2335 Barefoot Tr FNCE19-0094 FENCE WALL OR BARRIER PERMIT PERMIT NUMBER
' FNCE19-0094
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD ISSUED: 8/14/2019
ATLANTIC BEACH. FL 32233 EXPIRES: 2/10/2020
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL • ' K MUST CONFORM TO THE CURRENT 6TH EDITION • OF • '
CODE, ' OF ' CH CODE 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:
2335 BAREFOOT TRACE FENCE WALL OR BARRIER FENCE FENCE $5824.00
TYPE OF •
ZONING: :D •
• • • '
169463 0614 OCEANWALK UNIT 02
COMPANY: ADDRESS:
HARDWICK FENCE LLC P 0 BOX 3043 ST.AUGUSTINE FL 32085
• ADDRESS:
FRANK BRYAN D 2335 BAREFOOT TRCE ATLANTIC BEACH FL 32233-6604
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 ON SITE RUNOFF INFORMATIONAL
Notes:
All runoff must remain on-site during construction.
2 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,All American Roll Off,WCA Waste Corporation). Container cannot be placed on City right-of-way.
Issued Date:8/14/2019 1 of 2
City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
` 800 Seminole Road
o Atlantic Beach, Florida 32233-5445 `-r
Phone(904)247-5826 - Fax(904)247-5845
g E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
De e
Property Address: Z j� 6AgC_P7WT '
� g— p Department review required YNo
Applicant: C)LC)l('_t,\ �� � nnin &Zonm
('-- Tree Administrator
Project: is o- I1TI rks
Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified B
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: []Approved. ❑Denied. ❑Not applicable
(Circle one.) Comments:
Mdty s Cr d d rear J v,-e 1+ /Ir plydv jr
BUIL 1 C
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
OFFICE COPY
Building Permit Application Updated 10/9/18
City of Atlantic Beach Building Department "ALL INFORMATION
800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
Phone: (904) 247-5826 Email: Building-DepjLi�coa�.us IS REQUIRED.
Job Address: VILfoof Permit Number: 9 -0og'4
Legal Description Rc5—LD—d--T--LLaib N
Per 6c —RE# A410-0(914
Valuation of Work(Replacement Cost)$ 582'T - ()0 Heated/Cooled SF Non-Heated/cooled,
* Class of Work: 54ew DAddition OAlteration DRepair OMove ElDerno ElPool L]Winclow/Door
0 Use ofexisting/proposed structure(s): n-Commercial 54,sidential
0 If an existing structure,is afire sprinkler system installed?: 0Yes []No
0 Will tree(s)be removed in association with proposed groject?DYes imust submit separate Tree Removal Permit) ONO
1Describe in detail the type of work to be performed: r2cplacc cxi5Ti'oq r( ncc w�m
54" Wood 5POCC'd P-I-cXct rcnn-,
Florida Product Approval# for multiple products use product approval form
Propeft Owner Information
Name r Acldress-2,,�36 Bar fi T
—EL
City —State .--zip 322-,JJ Phone__
E-Ma4fl M1711co
2
Owner or Agent(if Age t,Power of Attorney or Agency Letter Required)
Contractor Information
Name of Company ard(IJI FL--txL Qualifying Agent rMna
Address P) YW jrg-i nc state FL Zip—J20B'!U--
office Phone—qQ4-A-)'=iQq-BL244
Qq Job Site ContacNumber'
State Certification/Registration 4NIHE1.91225122ICI E-Mail r 6-tln C U I i ri<Ff-&n--c 0 Z
Architect Name&Phone# J Z
Engineer's Name&Phone 0
Workers Compensation Insurer NiamnnAiT
--n5LJr/7= CO.ORExempto Expiration Dale
0
Application is hereby made to obtain a permit to do the work and installations as indicated.I certify that no work or installatiQ110 t= Z
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all the laws regulaf4go C, L)
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK,PLUMBING,SIG FW p <
t
WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS,and AIR CONDITIONERS,etc. NOTICE:in addition to the requirements a cc 2,
8 0
permit,there may be additional restrictions applicable to this property that may be found in the public records of this county(3n U-
there may be additional permits required from other governmental entities such as water management districts,state agencID!,bf' FN-
federal agencies. 0 —
LL LL LLJ
OWNER'S AFFIDAVIT-I certify that all the foregoing information is accurate and that all work will be done in compliance withd 0 UJ 53
applicable laws regulating construction and zoning. 11 CC
UJ LU F)
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMIVIENCEMENT MA� U vi W
L
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INT@D
I
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDS ORA ATTORMYBEFORE cc C
RECORDING YOUR NOTICE OF COMMENCEMENT. 7d
(Signature of Owner or Agent) (Signature/of Contractor)
-4
d wo ff' before m thL5:,5 d sworn to(or affirmed)before me this3l '
igned '5to(or,� i m Jda of Si sw day of
L�by 2019 b
I&
MCGAIilEy
TO my COMMISSION#FF969340
co�,","'l 0SION#F'92'951 .... ... EXPIRES PAAy 13,2020
QW1 9
C
��p Isonally Known OR (407)j4.�o153
rs Ir,)I,,,,d id,ntification
igivr— 6 52-664-S Type of Identification:
Z -,-;, 4-
OFFICE COPY
PermI FPC S-/9-Oo4y
NOTICE OF COMMENCEMENT
State of �Q� __-._._ Tax Folio No.
County of
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 CO
MMENCEMENT. \a ga. I IDG 4 6 O(o}4
Legal Description of property being improved:
4e1 aS- E 3;7- S-- D9 f; I, Om' L h& rL,57
Address of property being improved:IM 5 8 ff fQC —a "r 2
General description of improvements: ((!! CAj St ()(t
Owner:-Brt'1.11 f-r'a { ......_. __ _ Address:25 .Owner's interest in site of the improvement:
Fee Simple Titleholder(if other than owner):
Name:
Contractor: -flail(-U f I C9 Frlyxl L N----- —
Telephone No.:g01.5M Fax No: q04-4Lo0--Mj
Surety(if any)
Address: ............. Amount of Bond
Telephone No:_ Fax No: _ _ --
Name and address of any person malting a loan for the construction of the improvements
Name:
Address: _ r
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 is
specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
Sigrid:_ Date:
Be&ire we ihis day of J c.( in the County of Duval,State
Of Florida has personally ap
Notary Public at Large,Slat f lorida,Cour of Duval.
My commission expires:__- 1' Gn P7 o- A-
Personally Known- or
1.Doc#2019178325,OR BK 18883 Page 867, Produced Identification:
Number Pages:1 --
Recorded 07/31/2019 03:07 PM, _
RONNIE FUSSELL CLERK CIRCUIT COURT DUVAL '�`�
COUNTY t: TONI GINDLESPERGER
RECORDING $10.00 R MY COMMISSION#FF 924951
EXPIRES:October 6,2019
''L;pa c,4 Bonded Thru Notary Pubric Underwriters
City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road
Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845 qq��
9' E-mail: building-dept@coab.us Date routed: C J
City web-site: http://vmw.coab.us
APPLICATION REVIEW AND TRACKING FORM
3 Department review required Yes No
Property Address: (AVCyC�C p q
Applicant:
Tree Administrator
Project: i CKG7_`Z" F_e CPub is Works��
_ 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
St.Johns River Water Management District
Army Corps of Engineers v +
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Approved. ODenied. ❑Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING Reviewed by: //� Date: ?—
TREE
ate: ?—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 05/1912017
.0 AriCity of Atlantic Beach "Y'"' +, � APPLICATION NUMBER
pis Building Department (To be assigned by the Building Department.)
800 Seminole Road i Q '
Atlantic Beach, Florida 32233-5445 z?J 1 1 I�Ctyh ! —
Phone(904)247-5826 - Fax(904)247-5845
E-mail: building-dept@coab.us Date routed:
City web-site: hftp://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Department review required Yes No
Property Address: Z� (���OoT � � p q
Applicant: C'-)Lo(��'` �� �'� PI nnin &Zornn ,
Tree Administrator
Project: __ _ C:K_C�7" (leN(y, Pubiic Woks
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
St. Johns River Water Management District /�v
Army Corps of Engineers (1/ +
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 b� 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 05119/2017
REVOCABLE ENCROACHMENT AGREEMENT
City of Atlantic Beach **ALL INFORMATION
f 800 Seminole Road,Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
IS REQUIRED.
REVOCABLE ENCROACHMENT AGREEMENT 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
Q,('.,o,r1 n - Vrc ,,V— 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.
This work is generally described as f-eLnc_z-,. C e-1p�c� c pa,. -'
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
• 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 easement or 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 easements, 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.
V , ld--k- Date L-s L
Property Owner/Agent (signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this day of 1� 20 ,
b Ll alt �-CL6— - who persona ly appeared before me and
(printed a of Signer)
ack o edge tha he, he signed the instrument voluntarily for the purpose expressed in it.
C.,.
..........
d!;;:y•., TONT GINDLESPERGER Department A rovpl:
Signature of Nota Public, MYCOMM!SSctober ,2019 p pP
g Notary Stat Florida jr_ EXPIRES: 951
October6,2019
I \
F a:f` `. Bonded 7h u�10,ory public Urdertxnters
[ ] Personally Known -----
[ ] Produced Identification(Type) Scott W iams, PuNi s o irector
� !
H:\Applications&Forms\Word&Excel Document Originals\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18
RIGHT-OF-WAY/ EASEMENT PERMIT APPLICATION "ALL INFORMATION
City of Atlantic Beach HIGHLIGHTED IN GRAY IS
800 Seminole Road,Atlantic Beach, FL 32233 REQUIRED.
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES /�
Job Address Z_33 S 2',�f ` ,- Permit Number P�CE III - 00 qq
Contractor Information
Company ,Icy-d i t�7p-r"f Qualifying Agent
Address PO 6 a� 3 t3 4 City S-}-, Stated Zip 1 a SzS
Phone Ci O4 — S9" — (�?�,44 Email��s�r�c,,,e
State Certification/Registration# N 1�F L � 14 a.S ) a :619
Architect aV/nn Phone Email
Engineer /f—t Phone Email
Workers Compensation Insurer OR Exempt❑ Expiration Date
• 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 Public Works Director,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 Public Works Director and at the expense of the
Permittee unless reimbursement is authorized.
• All work shall meet City of Atlantic Beach or Florida Department of Transportation Standards and be performed under the
supervision of Ae (Project Superintendent)
with(Company Name) Phone
• All materials and equipment shall be subject to inspection by the Public Works Director.
• 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 Public Works Director 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 Public Works Director shall be notified 24 hours prior to starting work and again immediately upo comp tion.
Qi!=t!r P '�) , Date
Permittee(signed in presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL f
The foregoing instrument was acknowledged this day of C- 20
by Q f1 1_ who personally.appeared°before d
(printed name of Permittee) ?- li i "-r'1-
'6":...
, F`�'= MY COMMISSION#Fr 925951
ackn edged tghe/stigned the instrument voluntarily for the purpose expressed in=ft:. t= EX?!RES:October 6,2019
��' Bonded T u hbte� Public Underx i!ers
F —
iS
[ ] Personally Known \ �r
Signature of Notary Public,Sta of orida [ ] Produced Identification(Type) L
H:\Applications&Forms\Word&Excel Document Originals\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
City of Atlantic Beach APPLICATION NUMBER
Building Department (To be assigned by the Building Department.)
800 Seminole Road T-71
_ _ � /�_
Atlantic Beach, Florida 32233-5445 `�(
Phone(904)247-5826- Fax(904)247-5845
buildin de t
E-mail: coab.us Date routed:
9- P @
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Department review
Property Address: ARC— Cir required Yes No p
Applicant:
Tree Administrator
Project: i�K �" (��;NC� Public Works
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 /
St. Johns River Water Management District
Army Corps of Engineers L
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:
TREE ADMIN. Second Review: ❑Approved as revis d. ❑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
� � ;� ter' •..•: �>� K ��
2a
NN
vi ' -Sa' _ tv ai
M Ir!' u
1a•
;•� x3 r�dJr��.oCi�}E �+ rte jr�a?�
��a `X��cCaw'+-"'7 .�r'��,�T.�-s,✓Gucs�fs ,�.e . .�f�c,�-�e�,�c� a
T#.t.TE.aesvl'fi�E7s.z�seaart�.rrr�cx�a�csaf../srroe,m
tlo
pCEi/rSEG.�i+R'1 7l48w 6
�'GwtMcYNiTy'P.rrv'�'G ..-fp. if" �
12Oo75 Oqo( G. s�/OX.'C.✓LJJlE
�6�✓•a7rai.ts..O +� Th'Ll�` a�Pt}.¢Nfe°+rs TS fr�r�tr�c�G*zsr��`o�S�t^ .ark®Nage;
�a177r.Y•f.4L �{�'-'4�`- .0 c/E-/t�iC<fL OrITt/M- '[f.P/L`'D'�d✓BT"'tl�G°O.YtYt'�IAS O..BJ's
! 8i EBV ciERTtFYTO:AUV4.04 S. rt./WAr- FjSCl�G4�t?r�CawE�
i�+/SMT.tG rts•' :��,a,,,�5�'�+►' tr°�s�li'��.vt.
MN
THAT THlS'JU VEC MEETS T"K IL!!NINUM TECNNICAL
STANDARDS AS SET FORTY BY THE FLORIDA BOARD
OF LAND SURVEYORS.PURSUANT TO SECTION 4`2.027
H. A. DURDEN
FLORIDA STATUTES CQE CA�T R 21 HH--6 FLORIDA
& ASSOCIATES 9.4 - �.
a olow.o�waaeertwan swwRYow,/.o'y.74
"Nn t/r3QuCt pan'pPi r
"
SURVEYORSR� ff
{ SIGNED
y Post O*!�ea 90x c-0973 """^�� -
1103 Soots Thaw SVeos SCALE;
J'c;kzoaux.#Beach,kcwA 32250
THRE SURVEY NON VALID UNLESS TMIS PRINT IS EMBOSSED WITH THE SEAS..OF THE ABOVE SIGNED.
15'57/"3716
NOTICE OF COMMENCEMENT
State of Florida. ................................... Tax Folio No.
County of �
To Whom It X ay 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. Vt I VA 4 6 14
Legal Description of property being improved: i'3 --fled-Ds DCjE
Address of property being improved:-ZM-r._____.1` ( r` _ � � 322M
General description of improvements.,
Owner: _i/�a__.! x.__........_ ._. _.._._ Address:���...-t, e�-a�,�aTr-azc,
Owner's interest in site of the improvement:
Fee Simple Titleholder(if other than owner): _
Name:
Contractor: (t( ih* Fr-n[-
Address: - W
Telephone No,:q Q j' Fax No:
Surety(if any)_
Address: Amount of Bond$
Telephone No:^�— Fax No:
Name and address of any person snaking 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 elate is one(1)year from the date of recording unless a different date is
specified):
THIS SPACE FOR RECORDER'S USE ONLY OWNER
Signed:-v '' Date:
Befin re me this74" dai oP rJ ..c (_ in the County of Duval,State
Of Florida,has personally ap ed -7 o L_
Notary Public at Larne-Stat f lorida,County of Duval.
My commission expires:_..- P _,,....._V-7
Persoually Known: - or
Doc#2019178325,OR BK 18883 Page 867, Produced Identification:
Number Pages: 1 --
Recorded 07/31/2019 03:07 PM,
RONNIE FUSSELL CLERK CIRCUIT COURT DUVAL ._
COUNTY TONI(INDLESPERt,ER
RECORDING $10.00
My coMMISSION# T924951
EXPIRES:October 6,2019
�'„ Borded Thor Notary Pub&Urderwriters