427 Inland Way DWAY19-0042 S�'''� DRIVEWAY PERMIT PERMIT NUMBER
'S rte S''` DWAY19-0042
J CITY OF ATLANTIC BEACH
J� " ISSUED: 10/2/2019
800 SEMINOLE ROAD
°1i»r V ATLANTIC BEACH. FL 32233 EXPIRES: 3/30/2020
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLORIDA BUILDING
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH 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:
427 INLAND WAY DRIVEWAY SINGLE OR TWO DRIVEWAY $18000.00
FAMILY DRIVEWAY
TYPE OF REAL ESTATE ZONING: BUILDING USE SUBDIVISION:
CONSTRUCTION: NUMBER: GROUP:
169463 1526 OCEANWALK UNIT 04
COMPANY: ADDRESS: CITY: STATE: ZIP:
OWNER: ADDRESS: CITY: STATE: ZIP:
TILLMAN STANLEY W 427 INLAND WAY ATLANTIC BEACH FL 32233-4682
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.
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: 10/2/2019 1 of 2
,,5=-L`frr, DRIVEWAY PERMIT PERMIT NUMBER
=�S''� � DWAY19-0042
^.: µ CITY OF ATLANTIC BEACH
,iii
'� ISSUED: 10/2/2019
800 SEMINOLE ROAD
��`'''��` ATLANTIC BEACH. FL 32233 EXPIRES: 3/30/2020
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,All American Roll Off,WCA Waste Corporation). 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 MAXIMUM DRIVEWAY INFORMATIONAL
Notes:
Maximum driveway width within the City right-of-way is 20 feet.
6 PUBLIC WORKS DECKING REMOVED INFORMATIONAL
Notes:
All old decking and debris must be removed from job site by Contractor.
7 PUBLIC WORKS ADDITIONAL COMMENTS PUBLIC WORKS INFORMATIONAL
Notes:
Any damage done to infrastructure must be repaired by Contractor.
FEES
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
PW REVIEW BUILDING MOD OR ROW 001-0000-329-1004 0 $25.00
ZONING REVIEW SINGLE AND TWO FAMILY USES 001-0000-329-1003 0 $100.00
TOTAL:$125.00
Issued Date: 10/2/2019 2 of 2
EE
.0,m-r, City of Atlantic Beach - I V APPLICATION NUMBER
/✓ Building Department (To be assigned by the Building Department.)
800 Seminole Road SEI 6
-0� Atlantic Beach, Florida 32233 54 � ""t
Phone(904)247-5826 • Fax(904 7-5845411
E-mail: building-dept@coab.us Date routed: r
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 4 Z ' Nara Department review required Yes No
Building
Applicant: 0LZ IAC—{. ala Hing &Zonis
Tree Administrator
Project: (Ma\vfec,o- yQcy �UG{2- s�
1Jublic 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
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: ❑Approved. 1enied. ❑Not applicable
(Circle one.) Comments:
BUILDING
PLANNING &ZONING �/��/�j
Reviewed by: �
ate: / /
TREE ADMIN. Second Review: Approved as revised. ❑Denied. fNot applicable
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed . • y i /,� _ =.te:•
FIRE SERVICES Third Review: nApproved as revised. ❑Denied. ❑Not applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
Building Permit Application Updated 10/9/18
r,' . ' City of Atlantic Beach Building Department **ALL INFORMATION
',,:,.." , 800 Seminole Road, Atlantic Beach, FL 32233 HIGHLIGHTED IN GRAY
of#swv IS REQUIRED.
Phone: (904) 247-5826 Email: Building-Dept@coab.us
1M a 1/ ' }Perm' it h Pc j 9 OC kZ-
Job Address: �2- i n 1461,( �,.,v'�<1 � �1 f���1 z�- I,' ;a�� 1it Number: � /'
Legal Description �y 1 RE# ' (nC 4-(OSS 1'3 Z(P
Valuation of Work(Replacement Cost)$ I O 'Cl) Heated/Cooled SF Non-Heated/Cooled
• Class of Work: ❑New ❑Addition 74Alteration ❑Repair ❑Move ❑Demo ❑Pool ❑Window/Door
• Use of existing/proposed structure(s): ❑Commercial $Residential
• If an existing structure, is a fire sprinkler system installed?: ❑Yes TogNo
• Will tree(s) be removed in association with proposed project? ❑Yes(must submit separate Tree Removal Permit) ❑No
Describe
in detail the type of work to be performed: +(
i'�e Platt t" y [S 1,1" (i i, l ' t 1,l A.,-/ A-I, lA,tJ kit'L 61W 144 P/ty'e r_S S .
Florida Product Approval# for multiple products use product approval form
Property Owner Information + ` '
Name ra..,,,,,,,,_ "�#1(vt1,6-✓1 _ Address 'Z-1 I VI l� W ACity }k1 . �' 6/,—.%1 State f-L Zip '32.7— Phone C1Dy -5---&')el
E-Mail c(v1IC' -14IIk - -V Ci {4iSvl .6cvv1
Owner or Agent(If Agent, Po(ver of Attorney or Agency Letter Required) ®"ne &.
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 0 Expiration Date
Application is hereby made to obtain a permit to 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
RECO YO NOTICE OF COMMENCEMENT.
7------7, _7
(Signature of Owner or Agent) ) (Signature of Contractor)
�ned al sworn affi -' b-Akii me this 1'day of Signed and sworn to(• affirmed)before me this day of
� ...y 1 1 ( • .4 .A. . , •y
4 L . r (Signature of Notary)
,j ,G;;At"y,, TONT GINDLESPERGER """IIILLL33'11,
'd k.`I•� •,- MY COMMISSION#FF 924951
IV• xP 0 er 6,2019 [ ]Personally Known OR
7-.• � t}y`At:��c Underwriters
1....,
_, ,,_;_,:, ^^ - C / �7 [ ]Produced Identification
Type of Identification: ` 4---t - 19—�o I �1U[ ' ivPe of Identification:
1 Revision Request/Correction to Comments **ALL INFORMATION
rS /r HIGHLIGHTED IN
r' 1
'Si City of Atlantic Beach Building Department GRAY IS REQUIRED.
'0?- 800 Seminole Rd, Atlantic Beach, FL 32233
`-`-=i�� WAY19-0042
Phone: (904) 247-5826 Email: Building-Dept@coab,us PERMIT#: D
Revision to Issued Permit OR Corrections to Comments Date:09125/2019
Project Address: 427 Inland Way Atlantic Beach, FL 32233
Contractor/Contact Name: Stanley Tillman
Contact Phone: (904)509-5699 Email: stanleytillman@msn.com
Description of Proposed Revision/Corrections:
Modify the replacement paver driveway within the City right-of-way to maintain the same design as the existing driveway.
I Stanley Tillman affirm the revision/correction to comments is inclusive of the proposed changes.
(printed name)
• Will proposed revision/corrections add additional square footage to original submittal?-;
ENo EYes(additional s.f.to be added: )
• ill proposed revision/corrections add additional increase in building valudto,original submittal?
No 11*Yes(additional increase in building value: $ )(Contractor must sign if increase in valuation)
*Signature of Contractor/Agent: -`° '41111,4110,
(Office Use Only)
Approved El Denied ❑ Not Applicable to Department Permit Fee Due$
Revision/Plan Review Comments
Department Review Required:
Building �-
/ � " `��
gPlanning&Zoning j A l "v a Reviewed By
Tree Admmistrator.
CFO sir VVOI --_, '; SEP 2 G 2019 1 i f-Jo.1
Public Utilities 1 7
Public Safety IW Date
Fire Services Updated 10/17/18
0s.ut,..,, City of Atlantic Beach APPLICATION NUMBER
e$ 6 Building Department (To be assigned by the Building Department.)
- 800 Seminole Road _0/4
�. Atlantic Beach, Florida 32233-5445 _
filllPF Phone(904)247-5826 Fax(904)247-5845 ea
it 91' E-mail: building-dept@coab.us Date routed:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: 4 Z I 1 (-\\aV v ac- Department review required Yes No
l Buildin
Applicant: OC.sv kpe Z_ anning &Zonin
j (� Tree Administrator
Project: ►Th R\i ec,3 A(-1 i (�U�{L ¶ (ublic orks,
-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
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: F4Approved. ❑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. I INot applicable
Comments:
Reviewed by: Date:
Revised 05/19/2017
fiA„rergz...
m•
m
i NIN TATE
Residence Tillman ^,, tom '"`
I � { 427 Inland Way. Atlontic Beach,Florida 32233 - n''
3Y8 ;� -a Provide bullnoee coping e
iiii SCALE-va""I'-0" r ff;,` pavers at risers as shown. ( , 0
p d Approx.22 Linear Feet or .
bulllnoee coptng pevcs. < r••e a� - O
3 rnl.o,...n•.w Entry u-
i ❑ wlln•x u w Front Doors '� f 1
Xi
ill Mose ❑ \ I
id
FW4 GOp
N B e Existingriser♦ 1,i- h.',?.:.;:,. �, 3,1
iE Bullnose Gopl 1 - x1na. :z _..
g Split Leaf Philodendron Hoe.Bi. 4 21 r:.l, R 3' Cleyera
�.` ren a°vl®�r►;MO 3' 21' Multi-trunk Crape Myrtles......-)„;,:,A:" Q
' g Sago Palm ♦ -
MrG'ZEMP$ 451. eo 1 Garage Door
m M Split Leaf Philodendron m(�ilklS$i�il�l _
9 11N1l�RIII 3' `r=Ur=111 6 Plumbago u
Pg,, r 1 3' Ir...�•I. `� '.;,1
� ��I .al •
I- g ' mita3' 111091 MIMEO T
Plemirlg 7 Pia Bullnose Coping at Risers m 0
•
DV Palm Tree to be removed w _`rsi 2r Iii�i,ll���l�� H
€ Plant bed of Asiatic Jasmine in this area PRII•E 3,.1 Io-ai I(auuii a en
§,:-,f, to be removed. Re- Grade this area. 11�� X111■1101 w Z
Existing illiliMill
TI - 75 a
e
S.21 Giant Liriope canter Llne./f��:�r. J�1■L�VBI�■II 4 1`p o
W Existing Fern�� 4,:1� 1,�I €€ •
o!; � 71■IO7►Ef■1�1 Approximate Area of pi u g_
;a 40" Live Oa j R•e' l ���I.�I Woods 'tS 0
6 Transformer r - �� ��1111 U m 0_
gig 0 TE, c
o�N I •1 •Palm �:N� •pproximate Line of Existing - c p
91 r1 =MEW Driveway and Walkway '0 Q
to be removed. •(0 N Q
a,; Existing Mexican Petunias Pol: Palm �:`1 •
a
2 e" , •• Palm /®O</• 0 `Rt
F;btl ° • ®fin Multi-trunk Crape Myrtle 3 F
_ g� Green Utility Box �� ���• 0-0 U
_� a a �i 111I�r `>3 `a
I
� ' �� ePalma DENIED l DE I hone'q 48" Live Oak �_ 4s0®i Multi-trunk Crape Myrtle a
66M Miami curb •��MiG■nE�� �i� ��Z Qa ' Edge of asphalt `,::: �, R +� Green Pittosporum p
!i • Suggested Pavers - Roma terra -mi%�
b •
Property Line
li
Approximately 250 Ft.Pavers ��� }�,
>B pp 5 -q Consult Surveyor
P/Ni
PR: Contractor is responsible for measuri•• ��
3 in the field and calculating the square f. age. �/7� 711, \ I. Irrigation Spray Head AIIII MIL
AMINE-__ i
a 4,S Provide installation cost estimate including all permi .'ng. d/7 _IEL ", - h-
' W1' Provide optional cost of sealer. 44' //, ,�7..�3' Water Meter s dor F
o 97531 (/ `�ji 111 J
55n- II I I l Approximate Area of ager =
Woods
4 I I I I Mailbox //De1t•e-21-2019 Q
is eE 108642 1 0 20 30 40 l ) .'
d )
SCALE IN FEET No Outlet Sign ( ~J Devin ) N
W0 o �
Provide a grading plan with minimum slopes for drainage. Consult a Fl. Reg. Engineer for grading. Green Utility Box
u i si
4 Consult a Florida Reg. Land Surveyor for spot elevations according to directions from the engineer. w
�,
Stanley and Donna Tillman
s y 3 427 inland Way, Atlantic Beach, Florida 32233 1 j
RE# 169463-1526 a-
0 Disdness,: This drawing is for landscape planting purposes only. Consult a Florida Registered Engineer for dl structural work.civil work,and soi testing by others. }
The location of an objects shown on this drawing ore approximate locations for landscape planting purposes only. Consult a Florida Registered Land Surveyor for actual locations of objects shown. Layout Plan Q
1
Revision Request/Correction to Comments **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#: DWAY19-0042
ElRevision to Issued Permit OR El Corrections to Comments Date:09/25/2019
Project Address: 427 Inland Way Atlantic Beach, FL 32233
Contractor/Contact Name: Stanley Tillman
Contact Phone: (904)509-5699 Email: stanleytillman@msn.com
Description of Proposed Revision/Corrections:
Modify the replacement paver driveway within the City right-of-way to maintain the same design as the existing driveway.
I Stanley Tillman affirm the revision/correction to comments is inclusive of the proposed changes.
(printed name)
• Will proposed revision/corrections add additional square footage to original submittay
ENo E Yes(additional s.f.to be added:
•ALill proposed revision/corrections add additional increase in building valud_to;original submittal?
No Q*Yes(additional increase in building value: $ ) (Contractor must sign if increase in valuation)
*Signature of Contractor/Agent. ��Alir
4// priinow--
(Office Use Only)
pproved ❑ Denied ❑ Not Applicable to Department Permit Fee Due $
Revision/Plan Review Comments
Department Review Required: f
Building
ani nim Zoning Reviewed By
Tree Adminls ra or
u Ic or cs C
u c Utilities
Public Safety Date
Fire Services Updated 10/17/18
j'�'''�,. REVOCABLE ENCROACHMENT AGREEMENT
t **ALL INFORMATION
:.� w,i� City of Atlantic Beach
1 [ HIGHLIGHTED IN GRAY
800 Seminole Road,Atlantic Beach, FL 32233 IS REQUIRED.
..:
vas.?•
REVOCABLE ENCROACHMENT AGREEMENT by the City of Atlantic Beach, Florida, a municipal corporation organized and
existing under the laws of th tate of Florida, hereinafter referred to as "CITY" and
51-'/,(P�, ( tL[ 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.. n
This work is generally described as C,)I Ltail&(,LLt l'Udf4U (t 1 /.
Any facility maintained, repaired, erected, and/or installed in the exercise of tfie privilege granted remains subject to
relocation or removal on thirty(30)days'notice by CITY to USER,sai notic��tt�o p�US�ER shall e given by certified mail,return
receipt requested,to the following address I- 2,�1 ( k 1 '(-ttGC. ft-j ftt'ij t-- L , C� - (�- 3 Z 2,33
• 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.
41w 2A___---- Date
Cid« ( 9
Pro•• y Owner/Agent(signed in presence of Notary Public)
STATE OF FLORIDA, COUNTY OF DUVAL
The foregoing instrument was acknowledged this I (0 day of�) (DO , 20 C(1.- ,
11
by iN t eki It I 1✓Vl 0"0 , who personally appeared before me and
(pri ted name of igner)
ackno -dged thi : e signed the instrumen # ,r
t Eil ,t< ulas,;e>fpressed in it.
{!�Y'lik.'' TONI GINDLESPERGER
_ -� - MY COMMISSION#FF 92?951
,, EXPIRES:October 6,2019
r r1: Bonded Thru Notary Public Underwriters Department A. •royal:
Signature of Notary Public, State Florida ---3-- •
[ ]Personally Known .((.e,/ , z _
[ ] Produced Identification(Type) , J � Scott Williams, Public Works Director
H:\Applications&Forms\Word Documents\20180831 Revocable Encroachment Agreement.docx Revision Date:8/31/18 ff9.../f
gt;:ii;v... RIGHT-OF-WAY/EASEMENT PERMIT APPLICATION **ALL INFORMATION
'r .\ City of Atlantic Beach HIGHLIGHTED IN GRAY IS
l" 800 Seminole Road,Atlantic Beach, FL 32233 REQUIRED.
PERMITTEE RESPONSIBLE FOR NOTIFYING 811 AND OBTAINING UTILITY LOCATES
Job Address 42-1 L Ul la_fd ( v 0- Permit Number
Contractor Information
Company V t.e.)N C2 Qualifying Agent
Address `i ? - eJ(krvd (.(,, City - Ivv"it;G % ,(_C State Zip
Phone �[6� U l 9 1 Email S+yvN (i t i I I dVl / cJ Ems/v. C(.2,V .
State Certification/Registration#
Architect Phone Email
Engineer Phone Email
Workers Compensation Insurer OR ExemptExpiration 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 (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 P 31i Wo e" ector shall be notified 24 hours prior to starting work and again immediately upon ompleti n.
�� Date 9
1/4---i
Pern presence of Notary Public)
STATE OF FLORIDA,COUNTY OF DUVAL
The foregoing instrument was acknowledged this I CST day of (` )' ,201 CT:(
by w b'A( ` -' [ i t ✓ I OW ,whoersonall
p y appeared before me and
(printed name of Permittee)
n^ae�r+a
acknowledge. . he/she sign: the instrument voluntarily for the purpose expressed in it ' TONIC'I'vaLESPERGER
MY COMMISSION#FF 924951
EXPIRES:October S,2019
Bonded Thru Notary Public Underwriters
[ ]Personally,`K-ranw
Signature of Notary Public,Sta e of Florida 1 [ ]Produced Identification(Type)
H:\Applications&Forms\Word Documents\201801001 Right-of-Way Easement Permit Application.docx Revision Date:10/1/18
Owner Builder Affidavit **ALL INFORMATION
//f-''
i 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#:
I. 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.
IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT PEOPLE EMPLOYED BY YOU HAVE LICENSES
REQUIRED BY STATE LAW AND BY COUNTY OR MUNICIPAL LICENSING ORDINANCES.
II. INJURY LIABILITY; SINCE OWNERS MAY BE LIABLE FOR INJURIES TO WORKERS THEY HIRE,THE BUILDING DEPARTMENT
SUGGESTS WORKER'S COMPENSATION INSURANCE BE PURCHASED. .
III. 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 $5,000 PENALTY UNDER FLORIDA STATUTE NO. 455-228(1). AN "OCCUPATIONAL LICENSE" IS NOT ADEQUATE. THE
OWNER SHOULD PHYSICALLY SEE THE COUNTY "CERTIFICATE OF COMPETENCY" OR THE FLORIDA"CONTRACTORS
CERTIFICATE" TO ASCERTAIN IF A PERSON ISA LICENSED CONTRACTOR. CONTACT THE BUILDING DEPARTMENT(904-
247-5826 OR BUILDING-DEPT@COAB.US) IF IN DOUBT.
V. ACKNOWLEDGEMENT; I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE DISCLOSURE STATEMENT AND THAT I
COMPLY WITH ALL THE REQUIREMENTS FOR THE ISSUANCE OF AN OWNER-BUILDER PERMIT.
Job Address: I--}a n �// ` /-An�C� r4 ��-4 (/\vk�c_ (�C /x sac93
Owner Name: S- vNAL I el \ c ' VVI VAAl1 Phone Number: q.UCf
Mailing Address: (-07-- -v(A�d bMALI- F
) - City:
.� �� State: ( Zip: 3a).33
Notarized Signature of Owner�� —//
The f egoing ins ument was acknow edged before me this (Oday • I : (n in the State of Florida, County
of v',/o---1
44 _ i/L
Signature of Notary Public ` , -
[ ] Personally Known OR [ ] Produced Identification
Type of Identification: / . C—
ry.,
T
, , TONI GINDLESPERGER Updated 10/24/18
!_:' f:s MY COMMISSION#FF 924951
<= EXPIRES:October 6,2019
:;'Rr:eo= Bonded Thor Notary Public Underwriters
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ra w4 �` 427 Inland Way, aua,u<too .nne.32233 ,r r; L •
a e �'$ Prpvfdc bullnose coping '! 4
f �• pavers et risers as shown. J' - ( ) O
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ii' Split Leaf Philodendron--- I ,.‘„,..t.„,,_4' I Iff, 10;1_, j' Cleyerctu
m„ I - pl. / ----Multi-trunk Crape Myrtle ,.
>: Sago Poim�` �"� ar1F�1f�jg• I Garage Door •
a Split Lecf Philodendron--------.., ,,/1 \ 4 n'. -"{f a+, .--,.-,..--4„,,,,
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el • Ptenarg; 3'�4 - t.xa .-�I��r�r 6utVnoae Copino at RVs<_re rn .
§ PI Palm Tree to be removed `' • F'. . - --
3 F€g Plant bed of Asiatic Jasmine in this area, w .] Z
i@ to be removed. Re- Grade this area, "-,. __- s �;•�-j.-'••---I..1: , 41,16.--,-;
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u°. Oolr�' � �\:-, ..,. .-_-. 71N
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'�i j! to be removed. Q
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a i 48 Live Oak f v�, i
PSb 1 t1e�/r Miami:curb ..--. i.'i �W //""�� d Q tn1
fig / Edge of asphalt ��- -• �'+-•-- , �- r`,/� reen Pit tosparum
'8 Suggested Pavers - Roma Sierra 11
V % Property Line
t 5b Approximately 2250 5 I.Ft.Pay s �., ''�I ` Consuii Surveyor
pEQ8 Contractor is responsible for meosuriyig., ,r, '' ' ��' J ' U
r X r is the field and calculating the square f8adoge. 'P7/ ! ,gym rrigaticn Spray Heod
F 5 Provide installation cost estimate including all permm'itttng. d� ti U
oY 9 7$3 1 Provide optional cost of sealer. /, ,t` ‘"N.,,,,\/.11-Water Meter North r
Bac .`'N ({/0ls�/\,\\ ��„ Approxima le Area c. (.c.ue^ o) `F
idgQ 2 X� \' Montmj� Woods Q
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an1Ti. Utility Box 1 b
. Provide o grading pion with minimum slopes for drainage. Consult a ri. Reg. Engineer for grading. �� i+
u g; Consult a Florida Reg. Land Surveyor for spot elevations ccarding to directions from the engineer. \,:.....„, 'L
▪•▪ . , Stamey and Demo rcn,on 3
• ' eY/ski dvottui 427 Wood'Way. .(10.t.Nun. FIor ao 32233
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Building Department
City of Atlantic Beach, FL