by
my cummfs-idl M om 4
EXPIRES:October 27 7090
(Signature of Notary)
rvoriters
jihdatli�J of Notary)
Bonded Thru Notary Pub!ic unde
�ersonally Known OR Personally Known OR
VProduced Identifi ti Produced Identification
Type of Identification: it"JL-Y,� c i-0 A W__ Type of Identification:
CITY OF ATLANTIC BEACH
Department of Public Works
1200 Sandpiper Lane
Atlantic Beach, FL 32233
7/77 (904) 247-5834
19'
PUBLIC WORKS PLAN REVIEW COMMENTS
Date: 5/1/19 Applicant: Joseph Leppo
Permit #: RES019-0013 Email: leppool@hotmail.com
Review Status: DENIED Site Address: 598 Seaspray Avenue
THIS PLAN REVIEW IS ONE OF MULTIPLE DEPARTMENT REVIEWS
Correction Items must be submitted to the Building Department at 800 Seminole Road.
Submittals that respond to only one or a few correction items will not be accepted.
Revisions may not be submitted until ALL departments have completed their respective reviews.
Revisions must be submitted to the Building Department and must respond to EACH department review.
PUBLIC WORKS CORRECTION ITEMS:
• Section 24-66(b) of the Land Development Regulations requires on-site storage for increased
run-off if adding 250 SF or more impervious surface. Provide Delta volume calculations and
on-site retention required per Section 24-66(b).
• Maximum driveway width within the City right-of-way is 20'.
• Provide a detailed plan of water retention area and how water runoff gets to water retention
areas and then to street.
• Provide a detailed plan of driveway in City right-of-way.
PUBLIC WORKS CONDITIONS OF APPROVAL:
(The following comments will be printed on your permit as Conditions of Approval)
• 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.
• All runoff must remain on-site during construction.
• If on-site storage is required, a post construction topographic survey documenting proper
construction will be required. All water runoff must go to retention area and retention overflow
must run to street.
• 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, All American Roll Off, WCA Waste Corporation). Container cannot be placed on
City right-of-way.
• Full right-of-way restoration, including sod, is required.
• All runoff must remain on-site. Cannot raise elevation.
• Maximum driveway width within the City right-of-way is 20'.
Scott Williams, Public Works Director swilliams@coab.us/904-247-5834
Page 1 of 2
0:\Public Works\ADMIN\PLAN REVIEW COMMENTS\RES019-0013(Owner-Leppo).docx
Resubmittal Notes: All revisions and changes shall clearly stand out from the rest of the drawing on the sheet as a
revision by way of completely encircling the change with "clouding". The revision shall also be identified as to the
sequence of revision by indicating a triangle with the revision sequence number within it and located adjacent to the
cloud. The revision date and revision sequence number shall also be indicated in a conspicuous location in the title block
for each sheet on which a revision for that sequence occurs. For projects still in the initial review stage and permit
pending, all sheets with revisions shall be inserted into each set of drawings. The original sheets must be clearly marked
"VOID" but are to be left within the set of drawings. Complete new sets of drawings will not be accepted. ADDITIONAL
ITEMS MAY BE REQUIRED DEPENDING UPON NEW INFORMATION AND CLARITY OF FINAL PLANS SUBMITTED FOR REVIEW.
Page 2 of 2
0:\Public Works\ADMIN\PLAN REVIEW COMMENTS\RES019-0013(Owner-Leppo).docx
MAP SHOWING BOUNDARY SURVEY OF
LOT 33 BLOCK 4 ACCORDING TO THE PLAT OF
SEASPRAY
AS RECORDED IN PLAT BOOK 35 , PAGE(S) 64 OF THE CURRENT
PUBLIC RECORDS OF DUVAL COUNTY, FLORIDA.
1/2"
IRON PIPE
4*X4'
CONCRETE
MONUMENT
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WITH WALK
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X UTIUTIES & SEWERS
VD/ I I r-
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0. 1- 1 r_ — — — — — — — -
S 8226'50' W 41.72' (M) LOT-24
5' 10' S 82-28*36" W BLOCK 4
REFERENCE JOB NO. 66334 1 41.71' (R)
LOT-23 BLOCK 4
CONCRETE WALKWAY &A
4 A . -5.0 Total Area: 10,396.0
45% Max Impervious Area: 4,678.2
Paver Drive (21'4"x 9' 0"): 192 sq ft
C�Nc. :cr �!
U-nuTy _�! I Paver Walk (33'10" x 2'8y' + 9?9" x 3'0"): 119.5 sq ft
_< 12
PAD 0- 0 WALK CA Existing Impervious Area(s):
2 0' B.R.L. House: 2204
Shed: 150
20.6' o 13.8" U Existing Pavers: 232
(1i 2.3.6' cli Paver Drive: 192
c"D Paver Wa I k: 120
TOTAL IMPERVIOUS: 2878
0 1 -STORY
00
BRICK
NO. 598
House (38' x 58'): 2204 sq ft
Cob-
58.0' .15.2'.
:3
4__
Existing Pavers
(15'3" x 15 3
232.6 sq ft Ln
0 Ir-i
LU X
jr� X I
Ln 0
CPO
S H ED — -2L:3
Vp
ETE WALKW
0' CONCIR AY
5.
Total Area:
10,396.0
1 45% Max Impervious Area: 4,678.2
I Paver Drive (21'4"x 9' 0"): 192 sq ft
U71U7 New Driveway rcr �� I Paver Walk (33'10" x 2'8" + 9'9" x 3'0"): 119.5 sq ft
Area i2 -WALK
PAD
Existing Impervious Area(s):
(24' x 281) House: 2204
672 sq ft
Shed: 150
2 0.6 b 71, 13.8' U_ - Existing Pavers: 232
(,i-P- 23.6' c� - Paver Drive: 192
c, - Paver Walk - Front: 120
0 1 -STORY _0 TOTAL IMPERVIOUS: 2878
c6
BRICK
NO. 598
House (38' x 58'): 2204 sq
:3
y1_1 58.0' .15.2'.
0 T
> Proposed Impervious Area(s):
House: 2204
New Paver Patio Shed: 150
(24' x 24') Ln - Paver Drive: 192
rl
576 sq ft UJ X - Paver Walk - Front: 120
3: ft
0 New Patio: 576
New Driveway Area: 672
T'OTAL IMPERVIOUS: 3914
CP
�p cp 0
0-T�F 'PCE
-S
ECO-HOLLAND The classic shape, smooth ADA-compliant surface
PERMEABLE PAVERS and multiple color choices make Eco-Holland a highly
versatile option for an array of outdoor living applications,
AWN21ft including high-traffic areas and driveways.
owl
V
AVAILABLE COLORS
Adobe Napoli* Stat,
*Swatches represent product color only,not shape.
SHAPES & SIZES
Eco-Hottand 80mm Eco-Hotland 11 80mm(Mechanical)
4 x 8 x 3 1/s 4 x 8 x 3 1/s
BELGARD.COM 877-235-4273
4/26/2019 Property Appraiser-Property Details
LEPPO JOSEPH L Primary Site Address Official Record Book/Page Tile#
598 SEASPRAY AVE 598 SEASPRAY AVE 17760-01850 9417
ATLANTIC BEACH, FL 32233 Atlantic Beach FL 32233
LEPPO AKIKO
598 SEASPRAY AVE
roperty Detail Value Summary
RE# 170703-0432 Value Descripti 2018 Certified 2019 In Progress
_on
Value Method CAMA CAMA
Lax District LISD3 Total Building Value $179,562.00 $171,245.00
kmpertvM- 0100 Single Family Extra Feature Value $0.00 $0.00 -
#of Buildings I Land Value(Market) $195,000.00 $180,000.00
For full legal description see
Legal Desc. Land&Legal section below Land Value(ftfirg.) $0.00 $050
. — 3405 SEASPRAY Just(Market)Value $374,562.00 $351,245.00
Total Area Assessed Value $347,184.00 $351,245.00
"��sele-8114his p vp.ty....r7rsnft-M-R-1gFe-r`property taxes.For more information go to Save Cap Diff/Portabillity Amt $27,378.00/$0.00 $0.00/$0.00
Our Homes and our Property ax Estimator.'In Progress'property values,exemptions arFd-- ions 1$55,000.00
L_ See below
other supporting information on this page are part of the working tax roll and are subject to
change.Certified values listed in the Value Summary are those certified in October,but may Taxable Value 1$292,184.00 See below
include any official changes made after certification Learn how the Pr perty Apprg�i�v'sOfficg
values p p".
Taxable Values and Exemptions—In Progress
If there are no exemptions applicable to a taxing authority,the Taxable Value is the same as the Assessed Value listed above in the Value Summary box.
County/Municipal Taxable Value SIRWMD/FIND Taxable Value School Taxable Value
Assessed Value $351,245.00 Assessed Value $351,245.00 Assessed Value ...................................$.3.51,2.4��00
................................................................................................................... ................................................................................................................ .................................................
Homestead(HX) -$25,000.00 Homestead(HX) -$25,000.00 Homestead(HX) -$25,000.00
...................................................... ........................................................... ................................................................................
Homestead Banding 196.031(l)(b)(HB) -$25,000.00 Homestead Banding 196.031(l)(b)(HB) -$25,000.00 Tot/Perm/Vet$5,000(VT)196.24(VT) -$5,000.00
.................................................................................... ................................................................................. ..............I.................................................................................................
Tot/Perm/Vet$5,000(VT)196.24(VT) -$5,000.00 Tot/Perm/Vet$5,000(VT)196.24(VT) -$5,000.00
.................................................................................................................. ...................................................................................................................... Taxable Value $321,245.00
Taxable Value $296,245.00 Taxable Value $296,245.00
Sales History
Book/Page Sale Date Sale Price Deed Instrument_lypg Code
Qualified/Un ualified Vacant/Improved
17760-01850 10/31/2016 $395,000.00 WD-Warranty Deed Qualified Improved
17479-01523 3/1/2016 $128,800.00 WD-Warranty Deed Unqualified Improved
12234-02345 12/23/2004 $100.00 QC-Quit Claim Unqualified Improved
05284-00159 2/5/1981 $49,000.00 WD-Warranty Deed Unqualified Improved
05169-00548 8/1/1980 $45,000.00 WD-Warranty Deed Unqualified Vacant
05069-00237 3/10/1980 $100.00 QC-Quit Claim Unqualified Vacant
Extra Features
No data found for this section
Land&Legal
Land
LN Code Use Description Zgping Front Depth Category Land Units jAnd Type I Land Value ILN I Legal Description
11 0100 RES LD 3-7 UNITS PER AC ARS-2 70.00 142.00 Common 1.00 Lot $180,000.00 1 35-64 17-2S-29E
2 SEASPRAY
3 LOT 33 BLK 4
Buildings
Building 1
Building 1 Site Address
598 SEASPRAY AVE Unit Element Code Detail
Atlantic Beach FL 32233 Exterior Wall 19 19 Common Brick
Roof Struct 3 3 Gable or Hip
uilding Type 0101-SF I STORY Roofing Cover 3 3 Asph/Comp Shng
Yew Bulk 1981 Interior Wall 5 5 Drywall F
OAS
Building Value $=171,245.00 Int Flooring 11 11 Cer Clay Tile
Int Flooring 12 12 Hardwood FGR
Type Grow Heated Effective Heating Fuel 4 4 Electric T—
I Area Area Area Heating Type 4 4 Forced-Ducted
Base Area 1781 1781 1781 Air Cond 3 3 Central
Finished Garage 375 0 188
Finished Open 8 0 2 Element Code Detail
Porch
Stories 1
Finished Open 10 0 3 Bedrooms 4�'.0.'.
Porch
Total 2174 1781 1974 Baths 2.500
Rooms/Units 1.000
https:Hpaopropertysearch.coj.net/Basic/Detaii.aspx?RE=l 707030432 1/2
REVOCABLE ENCROACHMENT PERMIT
19'
THIS REVOCABLE ENCROACHMENT PERMIT, issued on this 2,9 day of APIO-)L-_,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 -*6,WP1q L, Lee#06
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 for the purpose as described in the City of Atlantic Beach Right-of-Way Permit#
This work is generally described as P4VIF IV&-rAUA-rJZ A3
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 USER, said notice to USER shall be given by certified mail,
return receipt requested,to the following address __S r7
,AS Pe243 A VE
• 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.
Date— 2-1q —
Property 0!�njelAgent(signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL
The foregoing instrument was acknowledged this a'�l day of 20 C1,
by on L tPP D who personally appeared before me and
(printed name of Signer�
acknowledged that he/she signed the instrument voluntarily for the purpose expressed in it.
SigneUu eWotary Public, State of Florida Approved/Public Works Department:
Personally Known
Produced Identification(Type) IFL
Scott Williams, Interim Public Works Director
JENNIFER JOHNSTON
My COMMISSION#GG 042984
EXPIRES:October 27,2020
Bonded Thru NotarY Public UrkkhVAMM
Owner Builder Affidavit "ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
1. FLORIDA STATUTES; CHAPTER 489, FLORIDA STATUTES, PART 1 "CONSTRUCTION CONTRACTING" REQUIRES
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 ACT 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 BUILD OR IMPROVE A COMMERCIAL BUILDING AT A COST OF$25,000.00 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.
ITISYOUR ESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE LICENSES
REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING ORDINANCES.
11. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,THE BUILDING DEPARTMENT
SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED. .
111. IRS WITHHOLDING;OWNERS HIRING WORKERS BECOME EMPLOYERS AND SHOULD ALSO OBSERVE IRS WITHHOLDING
TAX AND/OR FORM 1099 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(l). 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. CONTACT THE BUILDING DEPARTMENT(904-
247-5826 OR BUILDING-DEPT@COAB.US ) IF IN DOUBT.
V. ACKNOWLEDGEMENT; I 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.
JobAddress: �7g5 4vi-a
Owner Name: Jo-se"pq L_e6pb Phone Number: ?SLO -2-e4 2--(4 6k4
Mailing Address:_S9f3 2W&PjV4-V /jVjF City: tC- (SW14 State: r-L_ Zip: 3, ?_2X3
Notarized Signature of Owfg
The foregoing instrument was ackno dgged before me'this Q-'l day of Apt� k 20__!��in the State of Florida, County
of
Signature of Notary Public
L) U
JENNIFER J
OHNSTON
M OM ISSIO Personally Known OR [Lp"iroduced Identification
Y COMMISSION#GG 042984
�l S.Oto 0 0
-,7� EXPIRES:October 27,2020
otry Pu 1.U e,tr.
W Bonded Thru Notary Public Undermiterms Y pe of Identification: F
Updated 10124118